Essentials of Certified Nursing Assisting · Essentials of Certified Nursing Assisting ... Textbook activity answers, instructor resources, test bank questions, and workbook answer

Carrie L. Engelbright RN, MSN, CNEMid-State Technical College

Essentials of Certified Nursing Assisting

eng26054_00_fm_i-xxiii.indd 1 11/21/14 10:54 AM

Essentials of Certified Nursing Assisting, First EditionCarrie L. Engelbright RN, MSN, CNE

978-1-941626-05-4Published by August Learning SolutionsCleveland, OH

www.augustlearningsolutions.com

. 2014 August Learning Solutions. 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, electronic storage or transmission, or in any other medium, without the express written permission of August Learning Solutions or its licensors.

Cover photo by Andrey_Kuzmin

Textbook activity answers, instructor resources, test bank questions, and workbook answer keys are available to professors from the author via email at [email protected]


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.



v

Brief Contents

Chapter 1 The History of Healthcare in the United States 3

Chapter 2 Responding to Emerging Trends in Healthcare 15

Chapter 3 Healthcare Settings and Governance 27

Chapter 4 The Nursing Assistant Role and Scope of Practice 41

Chapter 5 Communication 53

Chapter 6 Professionalism in Healthcare 71

Chapter 7 Legal and Ethical Issues 87

Chapter 8 Body Structures and Functioning Processes 103

Chapter 9 Common Diseases and Disorders 131

Chapter 10 Infection Control Practices 165

Chapter 11 Body Mechanics and Workplace Safety 193


Chapter 12 Reducing Client Injury and Falls 209

Chapter 13 Restraints and Restraint Alternatives 223

Chapter 14 Basic First Aid Measures 235

Chapter 15 Stress Reduction and Management Techniques 253

Chapter 16 Holistic Care of Clients 271

Chapter 17 Client Room Environment 287

Chapter 18 Preventing Skin Breakdown 301

Chapter 19 Bedmaking 317

Chapter 20 Positioning Clients 335

Chapter 21 Moving, Transferring, and Transporting Clients 351

Chapter 22 Ambulation and Exercises for Clients 383

Chapter 23 Rehabilitation and Restorative Care 401

Chapter 24 Adaptive Equipment and Supportive Devices 411

Chapter 25 Vital Signs 423

Chapter 26 Bathing 451

Chapter 27 Grooming 487

vi Brief Contents


Brief Contents� vii

Chapter 28 Nutrition 517

Chapter 29 Elimination 543

Chapter 30 Specimen Collection 575

Chapter 31 Oxygen Therapy and Respiratory Interventions 589

Chapter 32 Care for the Medical and Surgical Client 603

Chapter 33 Care for the Client With Communication Disorders 617

Chapter 34 Care for the Client With Cancer 625

Chapter 35 Care for the Client With a Positive HIV Status 639

Chapter 36 Care for the Client With Dementia 649

Chapter 37 End-of-Life Care 671

Chapter 38 Common Medications 685

Appendix A Common Medical Abbreviations and Directional Terminology 699

Appendix B ISMP List of Error-Prone Abbreviations 702

Appendix C Glossary 704

Index 711


viii

A Note to Nursing Assistant Instructors xx

A Note to the Reader xxi

Acknowledgments xxii

About the Author xxiii

Chapter 1The History of Healthcare in the United States 3

LO 1.1 A Brief History of Healthcare in the United States 4

LO 1.2 The Beginning of Modern Healthcare 5

The Modernization of Medicine 6

LO 1.3 The Cost of Healthcare 7

LO 1.4 Healthcare Today 9

Summary of Learning Outcomes 11

Get Up and Think! 11

Reflect on This! 12

Let’s Review! 12

Multiple Choice Questions 12

References 13

Chapter 2Responding to Emerging Trends in Healthcare 15

LO 2.1 Who Is Your Client? 16

LO 2.2 Consumerism in America 16

LO 2.3 Home Healthcare Versus Facility Care 18

LO 2.4 Alternative Therapies 20

LO 2.5 Why the Nursing Assistant Needs to Know These Trends 21



Reflect on This! 24

Let’s Review! 24


References 25

Chapter 3Healthcare Settings and Governance 27

LOs 3.1–3.4 Work Settings for the Nursing Assistant 28

Acute Care Settings 28Subacute or Rehabilitation Facility 30Long-Term Care 31Assisted-Living Communities 32Home Healthcare 33Hospice Services 34Respite Services 35

LO 3.5 Advanced Training and Opportunities 36



Reflect on This! 38

Contents


Contents ix

Let’s Review! 38


Chapter 4The Nursing Assistant Role and Scope of Practice 41

LO 4.1 Members of the Healthcare Team 42

LO 4.2 Scope of Practice for the Nursing Assistant 43

LO 4.3 Chain of Command 44

LO 4.4 Delegated Tasks 45

LO 4.5 Teaching Versus Reinforcing 47

LO 4.6 Time Management and Organization 48



Reflect on This! 49

Let’s Review! 50


Reference 51

Chapter 5Communication 53

Communication in Healthcare 54

LO 5.1 Causes of Medical Errors 54

LO 5.2 Subjective Versus Objective Data 56

LO 5.3 Oral Reporting 58

LO 5.4 Written Documentation and the Nursing Assistant 58

LO 5.5 Verbal Versus Nonverbal Communication 62

Verbal Communication 62Nonverbal Communication 63

LO 5.6 Therapeutic Communication 64

LO 5.7 Confrontational Situations 66



Reflect on This! 68

Let’s Review! 68


Reference 69

Chapter 6Professionalism in Healthcare 71

LO 6.1 Education and Certification 72Nurse Aide Registry 72Continuing Education 73

