cna - august learning solutions · 16 holistic care of clients 229 17 client room environment 242...

Nursing Assistant Certification

CNA

Dr. Carrie L. Engelbright RN, CNE, CWP

eng26306_00_fm_i-xxxvi.indd 1 8/10/17 4:07 PM

CNA: Nursing Assistant CertificationDr. 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: 978-1-941626-30-6ISBN-10: 1-941626-30-0Printed 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: Row 1 (left to right): August Learning Solutions, August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock;

Row 2 (left to right): August Learning Solutions, ElenaMedvedeva/iStock/Thinkstock; Row 3 (left to right): August Learning Solutions,

ElenaMedvedeva/iStock/Thinkstock, ElenaMedvedeva/iStock/Thinkstock; Row 4 (left to right): August Learning Solutions, August Learning

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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 Contents 1 The History of Healthcare in the United States 1

2 Responding to Emerging Trends in Healthcare 10

3 Healthcare Settings and Governance 19

4 The Nursing Assistant Role and Scope of Practice 31

5 Communication 41

6 Professionalism in Healthcare 56

7 Legal and Ethical Issues 69

8 Body Structures and Functioning Processes 82

9 Common Diseases and Disorders 107

10 Infection Control Practices 137

11 Body Mechanics and Workplace Safety 163

12 Reducing Client Injury and Falls 178

13 Restraints and Restraint Alternatives 190

14 Basic First Aid Measures 200

15 Stress Reduction and Management Techniques 216

16 Holistic Care of Clients 229

17 Client Room Environment 242

18 Preventing Skin Breakdown 253

19 Bedmaking 267

20 Positioning Clients 282

21 Moving, Transferring, and Transporting Clients 295

22 Ambulation and Exercises for Clients 322

23 Rehabilitation and Restorative Care 338

24 Adaptive Equipment and Supportive Devices 347

25 Vital Signs 356

26 Bathing 380

27 Grooming 411

28 Nutrition 438

29 Elimination 459

30 Specimen Collection 485

31 Oxygen Therapy and Respiratory Interventions 497

32 Care for the Medical and Surgical Client 510

33 Care for the Client With Communication Disorders 521

34 Care for the Client With Cancer 527

35 Care for the Client With a Positive HIV Status 538

36 Care for the Client With Dementia 546

37 End-of-Life Care 563

38 Common Medications 574

Common Medical Abbreviations and Directional Terminology 585

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 587

Glossary 591

Index 597


ContentsA Note to Nursing Assistant Instructors xxiii

A Note to the Students xxv

Visual Walkthrough xxvi

Acknowledgements xxxiii

About the Author xxxv

Chapter 1The History of Healthcare in the United States 1

1.1 A Brief History of Healthcare in the United States 2

1.2 The Beginning of Modern Healthcare 3

The Modernization of Medicine 4

1.3 The Cost of Healthcare 5

1.4 Healthcare Today 6

Summary of Learning Objectives 7

Get Up and Think! 8

Reflect on This! 8

Let’s Review! 8

Multiple Choice Questions 8

References 9

Chapter 2Responding to Emerging Trends in Healthcare 10

2.1 Who Is Your Client? 11

2.2 Consumerism in America 11

2.3 Home Healthcare Versus Facility Care 12

2.4 Alternative Therapies 13

2.5 Why the Nursing Assistant Needs to Know These Trends 14


Get Up and Think! 16

Reflect on This! 17

Let’s Review! 17


References 18

Chapter 3Healthcare Settings and Governance 19

3.1–3.4 Work Settings for the Nursing Assistant 20

Acute Care Settings 20Subacute or Rehabilitation Facility 22Long-Term Care 22Assisted-Living Communities 23Home Healthcare 25Hospice Services 26Respite Services 26

3.5 Advanced Training and Opportunities 27



Reflect on This! 29

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Contents vii

Let’s Review! 29


Chapter 4The Nursing Assistant Role and Scope of Practice 31

4.1 Members of the Healthcare Team 32

4.2 Scope of Practice for the Nursing Assistant 33

4.3 Chain of Command 34

4.4 Delegated Tasks 35

4.5 Teaching Versus Reinforcing 37

4.6 Time Management and Organization 37



Reflect on This! 39

Let’s Review! 39


Reference 40

Chapter 5Communication 41

Communication in Healthcare 42

5.1 Causes of Medical Errors 42

5.2 Subjective Versus Objective Data 43

5.3 Oral Reporting 45

5.4 Written Documentation and the Nursing Assistant 46

5.5 Verbal Versus Nonverbal Communication 49

Verbal Communication 49Nonverbal Communication 50

5.6 Therapeutic Communication 51

5.7 Confrontational Situations 52



Reflect on This! 54

Let’s Review! 54


Reference 55

Chapter 6Professionalism in Healthcare 56

6.1 Education and Certification 57Nurse Aide Registry 57Continuing Education 57

6.2 Job Searching 58Applications 58Resume 60

6.3 Interviewing 62

6.4 Accepting and Resigning From a Position 63

6.5 Acting Like a Professional 64Dependability 64Promptness 64Customer Service 64Flexibility 64Hygiene 65



Reflect on This! 67

Let’s Review! 67


Chapter 7Legal and Ethical Issues 69

7.1 Client Rights 70Health Insurance Portability and Accountability Act (HIPAA) 70Informed Consent 71

7.2 Client Responsibilities 72

7.3 Employee Rights 72

7.4 Employee Responsibilities 73Following the Care Plan 73Mandatory Reporting 74


Contentsviii

7.5 Laws 75Invasion of Privacy 75Misappropriation of Funds 76Negligence 76Abandonment 76False Imprisonment 76Neglect 77Assault and Battery 77Abuse 78

7.6 Cultural Awareness 78



Reflect on This! 80

Let’s Review! 80


Chapter 8Body Structures and Functioning Processes 82

8.1 Basic Structures 83

8.2 Tissue Types 83

8.3 Body Systems 83Integumentary System 83Musculoskeletal System 85Respiratory System 87Cardiovascular System 89Nervous System 91Sensory Organs 92Endocrine System 95Digestive System 98Urinary System 100Reproductive System 101



Reflect on This! 105

Let’s Review! 105


Chapter 9Common Diseases and Disorders 107

9.1 Understanding Disease Processes 108

9.2 Risk Factors 108

9.3 Emergency Medical Services 108

9.4 Common Diseases and Disorders 109Integumentary System 109Musculoskeletal System 111Respiratory System 113Cardiovascular System 115Nervous System 118Sensory Organs 122Endocrine System 123Digestive System 127Urinary System 130Reproductive System 133




