OER - CNA Field Manual Revised 8-27-2014

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Contents
Module 1: Overview of the Field....................................................................................................................2
Module 2: Communication...............................................................................................................................16
Module 3: Documentation and Reporting...................................................................................................20
Module 4: Infection Control.........................................................................................................................27
Module 5: Safety and Emergencies............................................................................................................44
Module 6: Human Growth and Development..............................................................................................61
Module 7: Rights and Abuse Reporting.......................................................................................................71
Module 8: Cardio-Respiratory System.......................................................................................................82
Module 9: Taking and Recording Vital Signs.............................................................................................90
Module 10: Digestion and Nutrition............................................................................................................95
Module 11: Integumentary System............................................................................................................110
Module 12: Musculoskeletal System..........................................................................................................115
Module 13: Body Mechanics and Assisting With Transfers...............................................................122
Module 14: Nervous System and Disorders............................................................................................127
Module 15: Dementia......................................................................................................................................141
Module 16: Urinary System.........................................................................................................................149
Module 17: Death and Dying........................................................................................................................155
NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 1

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NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 2: Module 1

Module 1
Overview of the Field
The Main Ingredient..............................................................................................................3

The Purposes, People and Places of Health Care...........................................................4
Essential Skills for Providing Care....................................................................................5
Overview of O.B.R.A..............................................................................................................6
Nurse Practice Act................................................................................................................7
Legal And Ethical Behavior..................................................................................................8
Medicare and Medicaid.........................................................................................................9
The Rights and Responsibilities of People Receiving Care.........................................10
Confidentiality........................................................................................................................11
Greenfield Community College C.N.A. and H.H.A program Confidentiality
Certification...........................................................................................................................12
Professional Boundaries......................................................................................................13
Sue’s Caregiver Creed.........................................................................................................14
Guidelines for Personal Safety:........................................................................................15

The Main Ingredient
Water makes up about the same percentage of the
human body as it does of the planet, about 70%
Water is needed for every bodily process

It carries nutrients and oxygen to the cells.
It regulates body temperature, lubricates the joints, protects
vital organs, helps with digestion and to prevent constipation,
keeps skin looking young. It even helps to prevent bad breath.
Water is vital to mental performance!

Just a 2% drop in water in the body can cause mental confusion.
Lack of water is the #1 cause of daytime fatigue.
Our bodies are constantly using/losing water

Even inhaling and exhaling uses water
Thirst lags behind our body’s water need.
Don’t wait to be thirsty –
Drink Water!

The Purposes, People and Places of Health Care
The focus of health care should always be on the person receiving care. The goal of
health care should always be to help the person receiving care be as involved in their
own care as possible and to achieve and maintain the highest possible level of function
and independence.
There are many disciplines within the health care profession. Nurses, Doctors,
Therapists, Social Workers, Dietitians, CNAs, HHAs and many others are all members
of the health care team.
People Seek Assistance from Health Care Providers for:

 Traumatic Injury or Emergency Care = Urgent
 Treatment of Acute illness = sudden and severe
 Management of Chronic illness/condition = long term or progressive
 Rehabilitation = to restore health/function after illness, injury, surgery
 Care for Terminal illness = ending in death
The Places People Receive Health Care

 Hospitals treat emergencies and acute illness
 Rehabilitation takes place at Rehab Centers & Nursing Homes
 Nursing Homes/Skilled Nursing Facilities provide management of chronic health
care conditions and support with Activities of Daily Living = ADLs
 Hospice provides care at the end of life
People also receive health care in their own homes, assisted living and other
community living settings.
CNAs-HHAs are important members of the health care team. They assist the nurse
by performing tasks and procedures that support a person with ADLs: Hygiene,
Grooming, Nutrition, Mobility, Elimination, Comfort and Socialization.
They also play an important role in the management of health care conditions.
This includes observation/monitoring of health conditions and reporting changes.
Culture influences people’s beliefs and approach to health care. Many individuals seek
alternative sources of health care. Acupuncture, herbal medicine, chiropractic,
reflexology, massage therapy, Reiki, and homeopathy are just a few examples. Health
care providers must always be respectful of cultural differences.

Essential Skills for Providing Care
As a Nursing Assistant/Home Health Aide student you will learn many

techniques and skills for providing care and assisting a person with all of their
activities of daily living.
You will gain knowledge about the function and disorders of each body system
as well as procedures to assist people with the management of health conditions
and disease.
You will learn how to observe, monitor, measure and report signs and symptoms
in order to support the health and well-being of the people for whom you
provide care.
Embedded in every task that a caregiver performs are 3 very

essential skill areas:
 SAFETY - This includes infection control, back safety,

environmental safety and emotional safety – for both the consumer
and the caregiver.
 COMMUNICATION - Effective communication skills help to engage

the person and promote their highest level of involvement.
 RIGHTS - Respect for the right of the person to be treated with

dignity and respect.