LO 6.2 Job Searching 73Applications 74Resume 75

LO 6.3 Interviewing 78

LO 6.4 Accepting and Resigning From a Position 79

LO 6.5 Acting Like a Professional 80Dependability 80Promptness 80Customer Service 80Flexibility 81Hygiene 81



Reflect on This! 84

Let’s Review! 84


Chapter 7Legal and Ethical Issues 87

LO 7.1 Client Rights 88Health Insurance Portability and Accountability Act (HIPAA) 88Informed Consent 89

LO 7.2 Client Responsibilities 90


x Contents

LO 7.3 Employee Rights 90

LO 7.4 Employee Responsibilities 91Following the Care Plan 91Mandatory Reporting 92

LO 7.5 Laws 93Invasion of Privacy 94Misappropriation of Funds 95Negligence 95Abandonment 95False Imprisonment 96Neglect 96Assault and Battery 96Abuse 97

LO 7.6 Cultural Awareness 98



Reflect on This! 100

Let’s Review! 100


Chapter 8Body Structures and Functioning Processes 103

LO 8.1 Basic Structures 104

LO 8.2 Tissue Types 104

LO 8.3 Body Systems 105Integumentary System 105Musculoskeletal System 106Respiratory System 109Cardiovascular System 111Nervous System 113Sensory Organs 115Endocrine System 118Digestive System 120Urinary System 123Reproductive System 124




Let’s Review! 129


Chapter 9Common Diseases and Disorders 131

LO 9.1 Understanding Disease Processes 132

LO 9.2 Risk Factors 132

LO 9.3 Emergency Medical Services 132

LO 9.4 Common Diseases and Disorders 133

Integumentary System 133Musculoskeletal System 136Respiratory System 139Cardiovascular System 141Nervous System 144Sensory Organs 147Endocrine System 149Digestive System 153Urinary System 156Reproductive System 159




Let’s Review! 162


Reference 163

Chapter 10Infection Control Practices 165

Introduction 166

LO 10.1 The Importance of Hand Washing 166

Germ Theory 166Global Society and Spread of Disease 167

LO 10.2 Chain of Infection 168

LO 10.3 Primary Prevention 169


Contents xi

LO 10.4 Body Defense Mechanisms 170

LO 10.5 Hand Hygiene 172

LO 10.6 Standard Precautions 176Personal Protective Equipment (PPE) 176

LO 10.7 Specialty Precautions 180Airborne Precautions 180Droplet Precautions 180Contact Precautions 181Transporting a Client to and From an Isolation Room 181Blood Spill Kits 182Double-Bagging Technique 183

LO 10.8 Drug-Resistant Infections 184MRSA Infection 184VRE 184




Let’s Review! 187


Skills 187

References 190

Chapter 11Body Mechanics and Workplace Safety 193

Introduction 194

LO 11.1 Exposure to Blood-Borne Pathogens and Chemicals 194

LO 11.2 Latex Allergies 196

LO 11.3 Injury Prevention 197Ergonomics 197Moving Clients 198Lifestyle Choices to Prevent Back Injuries 199Slips, Trips, and Falls 200

LO 11.4 Fire Safety 200

LO 11.5 Natural Disasters 201

LO 11.6 Bomb Threats 203

LO 11.7 Workplace Violence 203




Let’s Review! 206


Chapter 12Reducing Client Injury and Falls 209

Introduction 210

LO 12.1 Why Falls and Immobility Are Dangerous 210

LO 12.2 Risk Factors for Falling 211

LO 12.3 Care During a Fall 212

LO 12.4 Care After a Fall 213

LO 12.5 How to Prevent Fall Injuries 214

LO 12.6 Alarm Systems 216

LO 12.7 Other Strategies 217




Let’s Review! 219


Skills 220

Chapter 13Restraints and Restraint Alternatives 223

LO 13.1 Restraints 224

LO 13.2 Working With Restraints 224

LO 13.3 Types of Restraints 225

LO 13.4 Risks of Using Restraints 227

LO 13.5 Instances When Restraints Are Allowed 228

LO 13.6 Side Rails 229


xii Contents

LO 13.7 Restraint Alternatives 229




Let’s Review! 232


Reference 233

Skill 233

Chapter 14Basic First Aid Measures 235

Introduction 236

LO 14.1 Airway Obstruction 236

LO 14.2 Cardiac Arrest 237

LO 14.3 Syncope 238

LO 14.4 Seizures 239

LO 14.5 Hemorrhage 241

LO 14.6 Shock 242

LO 14.7 Burns 243

LO 14.8 Poisoning 244




Let’s Review! 246


Skills 247

Chapter 15Stress Reduction and Management Techniques 253

LO 15.1 Why Is Healthcare So Stressful? 254

LO 15.2 Ways to Prevent Stress From Taking Charge 256

LO 15.3 Time-Management Techniques to Reduce Stress While at Work 257

LO 15.4 Preventing Stress and Promoting Job Satisfaction 258

Good General Health 258Yoga 259Meditation 259Pet Therapy 260Humor 260Journaling 261Visualization Techniques 261Breathing Exercises 262

LO 15.5 Client Stressors 263Pain 263Illness 263Sleep Deprivation 263Anxiety and Depression 264Grief 264Coach Your Clients 265