Let’s Review! 135


References 136

Chapter 10Infection Control Practices 137

Introduction 138

10.1 The Importance of Hand Washing 138

Germ Theory 138Global Society and Spread of Disease 139

10.2 Chain of Infection 139

10.3 Primary Prevention 140

10.4 Body Defense Mechanisms 141

10.5 Hand Hygiene 143

10.6 Standard Precautions 146Personal Protective Equipment (PPE) 147

10.7 Specialty Precautions 149Airborne Precautions 149Droplet Precautions 149Contact Precautions 150Transporting a Client to and From an Isolation Room 150Blood Spill Kits 151Double-Bagging Technique 151


Contents ix

10.8 Drug-Resistant Infections 151MRSA Infection 151VRE 152




Let’s Review! 154


Skills 155

References 161

Chapter 11Body Mechanics and Workplace Safety 163

Introduction 164

11.1 Exposure to Blood-Borne Pathogens and Chemicals 164

11.2 Latex Allergies 166

11.3 Injury Prevention 167Ergonomics 167Moving Clients 168Lifestyle Choices to Prevent Back Injuries 169Slips, Trips, and Falls 170

11.4 Fire Safety 170

11.5 Natural Disasters 172

11.6 Bomb Threats 173

11.7 Workplace Violence 173




Let’s Review! 176


Chapter 12Reducing Client Injury and Falls 178

Introduction 179

12.1 Why Falls and Immobility Are Dangerous 179

12.2 Risk Factors for Falling 180

12.3 Care During a Fall 181

12.4 Care After a Fall 181

12.5 How to Prevent Fall Injuries 183

12.6 Alarm Systems 184

12.7 Other Strategies 185




Let’s Review! 187


Skills 188

Chapter 13Restraints and Restraint Alternatives 190

13.1 Restraints 191

13.2 Working With Restraints 191

13.3 Types of Restraints 192

13.4 Risks of Using Restraints 193

13.5 Instances When Restraints Are Allowed 194

13.6 Side Rails 195

13.7 Restraint Alternatives 195




Let’s Review! 198


Reference 199

Skill 199

Chapter 14Basic First Aid Measures 200

Introduction 201

14.1 Airway Obstruction 201

14.2 Cardiac Arrest 202


Contentsx

14.3 Syncope 203

14.4 Seizures 204

14.5 Hemorrhage 205

14.6 Shock 206

14.7 Burns 207

14.8 Poisoning 208




Let’s Review! 210


Skills 211

Chapter 15Stress Reduction and Management Techniques 216

15.1 Why Is Healthcare So Stressful? 217

15.2 Ways to Prevent Stress From Taking Charge 218

15.3 Time-Management Techniques to Reduce Stress While at Work 219

15.4 Preventing Stress and Promoting Job Satisfaction 219

Good General Health 220Yoga 220Meditation 220Pet Therapy 221Humor 222Journaling 222Visualization Techniques 222Breathing Exercises 223

15.5 Client Stressors 223Pain 223Illness 224Sleep Deprivation 224Anxiety and Depression 224Grief 225Coach Your Clients 225




Let’s Review! 226


Skills 227

Chapter 16Holistic Care of Clients 229

16.1 Holistic Care 230

16.2 Maslow’s Hierarchy of Needs 230Human Needs 230Application of Maslow’s Hierarchy to Caregiving 231

16.3 Growth and Development 233

16.4 Quality of Life 234

16.5 Meeting the Needs of Loved Ones 239




Let’s Review! 241


Chapter 17Client Room Environment 242

Introduction 243

17.1 Safety 243

17.2 The Physical Environment 244

17.3 Individual Room Requirements 245

17.4 Noise and Odor Control 246Noise Control 246Odor Control and Cleanliness 247

17.5 Transfers and Discharges 248

17.6 Current Trends 249




Contents xi


Let’s Review! 251


Reference 252

Chapter 18Preventing Skin Breakdown 253

18.1 The Importance of Healthy Skin 254

18.2 Types of Skin Breakdown 254Rashes 254Friction and Shearing 255Pressure Injuries 255

18.3 Stages of Pressure Injuries 256

18.4 Risk Factors for Developing Pressure Injuries 258

18.5 Interventions for Preventing Skin Breakdown 260

Inspection and Cleanliness 260Positioning and Turning 260Pressure-Relieving Devices 261Positioning Devices 262Incontinence Care 262Nutrition and Hydration 263Reducing the Microclimate 264




Let’s Review! 265


Reference 266

Chapter 19Bedmaking 267

Introduction 268

19.1 Linens 268

19.2 Infection Control 270

19.3 Body Mechanics 271

19.4 The Closed Versus Open Bed 272

19.5 Making the Unoccupied and Occupied Bed 273

Unoccupied Bed 273Occupied Bed 273




Let’s Review! 276


Skills 277

Chapter 20Positioning Clients 282

Introduction 283

20.1 Frequency of Repositioning Clients 283

20.2 Basic Positions for Clients in Bed 283

20.3 Position to Relieve Pressure Injuries 284

Supine 284Fowler’s Position 285Prone Position 286Side-Lying Position 287Sims’s Position 287Tripod Position 288

20.4 Wheelchair Positioning 288




Let’s Review! 290


Skills 291

References 294

Chapter 21Moving, Transferring, and Transporting Clients 295

Introduction 296

21.1 Moving a Client in Bed 296


Contentsxii

21.2 Preventing Friction and Shearing Injuries 297

21.3 Log Rolling a Client 298

21.4 Moving a Client From Bed to Stretcher 298

21.5 Transferring the Client Using a One- and a Two-Assist Transfer 299

Dangling 299Footwear 299Gait Belt 299One- and Two-Assist Transfers 300Mechanical Devices Used for Transfers 302

21.6 Transferring a Bariatric Client 304

21.7 Transporting a Client in a Wheelchair 305




Let’s Review! 308


Skills 309

References 321

Chapter 22Ambulation and Exercises for Clients 322

Introduction 323

22.1 Why We Move 323Self-Esteem 323Effects on the Digestive System 323Effects on the Cardiovascular System 323Effects on the Integumentary System 324Effects on the Musculoskeletal System 324