Overview of O.B.R.A.
In 1987 Congress passed health care reform into law. This was due largely to the work
of the Citizens’ Coalition for Nursing Home Reform. The law is known as OBRA, the
Omnibus Budgetary Reconciliation Act.
The purpose of OBRA was to improve the quality of health care, especially in nursing
homes. Standards of practice and systems for clinical oversight were established to
insure quality care and to promote the person’s highest level of function. The
philosophy of OBRA is to approach care from a holistic prospective, which means to
consider the whole person: Physical, Mental, Social, Emotional and Spiritual. The
goal is to support the individual resident’s right to choice and to be treated with
dignity and respect.
The state has a process for evaluating quality of care and compliance with the federal
OBRA standards/regulations. Annually a team of state surveyors visit each facility to
determine if they are meeting all requirements and following all the rules, to see that:
 The environment is home like, clean, neat and odor free.
 The food taste good is nutritious and served in a timely manner.
 The residents’ medical needs are being met and managed well.
 To evaluate the staff and their treatment of residents.
 To ensure residents have access to meaningful activities.
Before OBRA there were no accepted training standards for nursing assistants. Now
individuals must:
 Complete a 75 hour training program

 Pass a competency exam, including both written and skills tests
 Renew certification every two years
 Work under the supervision of nurse at least 8 hours.
 Complete 12 hours of in-service education a year.

O.B.R.A. requires each state to maintain a Nurse Aide Registry, an official record of
each person that completes the program.
O.B.R.A. defines what a Nursing Assistant can do and what

they can’t. Each state has a nurse practice act that
determines the scope of practice.

Nurse Practice Act
Each state has a Nurse Practice Act to determine the scope of practice and level of
education required for nurses.
A Registered Nurse (RN) must have, at least, an Associate's degree, which

requires 2 years of training/education. They may have a Bachelor or Master's
degree.
An RN has advanced knowledge about body systems and related disorders, clinical
practices and medication. The RN is generally responsible for assessment and
admission of clients and residents.
Licensed Practical Nurse (LPN) has from 10 to 15 months of training/education. An

LPN can administer most medications and preform most skilled nursing tasks. They
always work under the supervision of the RN. Even when an RN is not right in the
room, or even the building, the LPN is working under the RN license.
Nursing Assistants are not licensed. They are certified. They must complete a
minimum of 75 hours of training in order to be eligible to take the certification exam.
Certified Nursing Assistants (CNA) and Home Health Aides (HHA) are considered
Dependent Practitioners. This means that they are allowed to perform certain nursing
tasks, under the supervision of a licensed nurse. When a nurse gives an assignment to a
CNA or HHA it is called a delegation, which means they have authorized them to
perform the task. The nurse always shares responsibility for the task and for the
health and safety of the person receiving care.
The Five Rights of Delegation

· The Right Task - Is the task within the CNA/HHA role limits and job
description?
· The Right Circumstances - Consider the person's situation, condition, mood,
needs and desires at the time.
· The Right Person - The CNA/HHA must have the training and experience to
safely and effectively perform the task.
· The Right Direction and Communication - The nurse gives clear instructions,
which should include what to observe and report helps to set priorities and allows
time for questions.
·The Right Supervision - The nurse guides, directs and evaluates the care, provides
additional supervisor and demonstrates task as needed.

Legal And Ethical Behavior
Laws = Rules set by government to help people to live safely and peacefully together.
Nursing Assistants have to follow the laws related to the legal limits of their role.
Role Limits of CNA and HHA
 Do not administer medication – Only cue, remind, or assist with pre-poured medication
 Do not insert or remove tubes or other objects in to body openings. The exception to
this is feeding a person.
 Do not take Doctors’ orders. Only a nurse can do this.
 Do not perform procedures that require sterile technique.
 Do not diagnose or prescribe treatment. Only Doctors can do this.
 Do not tell the person or family the diagnosis. Refer them to the nurse/Doctor.
 Do not ignore a delegation from a nurse. You may decline a delegation that is beyond
your scope, or that you are not familiar with. You may ask to be shown.
 Do not supervise another nursing assistant. You may mentor or orient another
CNA/HHA, but you do not have the authority to supervise.
Ethics = principles and values governing conduct.