Let’s Review! 266


Skills 267

Chapter 16Holistic Care of Clients 271

LO 16.1 Holistic Care 272

LO 16.2 Maslow’s Hierarchy of Needs 272

Human Needs 272Application of Maslow’s Hierarchy to Caregiving 274

LO 16.3 Growth and Development 275

LO 16.4 Quality of Life 277

LO 16.5 Meeting the Needs of Loved Ones 282




Let’s Review! 284



Contents xiii

Chapter 17Client Room Environment 287

Introduction 288

LO 17.1 Safety 288

LO 17.2 The Physical Environment 289

LO 17.3 Individual Room Requirements 290

LO 17.4 Noise and Odor Control 292Noise Control 292Odor Control and Cleanliness 293

LO 17.5 Transfers and Discharges 294

LO 17.6 Current Trends 295




Let’s Review! 298


Reference 299

Chapter 18Preventing Skin Breakdown 301

LO 18.1 The Importance of Healthy Skin 302

LO 18.2 Types of Skin Breakdown 302Rashes 302Friction and Shearing 303Pressure Ulcers 303

LO 18.3 Stages of Pressure Ulcers 305

LO 18.4 Risk Factors for Developing Pressure Ulcers 307

LO 18.5 Interventions for Preventing Skin Breakdown 308

Inspection and Cleanliness 309Positioning and Turning 309Pressure-Relieving Devices 310Positioning Devices 311Incontinence Care 311Nutrition and Hydration 312Reducing the Microclimate 313




Let’s Review! 314


Chapter 19Bedmaking 317

Introduction 318

LO 19.1 Linens 318

LO 19.2 Infection Control 320

LO 19.3 Body Mechanics 321

LO 19.4 The Closed Versus Open Bed 322

LO 19.5 Making the Unoccupied and Occupied Bed 324

Unoccupied Bed 324Occupied Bed 324




Let’s Review! 328


Skills 329

Chapter 20Positioning Clients 335

Introduction 336

LO 20.1 Frequency of Repositioning Clients 336

LO 20.2 Basic Positions for Clients in Bed 337

LO 20.3 Position to Relieve Pressure Sores 338

Supine 338Fowler’s Position 338Prone Position 340Side-Lying Position 341


xiv Contents

Sims’s Position 342Tripod Position 342

LO 20.4 Wheelchair Positioning 343




Let’s Review! 345


Skills 346

References 349

Chapter 21Moving, Transferring, and Transporting Clients 351

Introduction 352

LO 21.1 Moving a Client in Bed 352

LO 21.2 Preventing Friction and Shearing Injuries 353

LO 21.3 Log Rolling a Client 354

LO 21.4 Moving a Client From Bed to Stretcher 355

LO 21.5 Transferring the Client Using a One- and a Two-Assist Transfer 356

Dangling 356Footwear 356Gait Belt 356One- and Two-Assist Transfers 357Mechanical Devices Used for Transfers 359

LO 21.6 Transferring a Bariatric Client 361

LO 21.7 Transporting a Client in a Wheelchair 362




Let’s Review! 366


Skills 367

References 381

Chapter 22Ambulation and Exercises for Clients 383

Introduction 384

LO 22.1 Why We Move 384Self-Esteem 384Effects on the Digestive System 384Effects on the Cardiovascular System 384Effects on the Integumentary System 385Effects on the Musculoskeletal System 385

LO 22.2 Levels of Assistance 385

LO 22.3 Safety Measures Used During Ambulation 387

LO 22.4 Assistive Devices for Ambulation 388

LO 22.5 Range-of-Motion Exercises 390

LO 22.6 Soothing Sore Muscles 391




Let’s Review! 394


Skills 395

Chapter 23Rehabilitation and Restorative Care 401

LO 23.1 Therapy Services Overview 402

LO 23.2 Rehabilitation Therapy 402Physical Therapy 402Occupational Therapy 403Speech Therapy 404

LO 23.3 Activities Therapy 405

LO 23.4 Restorative Care 406





Contents xv

Let’s Review! 409


Chapter 24Adaptive Equipment and Supportive Devices 411

Introduction 412

LO 24.1 The Client With a Prosthesis 412Prosthesis Overview 412Types of Prostheses 414Care Measures 415

LO 24.2 The Client With an Orthosis 415Orthosis Overview 415Care Measures 415

LO 24.3 Adaptive Tools Used at Meal Times 416

LO 24.4 Adaptive Tools for Grooming and Other ADLs 418




Let’s Review! 420


Chapter 25Vital Signs 423

LO 25.1 Introduction 424

LO 25.2 When Vital Signs Are Taken 424

LO 25.3 Infection Control 425

LO 25.4 Accurately Measuring Vital Signs 425

Temperature 425Pulse 428Respiration 429Pulse Oximetry 430Blood Pressure 431Height 435Weight 435




Let’s Review! 438


Skills 439

References 449

Chapter 26Bathing 451

Introduction 452

LO 26.1 Routine Bathing 452

LO 26.2 Distressed Bathing 453Alternatives to Tub Bathing and Showering 454Easing Distressed Bathing 454