22.2 Levels of Assistance 324

22.3 Safety Measures Used During Ambulation 325

22.4 Assistive Devices for Ambulation 327

22.5 Range-of-Motion Exercises 328

22.6 Soothing Sore Muscles 329




Let’s Review! 332


Skills 333

Chapter 23Rehabilitation and Restorative Care 338

23.1 Therapy Services Overview 339

23.2 Rehabilitation Therapy 339Physical Therapy 339Occupational Therapy 340Speech Therapy 341

23.3 Activities Therapy 342

23.4 Restorative Care 343




Let’s Review! 346


Chapter 24Adaptive Equipment and Supportive Devices 347

Introduction 348

24.1 The Client With a Prosthesis 348Prosthesis Overview 348Types of Prostheses 349Care Measures 350

24.2 The Client With an Orthosis 350Orthosis Overview 350Care Measures 351

24.3 Adaptive Tools Used at Meal Times 351

24.4 Adaptive Tools for Grooming and Other ADLs 352


Contents xiii




Let’s Review! 355


Chapter 25Vital Signs 356

25.1 Introduction 357

25.2 When Vital Signs Are Taken 357

25.3 Infection Control 358

25.4 Accurately Measuring Vital Signs 358Temperature 358Pulse 360Respiration 361Pulse Oximetry 362Blood Pressure 363Height 365Weight 365




Let’s Review! 368


Skills 369

References 379

Chapter 26Bathing 380

Introduction 381

26.1 Routine Bathing 381

26.2 Distressed Bathing 382Alternatives to Tub Bathing and Showering 383Easing Distressed Bathing 383

26.3 Rinseless Systems 383

26.4 Peri-Care 384

26.5 Bed Baths 388Partial Bed Bath 388Complete Bed Bath 389

26.6 Shower and Tub Baths 390Shower 390Whirlpool Tub Bath 392Hair Care 392

26.7 Responsibilities on Bath Day 393




Let’s Review! 395


Skills 396

Reference 410

Chapter 27Grooming 411

27.1 Promoting Independence 412

27.2 Dressing 412Dressing a Client With One-Sided Weakness 413

27.3 Hair 413

27.4 Vision and Hearing 414Glasses and Contacts 414Hearing Aids 415

27.5 Shaving 416

27.6 Oral Care 417

27.7 Nail and Foot Care 420Nail Care 420Foot Care 421




Let’s Review! 424


Skills 425


Contentsxiv

Chapter 28Nutrition 438

Introduction 439

28.1 MyPlate 439

28.2 Nutrients Essential for Life 439Calories 439Carbohydrates 440Proteins 441Fats 441Vitamins and Minerals 441

28.3 Water and Fluid Needs 443

28.4 Food Groups 444Grains 444Fruits 444Vegetables 445Dairy Products 445Protein 446

28.5 Types of Diets 446Specialty Diets 446Mechanically Altered Diets and Fluids 449Thickened Fluids 449Diets for the Postsurgical Client 450Mechanical Feeding 451

28.6 Problems With Digestion 451Nausea, Vomiting, and Diarrhea 451Malnutrition and Overeating 452

28.7 Feeding Dependent Clients 453




Let’s Review! 456


Skill 457

References 458

Chapter 29Elimination 459

Introduction 460

29.1 Urinary Elimination via Catheter 460

Types of Catheters 460The Nursing Assistant’s Role in Care of the Client With a Catheter 461Cleaning the Catheter 462Changing the Collection Bag to a Leg Bag 462Positioning the Client With a Collection Bag 463Protecting the Privacy of the Client Who Uses a Catheter 463Emptying the Collection or Leg Bag 463Cleaning Collection and Leg Bags 463

29.2 Urostomy 464

29.3 Incontinence 464Care of the Client Who Is Incontinent 464Types of Incontinence Products 465

29.4 Dialysis 465Hemodialysis 466Peritoneal Dialysis 466Care of the Client Who Is on Dialysis 466

29.5 Bowel Elimination 467

29.6 Ostomies 468

29.7 Digestive Tract Bleeding 469

29.8 Devices Used for Elimination 470




Let’s Review! 473


Skills 474

Chapter 30Specimen Collection 485

Introduction 486

30.1 Basic Principles of Collection and Transport 486

30.2 Urine Specimens 487

30.3 Straining for Kidney Stones 488

30.4 Fecal Specimens 488

30.5 Occult Blood 489



Contents xv



Let’s Review! 491


Skills 492

Chapter 31Oxygen Therapy and Respiratory Interventions 497

31.1 Why Supplemental Oxygen Is Needed 498

31.2 The Nursing Assistant’s Role in Oxygen Therapy 498

31.3 Delivery Routes 499

31.4 Delivery Systems 500

31.5 Interventions to Ease Anxiety Related to Breathing Difficulties 502

31.6 Interventions to Aid Lung Function 502

Coughing and Deep Breathing Exercises 502Incentive Spirometry 502




Let’s Review! 505


Skills 506

Chapter 32Care for the Medical and Surgical Client 510

Introduction 511

32.1 The Medical Client 511

32.2 The Postsurgical Client 511

32.3 Diet for the Postsurgical Client 512

32.4 Activity for the Postsurgical Client 512

32.5 Weight-Bearing Status 513

32.6 Respiratory Complications 514

32.7 Cardiac Complications 514

32.8 Intravenous Therapy 515




Let’s Review! 517


Skills 518

Chapter 33Care for the Client With Communication Disorders 521

Introduction 522

33.1 Hearing-Impaired Clients 522

33.2 Speech-Impaired Clients 523

33.3 Emotional Communication Deficits 524




Let’s Review! 526


Chapter 34Care for the Client With Cancer 527

Introduction 528

34.1 What Is Cancer? 528

34.2 What Causes Cancer? 529

34.3 How Is Cancer Diagnosed? 531Staging Cancer 531

34.4 Treatment Options 531

34.5 Common Side Effects of Cancer and Treatment 532

34.6 Palliative Care 534


Contentsxvi




Let’s Review! 536


References 537

Chapter 35Care for the Client With a Positive HIV Status 538

35.1 HIV Versus AIDS 539

35.2 HIV Transmission 539

35.3 Effects of HIV and AIDS 540

35.4 Testing for HIV 541

35.5 Preventing an HIV Infection 541

35.6 Rights of Individuals With HIV/AIDS 543




Let’s Review! 544


References 545

Chapter 36Care for the Client With Dementia 546

36.1 Types of Dementia 547

36.2 Risk Factors for Dementia 547

36.3 Treatment of Dementia 547

36.4 Diagnosing Dementia 548Stages of Alzheimer’s Dementia 548Common Signs, Symptoms, and Behaviors Associated With Dementia 549

36.5 Managing the Behaviors Associated With Dementia 551

Meeting Unmet Needs of the Client 551Therapeutic Interventions 552

Maintaining Function 553Approach to Specific Behaviors 554Improving Meal Time 554Managing Pain 554Sleep Disturbances 555Toileting Interventions 556Bathing Interventions 556Wandering and Elopement Safety Measures 557Discouraging Sexual Inappropriateness 558