Nursing Assistants and all medical professionals must follow a code of conduct to guide
them in making right decisions and to protect the people that they are caring for.
Guidelines for Ethical Behavior
 Be honest. If you make a mistake report it.

 Protect the privacy of residents/clients. Share information only on a need to know
basis. Also respect the privacy of coworkers.
 Report abuse or suspected abuse. Assist residents/clients to report abuse.
 Follow the care plan. Report/document observations and incidents promptly and
accurately.
 Do not perform tasks beyond your role limits.
 Follow all rules on safety and infection control. Report violations to nurse.
 Do not accept gifts or tips.
 Maintain professional boundaries. Do not get personally involved with
residents/clients or their family members. Talk to a supervisor when this becomes
challenging.

Medicare and Medicaid
Medicare is the federally funded health care (entitlement) for:
 People who have paid in to social security for a certain period.

 People age 65 or older
 People under 65 with certain disabilities
Medicare is run by the US Department of Health and Human Services. It has many
options for types of plans and coverage.
Medicare will pay for Skilled Nursing and Rehabilitation services at home and in
nursing homes for a limited period of time.
Medicaid
Medicaid is the federal health care program for certain low income people. It is
funded jointly by state and federal government and managed by each state. In
Massachusetts the program is called MassHealth.
About 60% of long term nursing home residents are paid for by Medicaid. There are
also programs within MassHealth for children’s health and social service programs.
There are home care options for elders and adults with disabilities under Medicaid as
well.
The US Department of Health and Human Services sets standards of practice for
Medicare and Medicaid. Any health care provider that accepts payment from
Medicare or Medicaid must meet the standards and follow the conditions of
participation.
For example, the C in CNA stands for certified. That means that the nursing assistant
has met the federal standards for training and testing. Some states require more
training and/or additional testing.
The Rights and Responsibilities of People Receiving Care
If you have Medicare you have certain guaranteed rights. People who have Medicare
have the right to:
 Appeal denied services

 Receive information about their care
 Receive emergency room services
 See doctors, specialists, and women’s health specialists
 Go to Medicare Certified hospitals
 Participate in treatment decisions
 Be informed of treatment decisions
 Get information in a culturally competent manner
 File complaints
 Non discrimination
 Privacy/ Confidentiality
Medicare guarantees these rights through standards and regulations. All providers
that accept Medicare payments (Medicare Certified providers) must adhere to
Medicare standards, regulations, and oversight. This includes Nursing Assistance.
INFORMED CONSENT
Every person has the right to decide what will be done to his or her body and who can
touch his or her body. Consent is “informed” when the person clearly understands:
 The reason for the treatment

 What will be done
 How it will be done
 Who will do it
 The expected outcome
 Other treatment options
 The effects of not having the treatment
People who are under 18 years of age or have been declared mentally incompetent
must have a designated “Responsible Person” give consent. Everyone should have a
Health Care Proxy, a person designated to make health care choices in the event
that he or she is unable to give consent.
Confidentiality
Confidentiality = A conscious effort by all healthcare professionals to keep private all
personal information related to the person who is receiving care and their families.
This may include:
* Identity – Name, address, phone number, E-mail, any personal information.
* Physical and Psychological Condition. - Diagnosis, signs, symptoms.
* Emotional Status – Mood, behaviors, attitude.
* Financial Circumstances – Any information related to the person’s finances, or
method of payment for services.
* Personal/Family History – Any personal information, where they grew up, went to
school, which they are related to, what they do/did for work, where they vacation or
do for leisure activities.
Privacy is a basic right in our society. Safeguarding that right is an ethical and legal
responsibility of all health care professional.
In addition to monitoring their own behavior in regards to confidentiality, a CNA/
HHA may need to remind coworkers, visitors, volunteers, etc. of the importance of
privacy and confidentiality. In some cases violations may need to be reported.
Guidelines for Confidentiality

* Information should be shared only with those that have a need to know in order to
deliver safe and effective care.
* Never share confidential information without prior consent from the person
receiving care, even with close family members or friends.
* Be aware of surroundings and environment. Never discuss private information
where it may be overheard by others.
* Do not use client/resident’s full name when discussing them with others.
Congress passed HIPAA – Health Insurance Portability and Accountability Act - in