LO 26.3 Rinseless Systems 455

LO 26.4 Peri-Care 456

LO 26.5 Bed Baths 459Partial Bed Bath 459Complete Bed Bath 461

LO 26.6 Shower and Tub Baths 462Shower 462Whirlpool Tub Bath 464Hair Care 465

LO 26.7 Responsibilities on Bath Day 465




Let’s Review! 468


Skills 469

Reference 485

Chapter 27Grooming 487

LO 27.1 Promoting Independence 488

LO 27.2 Dressing 488Dressing a Client With One-Sided Weakness 489

LO 27.3 Hair 489


xvi Contents

LO 27.4 Vision and Hearing 490Glasses and Contacts 490Hearing Aids 491

LO 27.5 Shaving 492

LO 27.6 Oral Care 494

LO 27.7 Nail and Foot Care 498Nail Care 498Foot Care 499




Let’s Review! 501


Skills 502

Chapter 28Nutrition 517

Introduction 518

LO 28.1 MyPlate and MyPyramid 518

LO 28.2 Nutrients Essential for Life 519Calories 519Carbohydrates 519Proteins 519Fats 520Vitamins and Minerals 520

LO 28.3 Water and Fluid Needs 522

LO 28.4 Food Groups 523Grains 523Fruits 524Vegetables 524Dairy Products 525Protein 525

LO 28.5 Types of Diets 526Specialty Diets 526Mechanically Altered Diets and Fluids 529Thickened Fluids 530Diets for the Postsurgical Client 530Mechanical Feeding 531

LO 28.6 Problems With Digestion 532Nausea, Vomiting, and Diarrhea 532Malnutrition and Overeating 533

LO 28.7 Feeding Dependent Clients 534




Let’s Review! 538


Skill 539

References 541

Chapter 29Elimination 543

Introduction 544

LO 29.1 Urinary Elimination via Catheter 544

Types of Catheters 544The Nursing Assistant’s Role in Care of the Client With a Catheter 545Cleaning the Catheter 546Changing the Collection Bag to a Leg Bag 547Positioning the Client With a Collection Bag 547Protecting the Privacy of the Client Who Uses a Catheter 548Emptying the Collection or Leg Bag 548Cleaning Collection and Leg Bags 548

LO 29.2 Urostomy 549

LO 29.3 Incontinence 549Care of the Client Who Is Incontinent 549Types of Incontinence Products 550

LO 29.4 Dialysis 551Hemodialysis 551Peritoneal Dialysis 551Care of the Client Who Is on Dialysis 552

LO 29.5 Bowel Elimination 552

LO 29.6 Ostomies 553

LO 29.7 Digestive Tract Bleeding 555

LO 29.8 Devices Used for Elimination 556




Let’s Review! 560


Contents xvii


Skills 561

Chapter 30Specimen Collection 575

Introduction 576

LO 30.1 Basic Principles of Collection and Transport 576

LO 30.2 Urine Specimens 577

LO 30.3 Straining for Kidney Stones 578

LO 30.4 Fecal Specimens 579

LO 30.5 Occult Blood 580




Let’s Review! 582


Skills 583

Chapter 31Oxygen Therapy and Respiratory Interventions 589

LO 31.1 Why Supplemental Oxygen Is Needed 590

LO 31.2 The Nursing Assistant’s Role in Oxygen Therapy 590

LO 31.3 Delivery Routes 592

LO 31.4 Delivery Systems 593

LO 31.5 Interventions to Ease Anxiety Related to Breathing Difficulties 595

LO 31.6 Interventions to Aid Lung Function 595

Coughing and Deep Breathing Exercises 595Incentive Spirometry 596




Let’s Review! 598


Skills 599

Chapter 32Care for the Medical and Surgical Client 603

Introduction 604

LO 32.1 The Medical Client 604

LO 32.2 The Postsurgical Client 605

LO 32.3 Diet for the Postsurgical Client 605

LO 32.4 Activity for the Postsurgical Client 606

LO 32.5 Weight-Bearing Status 607

LO 32.6 Respiratory Complications 607

LO 32.7 Cardiac Complications 608

LO 32.8 Intravenous Therapy 609




Let’s Review! 611


Skills 612

Chapter 33Care for the Client With Communication Disorders 617

Introduction 618

LO 33.1 Hearing-Impaired Clients 618

LO 33.2 Speech-Impaired Clients 619

LO 33.3 Emotional Communication Deficits 621




xviii Contents


Let’s Review! 623


Chapter 34Care for the Client With Cancer 625

Introduction 626

LO 34.1 What Is Cancer? 626

LO 34.2 What Causes Cancer? 627

LO 34.3 How Is Cancer Diagnosed? 629Staging Cancer 630

LO 34.4 Treatment Options 630

LO 34.5 Common Side Effects of Cancer and Treatment 632

LO 34.6 Palliative Care 634




Let’s Review! 636


Reference 637

Chapter 35Care for the Client With a Positive HIV Status 639

LO 35.1 HIV Versus AIDS 640

LO 35.2 HIV Transmission 640

LO 35.3 Effects of HIV and AIDS 641

LO 35.4 Testing for HIV 642

LO 35.5 Preventing an HIV Infection 643

LO 35.6 Rights of Individuals With HIV/AIDS 645




Let’s Review! 647


References 647

Chapter 36Care for the Client With Dementia 649

LO 36.1 Types of Dementia 650

LO 36.2 Risk Factors for Dementia 650

LO 36.3 Treatment of Dementia 651

LO 36.4 Diagnosing Dementia 651Stages of Dementia 652Common Signs, Symptoms, and Behaviors Associated With Dementia 653

LO 36.5 Managing the Behaviors Associated With Dementia 655

Meeting Unmet Needs of the Client 655Therapeutic Interventions 656Maintaining Function 658Approach to Specific Behaviors 658Improving Meal Time 659Managing Pain 660Sleep Disturbances 661Toileting Interventions 661Bathing Interventions 662Wandering and Elopement Safety Measures 663Discouraging Sexual Inappropriateness 664