36.6 Remember the Families 558

36.7 Caregiver Strain 559




Let’s Review! 561


References 562

Chapter 37End-of-Life Care 563

Introduction 564

37.1 Body System Changes 564Respiratory Changes 564Cardiovascular Changes 565Nervous System and Sensory Organ Changes 565Digestive Changes 565Urinary Changes 566

37.2 Special Care for the Dying Client 566

37.3 Faith and Religion 567

37.4 Care for the Family 568

37.5 Post-Mortem Care 568




Let’s Review! 571


Skill 572


Contents xvii

Chapter 38Common Medications 574

38.1 Scope of Practice 575

38.2 Drug Names 575

38.3 Actions of Medications 576Allergic Drug Reactions 576Drug Interactions 576

38.4 Medication Classifications 577Analgesics 578Antibiotics 578Bronchodilators 579Antihypertensives 579Anti-Anginals 580Cardiotonics 580Anticoagulants 580

Diuretics 581Antidiabetics 581Medications to Relieve Constipation 581




Let’s Review! 584


Common Medical Abbreviations and Directional Terminology 585

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 587

Glossary 591

Index 597


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


Skills Contentsxx

Skill 21.7 Applying a Gait Belt 313

Skill 21.8 Moving the Client From the Bed to the Wheelchair—One Assist 313

Skill 21.9 Moving the Client From the Bed to the Wheelchair—Two Assist 314

Skill 21.10 Transferring a Client With a Mechanical Sit-to-Stand Machine—One Assist 315

Skill 21.11 Transferring a Client With a Mechanical Lift—Two Assist 316

Skill 21.12 Transferring an Ambulatory Bariatric Client 317

Skill 21.13 Transferring a Non-Weight-Bearing Bariatric Client With a Mechanical Lift 319

Skill 21.14 Transporting the Client via Wheelchair 321

Skill 22.1 Ambulating a Client With One Assist and a Gait Belt 334

Skill 22.2 Ambulating a Client With Two Assist and a Gait Belt 335

Skill 22.3 Applying a Warm Compress 336

Skill 22.4 Applying a Cold Pack 336

Skill 25.1 Taking an Oral Temperature With a Digital Thermometer 370

Skill 25.2 Taking an Axillary Temperature With a Digital Thermometer 370

Skill 25.3 Taking a Rectal Temperature With a Digital Thermometer 371

Skill 25.4 Taking a Tympanic Temperature 372

Skill 25.5 Taking a Temperature With a Professional Model Temporal Artery Scanner 372

Skill 25.6 Counting Heart Rate—Radial Pulse 373

Skill 25.7 Counting Respirations 374

Skill 25.8 Obtaining a Pulse Oximetry Reading 374

Skill 25.9 Taking Blood Pressure With a Stethoscope and a Sphygmomanometer 375

Skill 25.10 Taking Blood Pressure With an Electronic Wrist Cuff 376

Skill 25.11 Taking Blood Pressure With an Electronic Arm Cuff 376

Skill 25.12 Obtaining and Recording Orthostatic Blood Pressures 377

Skill 25.13 Measuring Height 378

Skill 25.14 Measuring Weight on an Upright Scale 378

Skill 25.15 Measuring Weight on a Wheelchair Scale 379

Skill 26.1 Assisting With Female Perineal Care 397

Skill 26.2 Assisting With Male Perineal Care 398

Skill 26.3 Assisting With a Partial Bed Bath 400

Skill 26.4 Assisting With a Complete Bed Bath 401

Skill 26.5 Assisting With a Shower 403

Skill 26.6 Assisting With a Tub Bath 406

Skill 26.7 Shampooing Hair in Bed 409

Skill 27.1 Dressing the Client With an Affected or Weak Side 425

Skill 27.2 Assisting With Contact Lenses 427

Skill 27.3 Shaving a Face With an Electric Razor 428

Skill 27.4 Shaving a Face With a Disposable Razor 429

Skill 27.5 Shaving Legs With a Disposable Razor 430

Skill 27.6 Shaving Legs and Underarms With an Electric Razor 431

Skill 27.7 Providing Oral Care for a Client With Natural Teeth 431

Skill 27.8 Oral Care for an Unconscious Client 433

Skill 27.9 Oral Care for a Client With Dentures 433

Skill 27.10 Fingernail and Hand Care 435

Skill 27.11 Providing Foot Care 436

Skill 28.1 Feeding a Dependent Client 458

Skill 29.1 Applying a Condom Catheter 475

Skill 29.2 Care of an Indwelling Catheter 475


Skills Contents xxi

Skill 29.3 Changing a Collection Bag to a Leg Bag 476

Skill 29.4 Measuring Urine Output From a Collection Bag 477

Skill 29.5 Emptying a Urostomy Bag 478

Skill 29.6 Changing an Incontinence Garment 479

Skill 29.7 Administration of an Over-the-Counter Enema 479

Skill 29.8 Emptying an Ostomy Bag 480

Skill 29.9 Changing an Ostomy Appliance 481

Skill 29.10 Assisting the Client With a Bedpan 483

Skill 29.11 Assisting the Client With a Urinal 484

Skill 30.1 Obtaining a Clean Catch Urine Sample 492

Skill 30.2 Straining Urine for Kidney Stones 493

Skill 30.3 Obtaining a Stool Sample 494

Skill 30.4 Checking for Fecal Occult Blood 495

Skill 31.1 Assisting With the Delivery of Oxygen via Nasal Cannula 506

Skill 31.2 Assisting With the Delivery of Oxygen via Mask 507

Skill 31.3 Use of an Oxygen Concentrator 507

Skill 31.4 Routine Maintenance of an Oxygen Concentrator 508

Skill 31.5 Assisting With Coughing and Deep Breathing 508

Skill 31.6 Assisting With Incentive Spirometry 508

Skill 32.1 Splinting for Coughing and Deep Breathing 518

Skill 32.2 Applying Anti-Embolism Stockings 519

Skill 32.3 Applying Sequential Stockings 519

Skill 32.4 Dressing a Client With an IV 520

Skill 37.1 Post-Mortem Care 572


xxiii

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 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 class-room 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 spe-cific 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.


xxv

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. 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.

xxvi

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



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Learning Objectives

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

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

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

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

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

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

Bea is an older woman in the assisted-living facility where you work. Normally, she is active. Today she was complaining of feel-ing ill. She had a slight fever on the day shift,

and refused her supper on the evening shift. You are working the night shift. You answer

her call light, which usually she never uses. Upon entering her room, you find her crying. She is upset and tells you that she had an accident in her bed. She needs you to help her clean up, but she feels too weak to get to the bathroom. How can you help Bea?

bedmaking

Personas are applied to learning objectives throughout each chapter to assist with critical thinking skills as well as provide examples of clients that CNAs might encounter on the job.