LO 36.6 Remember the Families 664

LO 36.7 Caregiver Strain 665




Let’s Review! 668


References 669


Contents xix

Chapter 37End-of-Life Care 671

Introduction 672

LO 37.1 Body System Changes 672Respiratory Changes 672Cardiovascular Changes 673Nervous System and Sensory Organ Changes 673Digestive Changes 674Urinary Changes 675

LO 37.2 Special Care for the Dying Client 675

LO 37.3 Faith and Religion 676

LO 37.4 Care for the Family 677

LO 37.5 Post-Mortem Care 678




Let’s Review! 680


Skill 681

Chapter 38Common Medications 685

LO 38.1 Scope of Practice 686

LO 38.2 Drug Names 687

LO 38.3 Actions of Medications 687Allergic Drug Reactions 687Drug Interactions 688

LO 38.4 Medication Classifications 689Analgesics 689Antibiotics 690Bronchodilators 691Antihypertensives 691Anti-Anginals 692

Cardiotonics 692Anticoagulants 693Diuretics 693Antidiabetics 694Medications to Relieve Constipation 694




Let’s Review! 697


Appendix A: Common Medical Abbreviations and Directional Terminology 699

Common Medical Abbreviations 699

Directional Terms 701

Appendix B: ISMP List of Error-Prone Abbreviations 702

Appendix C: Glossary 704

Index 711


xx

Brief Contents

Adult learners have very specific traits and characteristics 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 classroom or school grounds to brainstorm new and creative problem-solving thought processes in relation to the content. The kinesthetic learner will benefit from partnered 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 content, and case studies to apply information learned to real-world scenarios to make the information applicable to that unique student. I incorporate prioritization exercises 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 elderly population, but also populations that are gender specific, age based, and setting specific to address the changing face of our healthcare delivery. Consumers of healthcare 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.

A Note to Nursing Assistant Instructors


xxi

You will be responsible for many things when working as a nursing assistant. One important aspect of caregiving 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 situation 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 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, that 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 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.

A Note to the Reader


xxii

Writing a textbook is a long and arduous yet rewarding 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 project, they not only supported me but also cheered me on all the way. 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 persistence. 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. Many thanks to the Posey Company, the makers of Bathing Without a Battle, 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 Cynthia Hintze, who was such an invaluable contributor. Finally I would like to thank those at Mid-State Technical College for their continued support in this venture, including administration and all the nursing assistant faculty who have given me inspiration, support, encouragement, ideas, and feedback throughout this endeavor; and Lisa Whitley and Candace Barth, who stepped outside of their comfort zone to author the accompanying workbook.

Acknowledgements


xxiii

About the Author

Carrie L. Engelbright RN, MSN, CNE is a registered nurse and Nursing Assistant Program Director at Mid-State Technical Col-lege in Wisconsin Rapids, Wisconsin. After receiving her associate’s degree in nursing from Mid-State Technical College, she received her bachelor’s degree in nursing from the University of Wisconsin Oshkosh. She cur-rently holds a master’s degree in nursing with an emphasis in education, graduating summa cum laude, from Bellin College of Nursing in Green Bay, Wisconsin. In the spring of 2007, she was inducted into the nursing honor society Sigma Theta Tau and in the spring of 2008 was inducted into the national scholars’ honors society Magna Cum Laude. In March of 2011 she became credentialed by the American Nurses Association as a Certified Nurse Educator. She is currently completing a doctorate in nurs-ing practice with an emphasis in system leadership focusing on rural food desert conditions.

Carrie started her career as a nursing assistant in long-term care. Enjoying healthcare, she continued on to work as a certified medication technician. After completing her nursing degree, she continued work-ing in long-term care as a staff nurse. Upon completion of her bachelor’s

degree in nursing, she worked for the Wood County Public Health Department in Wisconsin as a maternal child health nurse with emphases in children with special healthcare needs, childhood lead poisoning prevention, and prenatal health. Carrie has been employed at Mid-State Technical College in Wisconsin Rapids, Wisconsin, since 2007 as the nursing assistant program director, faculty in the gerontology program, and lead faculty in the health and wellness promotion program.


Chapter 1

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eng26054_01_c01_002-013.indd 2 11/18/14 1:03 PM

Learning Outcomes:

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.

Jennifer, a 32-year-old woman, presents to the after-hours urgent-care clinic com-plaining of severe shortness of breath. She has a history of asthma. The shortness of breath has been a problem for about a week now but has progressively gotten

worse. She tells you she didn’t come in right away because she really can’t afford the deductible on her insurance plan. She didn’t go to her normal doctor or clinic during the week because she can’t afford to miss any work. That time would be unpaid. Because of this she tried treating her problems at home with an herbal rem-edy she read about on the Internet. The doctor orders a breathing treatment while Jennifer is at the clinic and gives her two new prescriptions to fill at the pharmacy. Her insurance doesn’t cover much for prescription medications. When leaving, she says to you, “You may as well throw these prescriptions away; I can’t afford to fill them. I’ll probably see you in a few days again for another breathing treatment.” What do you do?

The History of Healthcare in the United States

eng26054_01_c01_002-013.indd 3 11/18/14 1:03 PM

4 Chapter 1 The History of Healthcare in the United States

LO 1.1 A Brief History of Healthcare in the United StatesWhat did Florence Nightingale feel was important in caregiving? How does that relate to nursing assistant work today?

Florence Nightingale is known as the founder of modern nursing (Figure 1–1). After working in a field hospital during the Crimean War, which took place in the 1850s, Nightingale used statistics to show the connection between sanitary conditions and the spread of infectious disease. In doing so, she helped establish the scientific basis of nursing. She portrayed the art of nursing through her compassionate care of the sick, injured, and poor, without regard to background, class, or wealth. 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 full-est recovery possible. When giving care, she considered not only the person, but also the person’s environment. She felt that a stable and healthy environment was an essential part of care 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 Nightingale regarded as necessary for basic nursing practice, and for which today’s nursing assistants are responsible, include bedmaking; cleanliness of the patient; activities for physical, intellectual, and mental well-being; proper food and water intake; documentation; and cleanli-ness of the patient’s room. By taking care of these needs, in addition to addressing the illness itself, we can help the client make the fullest recovery possible. We can also make sure the quality of life for our client is the best it can be. Nursing assis-tants play a very large role in caring for the client!

Florence Nightingale’s nursing, infection control, and compassionate care-giving principles lay the foundation for many nursing assistant tasks today, including bedmaking; cleanliness of the patient; activities for physical, intel-lectual, and mental well-being; proper food and water intake; documenta-tion; and cleanliness of the patient’s room.

FigUre 1–1. Florence Nightingale, the founder of modern nursing. photos.com

How would Florence Nightingale help Jennifer?

What was healthcare delivery in the United States like before the formation of regulated medical colleges?

In the early years of the United States, there were no real medical schools as we think of them today. There was no standard training, and there were no licensing boards or regulating bodies overseeing medical schools or doctors. There were no tests to pass. Although some medical schools were established, would-be physicians didn’t need to attend school of any kind—not even high school! Doc-tors, as they called themselves, were often the local tailor, clergyman, barman, or barber (Figure 1–2). Early healthcare practices mostly involved the use of herbal and home remedies. Practices were quite basic at this time.

Payment for a doctor’s services was completely paid for by the individual or his family. If there was no community doctor, or if the patient could not pay for the services in some way, the sick were simply cared for by family members within the home.

FigUre 1–2. in the early years of the United States no formal training was required to be a physician. Many were barbers, clergymen, or tailors. photos.com

Reflect on Jennifer!

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LO 1.2 The Beginning of Modern Healthcare 5

There were no hospitals during this time either—only almshouses. Almshouses were places for the poor, the elderly, the homeless, and the insane to stay. Most often these establishments were operated by donations from the community or religious orders. As you might expect, illness would easily spread through these almshouses. If there was a medical school in the area, often the students worked at the almshouses as part of their training. The training mainly consisted of an apprenticeship with a doctor, who usually had no formal train-ing himself.

Doctors had very little training. Many were community barbers, clergymen, or tailors. There were very few medical schools or hospitals. Most people were cared for at home by family members or in almshouses.

Almshouses Places for the poor, the elderly, the homeless, and the insane to stay; early form of a hospital

Imagine how care would be different in an almshouse compared to the patient’s home. Who would be caring for the patient? What if an emergency happened? Would a patient be safer in his home or in an almshouse? Would there be access to more care and supplies in an almshouse or in the patient’s home?

LO 1.2 The Beginning of Modern HealthcareWhat changes occurred in the U.S. healthcare system that led to the preva-lence of chronic illness versus infectious illness?

The concept of public health began to take hold in the mid-1800s (Figure 1–3). The goal of public health is to educate groups of people (not simply an individ-ual) about healthy ways to live and how to prevent illness before it starts. Before the start of public health, it was common for raw sewage to flow in city streets. That raw sewage would then flow on to streams and rivers and pollute drink-ing water. An example of public health is to teach communities the importance of a working sewage system and a clean water supply to prevent illness.

What is infectious illness, and what are some examples of infectious illness?

Public health interventions helped to reduce the prevalence of infectious illness, which was the type of disease that most often affected Americans. An infectious illness occurs when a germ enters the body and causes sickness. Before public health plans were put into place, people were more likely to suffer and die from infectious ill-nesses, like smallpox or cholera.

Infectious illness occurs when a germ enters the body and causes sickness. Examples of

Infectious illness Occurs when a germ enters the body and causes sickness

FigUre 1–3. Public health efforts began in the mid-1800s. stocksnapper

Reflect on Settings!

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infectious illness include smallpox, cholera, strep throat, the common cold, tuberculosis (TB), and HIV.

What is chronic illness, and what are some examples of chronic illness?

As the number of individuals 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, asthma, and arthritis. The trend shifted in the United States from people dying primarily of infectious illness to people dying primarily of chronic illness (Table 1–1).

TABLe 1–1. examples of infectious and Chronic illnesses

Examples of Infectious Illness Examples of Chronic Illness

Smallpox Heart disease

Cholera Asthma

Strep throat Arthritis

The common cold Diabetes

Tuberculosis (TB) Osteoporosis

HIV Epilepsy

Chronic illness is a condition or disease that people live with for a long period of time. Examples of chronic illness can include heart disease, asthma, arthri-tis, diabetes, osteoporosis, and epilepsy.

Public health interventions helped reduce the occurrence of infectious illness. As the number of individuals dying from infectious illnesses at an early age decreased, people began to live long enough to develop chronic illnesses.

Chronic illness A condition or disease that people live with for a long period of time

Have you thought about exposure to other germs at the clinic that might make Jennifer even sicker? Explain what the risks are to her. What could you do to limit those risks?