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

essential tools for passing the state certification

exam.


Chapter 19 Bedmaking272 19.5 Making the Unoccupied and Occupied Bed 273

Figure 19.6 The bed should be pulled away from the wall and raised to a good working height for bedmaking. August Learning Solutions

Figure 19.7 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

Closed bed A bed made with all of the linens in place over the mattress, and the top sheet, blanket, and bedspread drawn up to the head of the bed

Open bed A bed made with the top sheet, blanket, and bedspread fanfolded down to the foot of the bed, or to the side of the bed for the surgical client, to allow the client access into bed

To reduce the risk of injury, release the brakes on the bed and move it away from the wall and other furniture. Raise the bed to a good work-ing height. Always bend at the knees, not at the waist. Do not stretch, twist, and lean down or over to make the bed. Keep items close by your body. Lower the side rails while you work.

Reflect on Choices!

Keep yourself free from injury and illness while bedmaking by using correct body mechanics and maintaining proper infection-control practices.

Reflect on Settings!

Private homes and assisted-living facilities are unlikely to have hospital-type beds, which raise and lower. Body mechanics become especially important then. Always bend at the knees. Do not twist and bend at the same time. If making an occupied bed, ask your client to help you as much as possible when rolling to prevent injuring yourself.

19.4 The Closed Versus Open Bed

What is the difference between an open and a closed 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 19.7). 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. This keeps the mattress and inner bed linens clean. Mitered corners at the foot of the bed ensure a wrinkle-free, tidy bed (Skill 19.3). Upon admission of a new cli-ent, or when the client wants to go to bed, the bed is opened.

Reflect on Professionalism!

Part of your job as a nursing assistant is to ensure that the client’s room is tidy. Always make the bed after getting the client up and ready in the morning.

An open bed invites the client to lie down. Upon hospital admission, or when the client is ready to go to bed, the linens are fan-folded down to the foot of the bed. It 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. The client is transferred as reviewed in Skill 21.4. 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 relieves the pressure from the tucked linens on top of the client’s toes, reduc-ing the risk of a pressure injury.

A closed bed is made with all the linens in place over the mattress, with the top sheet, blanket, and bedspread drawn up to the head of the bed. In an open bed, the linens are fan-folded down to the foot of the bed, or, if the client is transferred from the stretcher to the bed, the linens are fanfolded to one side of the bed.

19.5 Making the Unoccupied and Occupied Bed

Unoccupied BedAn unoccupied bed is changed when the cli-ent can get out of the bed. First, assist the client out of bed. She may sit in a chair in the room or in the wheelchair while you perform this task. Changing the bed completely must be done on every bath day, whenever the lin-ens are heavily soiled or wrinkled, and upon client discharge. Skill 19.1 outlines the pro-cedure for changing an unoccupied bed.

Occupied BedWhat are two reasons the caregiver may have to complete an occupied bed change?

An occupied bed change becomes neces-sary when the 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 19.2 details the procedure necessary for changing a bed that is occupied.

Reflect on Bea!

How can you help Bea? How would you change her bed linens so that she remains comfortable?

An occupied bed may be changed when the client is unable to get out of bed or when it is uncomfortable for him to do so.

Reflect on Privacy!

Always pull the privacy curtain when per-forming an occupied bed change, even if the client’s roommate is sleeping.

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 rolling back and forth for the client. The client should never lie on a bare mattress during this process. Be careful not to contaminate 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 linens to prevent con-tamination. Wrinkles are smoothed in the clean linens before the client rolls back (Fig-ure 19.8).

Time-Management Tip!

It may be more time effective to perform an occupied bed change, rather than transfer the client out of bed and make an unoccupied bed. Offer the choice to your client.

Why should a side rail be used during an occupied bed change? Why is the side rail not considered a restraint during this procedure? What is the alternative to using the side rail if one is not present?

Occupied bed change A change of bed linens when the client is not able to get out of bed or when it is uncomfortable for the client to get out of bed

Learn how to perform this skill on page 281

SKILL 19.3


SKILL 19.1

See workbook page 143 to quiz

yourself on the topics covered in this chapter.

TeST yOUrSeLf

Key terms offer concise and accessible introductions to important topics from each chapter.

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.

Focus Questions are designed to motivate students to think about various learning objectives throughout each chapter.

Reflect on… scenarios develop critical thinking and encourage students to solve real world situations that they will encounter on the job.

Inside the Book


Chapter 19 Bedmaking272 19.5 Making the Unoccupied and Occupied Bed 273

Figure 19.6 The bed should be pulled away from the wall and raised to a good working height for bedmaking. August Learning Solutions

Figure 19.7 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

Closed bed A bed made with all of the linens in place over the mattress, and the top sheet, blanket, and bedspread drawn up to the head of the bed

Open bed A bed made with the top sheet, blanket, and bedspread fanfolded down to the foot of the bed, or to the side of the bed for the surgical client, to allow the client access into bed

To reduce the risk of injury, release the brakes on the bed and move it away from the wall and other furniture. Raise the bed to a good work-ing height. Always bend at the knees, not at the waist. Do not stretch, twist, and lean down or over to make the bed. Keep items close by your body. Lower the side rails while you work.

Reflect on Choices!

Keep yourself free from injury and illness while bedmaking by using correct body mechanics and maintaining proper infection-control practices.

Reflect on Settings!

Private homes and assisted-living facilities are unlikely to have hospital-type beds, which raise and lower. Body mechanics become especially important then. Always bend at the knees. Do not twist and bend at the same time. If making an occupied bed, ask your client to help you as much as possible when rolling to prevent injuring yourself.

19.4 The Closed Versus Open Bed

What is the difference between an open and a closed 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 19.7). 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. This keeps the mattress and inner bed linens clean. Mitered corners at the foot of the bed ensure a wrinkle-free, tidy bed (Skill 19.3). Upon admission of a new cli-ent, or when the client wants to go to bed, the bed is opened.

Reflect on Professionalism!

Part of your job as a nursing assistant is to ensure that the client’s room is tidy. Always make the bed after getting the client up and ready in the morning.