The Modernization of MedicineIn the early 1900s, scientists were identifying causes of illness, how to keep people from becoming ill, and how to better treat them if they did fall ill. A scientific basis for the practice of medicine became established. Medical schools, as we now know them, began to emerge. Medical training was much more demanding, took longer amounts of time to complete, and involved scientific instruction rather than just an apprenticeship.

In the late 1900s medicine became very organized. Doctors now have exten-sive training. They are also licensed and regulated strictly. There is a rise in spe-cialty healthcare providers. Doctors are furthering their training in areas such


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LO 1.3 The Cost of Healthcare 7

as specialty surgery and cancer care. Because of the specialty training, jobs in physical therapy and occupational therapy expanded, and specialty nursing degrees evolved.

What would healthcare look like today if we did not have formal schooling and education for healthcare professionals? What would happen if you were a nursing assistant without any formal training? Do you think being certified as a nursing assistant will encourage your clients to trust you more? How does being certified raise the standard of care for your clients? Should nursing assistants have to con-tinue their education once training has been complete? If so, how much continu-ing education do you think would be appropriate?

LO 1.3 The Cost of HealthcareWhat made healthcare become so costly in the United States?

With the increased sophistication of healthcare, the fees for accessing healthcare services greatly 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, people with cancer, pediatrics, and many more areas (Figure 1–4).

FigUre 1–4. Many hospitals now specialize in a certain type of care based on the population served, or the disease or injury the patient has. VILevi

Reflect on Professionalism!

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Medicare Health insurance plan for the elderly and, in certain situa-tions, the disabled, funded through federal taxes

Medicaid Health insurance plan for low-income people and the disabled, funded through federal and state taxes

What sources of funding help pay for healthcare?

Healthcare is now a large part of our economy. It is very costly to access. People cannot pay for treatment outright; they need help to pay the mounting costs. Health insurance became a standard in American life following the Second World War. The model for healthcare insurance was based on the workers’ com-pensation plans offered by large manufacturing companies. Originally, 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 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, however. 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 insur-ance to the elderly and to some younger people with certain disabilities. Medicare is funded through federal taxes. The Medicaid plan gives access to health insur-ance 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 providing and paying for healthcare worked well. During this time, however, there were several factors that started to increase the costs of healthcare. These included the growing use of technology and pur-chasing those technologies for practice; paying for specialty services; a growing older population with more chronic illnesses; and research dollars needed to cre-ate new technologies, treatments, and drugs.

Healthcare has become so costly due to the growing use of technology and purchasing those technologies for practice; paying for specialty services; a growing older population with more chronic illnesses; and research dollars needed to create new technologies, treatments, and drugs.

How did managed care organizations (MCOs) keep healthcare costs down?

Because of these rising costs, managed care organizations (MCOs) became the insurance provider of choice to better control healthcare costs. MCOs changed the way doctors and other healthcare workers were paid for their ser-vices. These large organizations placed limits on how much money healthcare agencies and providers could charge for each service and dictated the amount and type of services healthcare consumers enrolled in these plans could access. There were also financial incentives 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 at today in our healthcare system. This is why we see a great increase in the number of outpatient versus inpatient surgeries. It is also why hospital stays are much shorter than they were in the past. And it is why consum-ers of healthcare in America have limited 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.

MCOs placed limits on how much money healthcare agencies and providers could charge for each service and dictated the amount and type of services healthcare consumers enrolled in these plans could access. There were also financial incentives for providers to treat and discharge patients from hospi-tals quickly.

Managed care organizations (MCOs) Insurance programs that worked to reduce the rising health-care costs in the United States in the late 1980s

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LO 1.4 Healthcare Today 9

Healthcare premium The cost that the individual must pay every month toward her healthcare plan; when the individual is employed, this amount is usually taken out of the employee’s paycheck

Co-pay A specific dollar amount or percentage that must be paid by the individual for each healthcare service received

Deductible A certain amount of money that the individual must pay for healthcare services before the insurance company will start to pay for any services used; this is renewed at the start of every year

LO 1.4 Healthcare TodayToday, the rate of healthcare costs is growing faster than that of inflation. It is becoming very expensive for employers to offer insurance as an employee ben-efit. Healthcare plan premiums may cost too much for a family or an individ-ual to afford. A healthcare premium 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 paycheck. In addition to the insurance premium that is paid every month, individuals have other insurance- related expenses.

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

What is preventing Jennifer from seeking medical care? Is she noncompliant, mean-ing that she just doesn’t follow the doctor’s orders? Or is there another reason?

FigUre 1–5. insurance helps the consumer of health care afford medical services. An individual often purchases insurance through an employer and pays a premium every month for coverage. alexskopje


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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 Medicaid. 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 insurance. Therefore, everyone pays more healthcare costs. If a person does not have insurance and needs an emergency sur-gery, most often all or part of the cost of that surgery and the associated care goes unpaid. That means the price of future surgeries goes up for everyone. This is how the hospital can recoup unpaid costs.

The Affordable Care Act was passed by Congress and signed into law in 2010. The Supreme Court upheld this law in 2012. The Affordable Care Act aims to increase access to insurance. Instead of needing a job to get health insurance, individuals can now access a marketplace to purchase individual health insurance policies. Some of these policies are subsidized by the federal government, meaning the government helps pay the premium. This makes insurance much more afford-able. Some of the major tenets of the Affordable Care Act are:

• Insurance companies can no longer refuse coverage due to preexisting conditions.

• Children can be carried under a parent’s insurance plan until the age of 26.• Preventive care and immunizations are covered at 100%.• Lifetime limits on coverage are eliminated.• Premiums must be spent primarily on healthcare costs rather than

administrative costs (80 cents out of every healthcare dollar must be spent on healthcare costs).

• Barriers to emergency services are removed.• Hospital readmission rates are targeted for reduction.

Since the implementation of the Affordable Care Act, healthcare costs have slowed. The rate of healthcare inflation has also slowed. New research indicates an improved quality of care since its implementation. The Affordable Care Act will continue to impact the future of health care in the United States.

Do you think it is good for Jennifer to have to keep treating an acute problem in urgent care? Is this cost effective?

Imagine you had a $1,000 deductible to meet. Would you miss work and go to the doctor if you knew you would not only lose your wages for the day but would also end up with a $300 bill? Or would you just go to work sick and potentially infect your coworkers and clients with the illness?

Reflect on Choices!


Healthcare services are funded by private insurance purchased by an individ-ual or by an employer for the employees; by out-of-pocket spending; and by government plans, such as veteran programs, Medicare, and Medicaid.

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Summary 11

Summary of Learning Outcomes

1.1. Describe the history of healthcare in the United States.

Florence Nightingale’s nursing, infection control, and compassionate caregiving principles lay the foundation for many nursing assistant tasks today, including bedmaking; cleanliness of the patient; activities for physical, intellec-tual, and mental well-being; proper food and water intake; documentation; and cleanliness of the patient’s room.

1.2. Paraphrase the beginnings of modern healthcare.

Doctors had very little training. Many were commu-nity barbers, clergymen, or tailors. There were very few medical schools or hospitals. Most people were cared for at home by family members or in almshouses before the establishment of regulated medical colleges. Public health interventions helped diminish the prevalence of infectious illness. As the number of individuals dying from infectious illness at an early age decreased, people began to live long enough to develop chronic illnesses.

1.3. Describe the causes of the rising cost of healthcare.

The growing use of technology and purchasing those technologies for practice; paying for specialty services; a growing older population with more chronic illnesses; and research dollars needed to create new technologies, treat-ments, and drugs all helped to create a costly healthcare system.

1.4. Identify funding sources for healthcare services today.

Private insurance purchased by an individual or by an employer for employees; out-of-pocket spending; and government plans, such as veteran programs, Medicare, and Medicaid all fund healthcare services.

get Up and Think!Find a partner, and both of you get up and think. Take along a piece of paper and pencil. Jot down your brainstorming thoughts to these questions as you walk. Bring back your thoughts to the class.

Beth has come to the community clinic with her two children. The chil-dren both have fevers and respiratory illness. She tells you that they have been sick for about 2 days now. She will have insurance soon; she is sit-ting out the 30-day waiting period from her new employer for it to be activated. Until then she will pay for everything out of pocket. She seems stressed out and upset. She tells you she has a new job and she just moved into a new house, and now the kids are sick. She starts to cry and states, “It’s just a little too much to handle right now; sorry I don’t usually dump my problems on strangers.”

• What is Beth feeling right now?• Explain the financial and emotional worries she has right now.• What can you do to help Beth? What specifically would you say to her?• How would you feel in this situation?• How would you handle this situation?

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reflect on This!Your mother has had a heart attack today. She just came out of bypass surgery and is doing fairly well. The doctor comes in to speak with her and says that she will be able to be discharged to go home tomorrow. You are enraged at the poor care this hospital gives and how quickly they want to shove your mother out the door! It must be because she has bad insurance! How are you going to treat the hospital staff that comes into her room after the doctor leaves? Are additional hospital days needed for her? What other services would be available for her? What should you have asked when the doctor was talking about discharge? How would you have asked these questions? Is your anger justified, and, if so, how? Who could you go to in order to get more information after the doctor leaves?

Let’s review!Prioritize these action items. 1. I seek medical services. 2. I pay my co-pay for medical services. 3. I become employed and sign up for the group health insurance plan. 4. I pay my premium.

Multiple Choice Questions 1. A healthcare premium is (LO 1.4):

a. a set amount of money that the individual must pay for healthcare services before the insurance company will start to pay for any services used.

b. a specific dollar amount or percentage that must be paid by the individ-ual for each healthcare service received.

c. the cost that the individual must pay every month toward her health-care plan.

d. the cost that the employer must pay every month toward a service used.

2. Florence Nightingale founded the basics of nursing care by focusing on (LO 1.1):a. the connection between sanitary conditions and the spread of infectious

disease.b. compassionate care of the sick, injured, and poor, without questioning

background, class, or monetary status.c. both A and B.d. neither A nor B.

3. This federally funded medical plan gives health insurance access to the elderly and some younger people with certain disabilities (LO 1.4):a. Medicaid.b. Medicare.c. private health insurance.d. MCOs.

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Summary 13

4. A stomach illness from drinking contaminated water, causing diarrhea for 2 days, would be an example of a(n) (LO 1.2):a. chronic illness.b. infectious illness.c. both A and B.d. neither A nor B.

5. Janice went to the doctor. The visit cost a total of $120. She had to pay $15 out of pocket for that visit. This payment is called a (LO 1.4):a. deductible.b. premium.c. insurance.d. co-pay.

referencesU.S. Department of Health and Human Services (US DHHS). (2014, July 24).

About the law. Retrieved from http://www.hhs.gov/healthcare/rights/index .html

Office of the White House. (2013, November). Trends in health care cost, growth and the role of the Affordable Care Act. November 2013. Retrieved from http://www.whitehouse.gov/sites/default/files/docs/healthcostreport _final_noembargo_v2.pdf

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