An open bed invites the client to lie down. Upon hospital admission, or when the client is ready to go to bed, the linens are fan-folded down to the foot of the bed. It 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. The client is transferred as reviewed in Skill 21.4. 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 relieves the pressure from the tucked linens on top of the client’s toes, reduc-ing the risk of a pressure injury.

A closed bed is made with all the linens in place over the mattress, with the top sheet, blanket, and bedspread drawn up to the head of the bed. In an open bed, the linens are fan-folded down to the foot of the bed, or, if the client is transferred from the stretcher to the bed, the linens are fanfolded to one side of the bed.

19.5 Making the Unoccupied and Occupied Bed

Unoccupied BedAn unoccupied bed is changed when the cli-ent can get out of the bed. First, assist the client out of bed. She may sit in a chair in the room or in the wheelchair while you perform this task. Changing the bed completely must be done on every bath day, whenever the lin-ens are heavily soiled or wrinkled, and upon client discharge. Skill 19.1 outlines the pro-cedure for changing an unoccupied bed.

Occupied BedWhat are two reasons the caregiver may have to complete an occupied bed change?

An occupied bed change becomes neces-sary when the 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 19.2 details the procedure necessary for changing a bed that is occupied.

Reflect on Bea!

How can you help Bea? How would you change her bed linens so that she remains comfortable?

An occupied bed may be changed when the client is unable to get out of bed or when it is uncomfortable for him to do so.

Reflect on Privacy!

Always pull the privacy curtain when per-forming an occupied bed change, even if the client’s roommate is sleeping.

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 rolling back and forth for the client. The client should never lie on a bare mattress during this process. Be careful not to contaminate 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 linens to prevent con-tamination. Wrinkles are smoothed in the clean linens before the client rolls back (Fig-ure 19.8).

Time-Management Tip!

It may be more time effective to perform an occupied bed change, rather than transfer the client out of bed and make an unoccupied bed. Offer the choice to your client.

Why should a side rail be used during an occupied bed change? Why is the side rail not considered a restraint during this procedure? What is the alternative to using the side rail if one is not present?

Occupied bed change A change of bed linens when the client is not able to get out of bed or when it is uncomfortable for the client to get out of bed


SKILL 19.3


SKILL 19.1

See workbook page 143 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.

Take Action!

If you suspect that your client has suffered a spinal injury, report it immediately to the nurse! Do not move the client until the nurse has assessed him and given per-mission for movement.

Focus Answers are designed to assist with

comprehension by providing

solutions to the Focus Questions.

Take Action! provides advice for how best to

deal with a variety of scenarios that

students will encounter on the

job.

Reflect on… Personas correspond

with Personas at the beginning of each chapter and help

develop the critical thinking skills needed

to provide caregiver excellence.


Summaries provide an overview of the learning objectives covered throughout the chapter.

Chapter Summary

Chapter Summary198 Chapter Summary 199

Reflect on This! 1. Clarence is continuously trying to walk out the front door. He has dementia and is always

very confused. He tells you repeatedly that he needs to go home; his mother will be look-ing for him. It is very cold outside, and you worry that if he did get out, even for a few minutes, it would not be safe. What can you do to help Clarence? How can you decrease his agitation? Is a restraint needed in this scenario? If so, why; if not, why not?

2. Devin scratches himself a lot. Every time you help him into bed, he scratches his buttocks so fiercely that the skin begins to bleed. Devin is incontinent and you fear he will get fecal matter in his wounds. What could be the reason(s) that he is scratching so fiercely? How can you help prevent infection? What are some interventions you could try prior to apply-ing a restraint? If none of the interventions work, would a restraint be appropriate? If so, what type of restraint would be the least restrictive and most effective?

Let’s Review!Prioritize these action items.

MaryAnn has a wrist restraint on her left hand while in bed. 1. You take the restraint off because it has been on for 2 hours. 2. You tie a quick-release knot. 3. You check on her every 15 minutes and note the color and temperature of her left hand

and ask her about any sensation in the hand. 4. You ambulate her so she can stretch her legs, and you take her to the bathroom. 5. You reapply the restraint to the wrist.

Multiple Choice Questions 1. The goal of restraining an individual is to (13.1): a. keep the client safe. b. keep others around the client safe. c. prevent falls. d. a and b.

2. Before a client can be restrained, the nurse must obtain (13.5): a. consent. b. a physician’s order. c. a report from the nursing assistant that the client is acting out. d. none of the above.

3. A physical restraint must be released (13.4): a. every 15 minutes. b. every 30 minutes. c. every hour. d. every 2 hours.

4. When checking on a client who has a mitt restraint, the nursing assistant should (13.4): a. check the color of the client’s hand. b. check the warmth of the client’s hand. c. ask the client to wiggle his fingers. d. all of the above.

5. Restraining clients (13.1): a. prevents falls. b. prevents clients from wandering off. c. prevents outbursts. d. none of the above.

Summary of Learning Objectives13.1 Paraphrase what a restraint is and identify two main categories of restraints as defined by CMS.

A restraint is anything that prevents the client from freely mov-ing about her environment. A restraint can be either chemical or physical.

13.2 Describe the respon-sibilities of the nursing assistant when caring for the client who is restrained.

Check on the client every 15 minutes. When checking the client, look at the restraint itself and the extremity it affects. Look for color, sensation, warmth, function, and circulation, and ask if the client has any pain. Restraints must be released every 2 hours. Assist the client to the toilet or with changing the incontinence product, ambu-late the client, or perform ROM activities if she is unable to walk. Reposition her to prevent pressure injuries. Offer food and fluids and socialize with the client.

13.3 Identify six common types of restraints.

The six most common types of restraints used include wrist, ankle, vest, mitt, roll belt, and a belt restraint for wheelchair use.

13.4 Paraphrase the risks associated with restraint use.

Risks associated with restraint use are plentiful and include a decrease in mobility, increased dependency, behavioral problems, loss of dignity, depression, pressure injuries, muscle soreness and atrophy, decreased self-worth, incontinence, impaction, falls, and even death.

13.5 Generalize when restraint use is allowed.

The only appropriate reason to use a restraint is to ensure safety. A restraint must be ordered by the physician, and it must be listed on the client’s care plan or ISP. The facility must consistently try to reduce or eliminate the use of the restraint.

13.6 Contrast the use of a side rail as a restraint and as a positioning device.

A side rail is always considered to be a restraint unless it is used for purposeful movement by the client while in bed. Informed consent is always needed, as side rails can be life threatening.

13.7 Identify a key pri-mary prevention strategy to reduce the use of restraints.

A key strategy to prevent the use of restraints is to attend to basic human needs in a consistent and timely manner, which includes attending to toileting, food, fluid, exercise, and social needs.

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.

Every time you let Alma roam freely about the unit in her wheelchair, she immediately goes to Fred and starts screaming at him and kicking him. She thinks he is her late hus-band, who cheated on her many years ago. When this happens, Fred gets very upset, as does his family. They are threatening to move him to a different facility because of this. Today you lock Alma’s wheelchair brakes and put her in front of the television to distract her. She is very calm and does not even notice when Fred comes into the room. The day goes by without incidence.

• Was this an appropriate action to take?• Is keeping Fred safe and happy an appropriate reason for locking the brakes on Alma’s

wheelchair? Is keeping Fred safe and happy the ultimate goal in this scenario?• Would you get in trouble for locking Alma’s brakes? If so, why; if not, why not?• Alma was much more calm and relaxed while watching television. Do you think this inter-

vention will work every day?

Get Up and Think! encourages students to work together and brainstorm answers to scenarios they may face on the job.


Chapter Summary198 Chapter Summary 199

Reflect on This! 1. Clarence is continuously trying to walk out the front door. He has dementia and is always

very confused. He tells you repeatedly that he needs to go home; his mother will be look-ing for him. It is very cold outside, and you worry that if he did get out, even for a few minutes, it would not be safe. What can you do to help Clarence? How can you decrease his agitation? Is a restraint needed in this scenario? If so, why; if not, why not?

2. Devin scratches himself a lot. Every time you help him into bed, he scratches his buttocks so fiercely that the skin begins to bleed. Devin is incontinent and you fear he will get fecal matter in his wounds. What could be the reason(s) that he is scratching so fiercely? How can you help prevent infection? What are some interventions you could try prior to apply-ing a restraint? If none of the interventions work, would a restraint be appropriate? If so, what type of restraint would be the least restrictive and most effective?

Let’s Review!Prioritize these action items.

MaryAnn has a wrist restraint on her left hand while in bed. 1. You take the restraint off because it has been on for 2 hours. 2. You tie a quick-release knot. 3. You check on her every 15 minutes and note the color and temperature of her left hand

and ask her about any sensation in the hand. 4. You ambulate her so she can stretch her legs, and you take her to the bathroom. 5. You reapply the restraint to the wrist.

Multiple Choice Questions 1. The goal of restraining an individual is to (13.1): a. keep the client safe. b. keep others around the client safe. c. prevent falls. d. a and b.

2. Before a client can be restrained, the nurse must obtain (13.5): a. consent. b. a physician’s order. c. a report from the nursing assistant that the client is acting out. d. none of the above.

3. A physical restraint must be released (13.4): a. every 15 minutes. b. every 30 minutes. c. every hour. d. every 2 hours.

4. When checking on a client who has a mitt restraint, the nursing assistant should (13.4): a. check the color of the client’s hand. b. check the warmth of the client’s hand. c. ask the client to wiggle his fingers. d. all of the above.

5. Restraining clients (13.1): a. prevents falls. b. prevents clients from wandering off. c. prevents outbursts. d. none of the above.

Summary of Learning Objectives13.1 Paraphrase what a restraint is and identify two main categories of restraints as defined by CMS.

A restraint is anything that prevents the client from freely mov-ing about her environment. A restraint can be either chemical or physical.

13.2 Describe the respon-sibilities of the nursing assistant when caring for the client who is restrained.

Check on the client every 15 minutes. When checking the client, look at the restraint itself and the extremity it affects. Look for color, sensation, warmth, function, and circulation, and ask if the client has any pain. Restraints must be released every 2 hours. Assist the client to the toilet or with changing the incontinence product, ambu-late the client, or perform ROM activities if she is unable to walk. Reposition her to prevent pressure injuries. Offer food and fluids and socialize with the client.

13.3 Identify six common types of restraints.

The six most common types of restraints used include wrist, ankle, vest, mitt, roll belt, and a belt restraint for wheelchair use.

13.4 Paraphrase the risks associated with restraint use.

Risks associated with restraint use are plentiful and include a decrease in mobility, increased dependency, behavioral problems, loss of dignity, depression, pressure injuries, muscle soreness and atrophy, decreased self-worth, incontinence, impaction, falls, and even death.

13.5 Generalize when restraint use is allowed.

The only appropriate reason to use a restraint is to ensure safety. A restraint must be ordered by the physician, and it must be listed on the client’s care plan or ISP. The facility must consistently try to reduce or eliminate the use of the restraint.

13.6 Contrast the use of a side rail as a restraint and as a positioning device.

A side rail is always considered to be a restraint unless it is used for purposeful movement by the client while in bed. Informed consent is always needed, as side rails can be life threatening.

13.7 Identify a key pri-mary prevention strategy to reduce the use of restraints.

A key strategy to prevent the use of restraints is to attend to basic human needs in a consistent and timely manner, which includes attending to toileting, food, fluid, exercise, and social needs.

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.

Every time you let Alma roam freely about the unit in her wheelchair, she immediately goes to Fred and starts screaming at him and kicking him. She thinks he is her late hus-band, who cheated on her many years ago. When this happens, Fred gets very upset, as does his family. They are threatening to move him to a different facility because of this. Today you lock Alma’s wheelchair brakes and put her in front of the television to distract her. She is very calm and does not even notice when Fred comes into the room. The day goes by without incidence.

• Was this an appropriate action to take?• Is keeping Fred safe and happy an appropriate reason for locking the brakes on Alma’s

wheelchair? Is keeping Fred safe and happy the ultimate goal in this scenario?• Would you get in trouble for locking Alma’s brakes? If so, why; if not, why not?• Alma was much more calm and relaxed while watching television. Do you think this inter-

vention will work every day?

Reflect on This! provides examples of potential clients

and encourages students to figure

out how to address clients’ unique

needs.

Let’s Review! helps with

mastering key concepts and

learning objectives.

Multiple Choice Questions

help students assess their

understanding of learning objectives.


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 Summary200

ReferenceCenters for Medicaid and Medicare Services. (2005). Clarification of nursing home reporting

requirements for alleged violations of mistreatment, neglect, and abuse, including injuries of unknown source, and misappropriation of resident property. Baltimore, MD: Center for Medicaid and State Operations/Survey and Certification Group, Department of Health & Human Services. CMS, 42: 483.13; https://www.cms.gov/Regulations-and-Guidance/Guid-ance/Transmittals/downloads/R12SOM.pdf.

Skill

Skill 13.1 Tying a Quick-Release KnotWhen: A quick-release knot is used every time a restraint is applied.*Apply a restraint only when ordered by a physician and only when required to treat the

resident’s medical symptoms. Check the client every 15 minutes while a restraint is in use. Remove the restraint every 2 hours. Remove the restraint at meal times.

Why: All restraints must be fastened with a quick-release knot. The quick-release knot is a safety measure. In case of a fire or other emergency, the restraint can be untied quickly, and the client can be helped to a safe place.

What: Supplies needed for this skill include:

A restraint

How: 1. Wrap the strap once around a movable part of the bed frame leaving at least an 8-inch (20

cm) tail. 2. Fold the loose end in half to create a loop and cross it over the other end. 3. Insert the folded strap where the straps cross over each other, as if tying a shoelace. Pull

on the loop to tighten. 4. Fold the loose end in half to create a second loop. 5. Insert the second loop into the first loop. 6. Pull on the loop to tighten. Test to make sure strap is secure and will not slide in any

direction. 7. Repeat on other side. 8. Practice quick-release ties to ensure the knot releases with one pull on the loose end of

the strap.

Images and accompanying text provided courtesy of Posey Company, Arcadia, California.


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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.


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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.


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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.

Jennifer, a 32-year-old woman, presents to the after-hours urgent-care clinic complain-ing 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 remedy 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 prob-ably see you in a few days again for another breathing treatment.” What do you do?

the History of Healthcare in the United states

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Chapter 1 The History of Healthcare in the United States2

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 prac-tice, and for which today’s nursing assistants are responsible, include bedmaking; clean-liness of the patient; activities for physical, intellectual, and mental well-being; proper food and water intake; documentation; and cleanliness 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 assistants play a very large role in caring for the client!

Florence Nightingale’s nursing, infection con-trol, 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.

reflect on jennifer!

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 train-ing, and there were no licensing boards or reg-ulating 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! Doctors, 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 reme-dies. Practices were quite basic at this time.

Payment for a doctor’s services was com-pletely paid for by the individual or his family.

Figure 1–1. Florence Nightingale, the founder of modern nursing. photos.com/PHOTOS.com/Thinkstock

1.1 A Brief History of Healthcare in the United States

What 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 infec-tious 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 pro-fession 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 per-son’s environment. She felt that a stable and healthy environment was an essential part of care to help the patient regain his health.

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1.2 The Beginning of Modern Healthcare 3

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

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/PHOTOS

.com/Thinkstock

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.

There were no hospitals during this time either—only almshouses. Almshouses were places for the poor, older adults, the home-less, 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 med-ical 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 training himself.

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

reflect on settings!

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?

1.2 The Beginning of Modern Healthcare

What changes occurred in the U.S. healthcare system that led to the prevalence 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 pub-lic health is to educate groups of people (not simply an individual) about healthy ways to live and how to prevent illness before it starts. Before the start of public health, it was com-mon for raw sewage to flow in city streets. That raw sewage would then flow on to streams and rivers and pollute drinking water. An example of public health is to teach communities the

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

Figure 1–3. Public health efforts began in the mid-1800s. stocksnapper/iStock/Thinkstock

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 illnesses, like smallpox or cholera.

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

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, arthritis, diabetes, osteopo-rosis, 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.


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?

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

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 prac-tice of medicine became established. Med-ical 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 as specialty surgery and cancer care. Because of the specialty training, jobs in physical therapy and occupational therapy expanded, and specialty nursing degrees evolved.

reflect on Professionalism!

What would healthcare look like today if we did not have formal schooling and edu-cation for healthcare professionals? What would happen if you were a nursing assis-tant 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 continue their education once training has been com-plete? If so, how much continuing educa-tion do you think would be appropriate?

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

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1.3 The Cost of Healthcare 5

1.3 The Cost of Healthcare

What made healthcare become so costly in the United States?

With the increased complexity of health-care, 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, peo-ple with cancer, pediatrics, and many more areas (Figure 1–4).

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’ compensation 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 pro-vided by the employer became a standard benefit for working people.

There was a problem, however. Indi-viduals 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 disabili-ties. Medicare is funded through federal taxes. The Medicaid 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.

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/iStock/Thinkstock

Medicare Health insurance plan for older adults and, in certain situations, the disabled, funded through federal taxes

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

During this time, however, there were several factors that started to increase the costs of healthcare. These included the growing use of technology and purchasing those technol-ogies 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.

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 dol-lars needed to create new technologies, treat-ments, 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 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 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 sys-tem. This is why we see a great increase in the number of outpatient versus inpatient sur-geries. It is also why hospital stays are much

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

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shorter than they were in the past. And it is why consumers of healthcare in America have limited choices in where they access health-care 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 con-sumers enrolled in these plans could access. There were also financial incentives for pro-viders to treat and discharge patients from hospitals quickly.

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 insurance as an employee benefit. 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 specific dollar amount

or percentage that must be paid by the indi-vidual 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 ser-vices 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?

reflect on choices!

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?

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 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 and the asso-ciated 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 were able to

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

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/iStock/Thinkstock

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1.4 Healthcare Today 7

access a marketplace to purchase individ-ual health insurance policies. Some of these policies are subsidized by the federal govern-ment, meaning the government helps pay the premium. This makes insurance much more affordable. 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 dol-lar must be spent on healthcare costs).

• Barriers to emergency services are removed.

• Hospital readmission rates are targeted for reduction.

Since the implementation of the Afford-able Care Act, healthcare costs slowed. The

rate of healthcare inflation also slowed. New research indicates an improved quality of care since its implementation. As with any admin-istration changes the Affordable Care Act will change based on the passage of new Congres-sional bills. In healthcare change is constant. As a member of the health care delivery team that means we must be flexible to meet the ever-changing system.


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

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

summary of Learning Objectives

1.1 Describe the history of healthcare in the United States.

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

1.2 Paraphrase the begin-nings of modern healthcare.

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 before the establishment of regulated medical colleges. Public health interventions helped diminish the preva-lence 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 technol-ogies 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 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.

See workbook page 1 to quiz yourself on the topics covered

in this chapter.

TeST yoUrSelf

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Chapter Summary8

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 children 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 sitting 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?

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 individual for each healthcare service received.

c. the cost that the individual must pay every month toward her healthcare 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.

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Chapter Summary 9

c. both A and B. d. neither A nor B.

3. This federally funded medical plan gives health insurance access to older adults and some younger people with certain disabilities (LO 1.4):

a. Medicaid. b. Medicare. c. private health insurance. d. MCOs.

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.htmlOffice 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

*At the time of publication the Affordable Care Act was still in place; however, Senate Republicans were working to repeal and replace the act.

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