1996. Under this law, health care organizations must take special steps to protect
health information. Organizations and their employees can be fined or imprisoned if
they break the rules.
In certain circumstances, when a client/resident’s health is at risk, the CNA/HHA
may not be able to honor the client/resident’s wish for privacy.
Greenfield Community College C.N.A. and H.H.A program
Due to the nature and content of this training, personal experience is

often shared during class discussion.
You are learning how to care for people’s needs and you are a person with
needs.
You have experienced loss of loved ones, challenges brought on by illness

or chronic health conditions, the difficulties of holding it all together
when you feel like falling apart -- and at times you have experienced
falling apart.
You will be learning how to help individuals and their families cope with
the very same issues you yourself face.
You can enrich your learning experience when you share your stories, and
you can learn a lot from one another’s learned lessons.
As a caregiver you must protect your client’s privacy. You must keep
confidential any personal information you learn while providing care.
This class is an opportunity for you to practice the skill of confidentiality
by extending it to your classmates. If you agree, please sign the following.
I, ______________________________________, agree to keep

confidential all personal information I may learn about any of my
classmates during the course of this program.
Signature: ___________________________________________
Date: ______________________________________________
Professional Boundaries
As a Nursing Assistant you will develop relationships with the people for whom you
provide care. Nursing Assistants are guided by ethics and laws that set limits for
their relationships with clients/residents. These limits are called Professional
Boundaries. Boundaries help to support a healthy therapeutic relationship.
Therapeutic = Serving to cure, or to heal, or to preserve health. To develop and
maintain therapeutic relationships with the people you are caring for, it is best to give
them unconditional positive regard.
Unconditional Positive Regard = Basic acceptance and support of the person no matter
what they say or do. Humanist Carl Rogers felt that positive regard is essential to
healthy human development.
It is easy to have positive regard for someone who is nice and cooperative, but not
everyone is. Some people can’t control their behavior; others are simply not very nice.
Receiving care can be stressful. Stress, illness, pain, fear, etc., can make a person
irritable. You may not be able to control or change a client/resident’s behavior, but
you should be able to control your response. You must maintain a boundary between
your needs and feelings and the needs and feelings of the person for whom you are
providing care. Get support from a supervisor when your boundaries are challenged.
Psychologist Abraham Maslow believed that the ability to be completely open and
honest with at least one or two other people is essential to healthy growth toward full
human potential. He called this self-disclosure. Self-Disclosure = the process of
revealing authentic personal information, thoughts and feelings.
As a caregiver you may be the one person that the person you are caring for relates
to. You will want to encourage self-disclosure from them in order to foster their
fulfillment; however you must be careful not to disclose too much of your personal
information to them, in order to maintain a therapeutic relationship. Some helpful
rules:
 Do not share your personal problems or your own life concerns.

 Do not share information about other people for whom you provide care.
 Never complain about your work, your job or co-workers.
 Always present a positive attitude.
 Always stay focused on the health and well-being of the client/resident.
Sue’s Caregiver Creed
I will be mindful of my own needs and I will take care of myself, which will
enable me to better care for others.
My own safety and well-being comes first, not only in emergency situations, but in all
care procedures. Care is a reciprocal process. I must be mindful of myself as part of
the equation. Self–awareness is an essential tool of a caregiver.
I encourage the people for whom I provide care to do as much of their own care
as they can, and I help them to determine how much they can safely and
effectively do.
When assisting a person with their activities of daily living, my actions and approach
always support the highest level of involvement of the person for whom I am caring.
If a person has no other ability to participate, I involve them by verbalizing/explaining
what I am doing. As a caregiver I am an extension of the individual I am assisting. I
do for them only what they cannot do for themselves.
I develop and maintain relationships that are therapeutic to the people for whom
I provide care.
As a caregiver it is my responsibility to establish healthy connections with the

individuals for whom I provide care. It is essential for me to be sensitive, accountable
and to hold the person I am caring for in unconditional positive regard. I must create
and maintain a clear boundary between their needs and mine and I must be consistent
and realistic in what I can and cannot do.
I acknowledge and respect the whole person.
I approach each person and task holistically, taking into consideration any factors that
may impact or influence the person’s ability to receive or participate in care. I will
always strive to protect the individual’s dignity and to support their right to privacy
and self determination.
I am grateful to be of service and I believe that care giving is sacred work.
I consider it a privilege to be allowed in to a person’s vulnerability. As a caregiver I

have opportunities to interact at a level of deep humanity. I find these interactions
very spiritually and emotionally satisfying and rewarding and at times transformative.
Guidelines for Personal Safety
 Maintain good hydration. Drink plenty of water.
 Get enough rest and nourishment.
 Perform only tasks that are within your job description.
 Accept only the tasks you feel confident performing. Request assistance with
any task you are unsure of.
 Always follow the care plan.
 Don’t rush.
 Ask question to clarify anything you don’t understand.
 Use proper body mechanics.
 Request assistance with care or transfer as needed.
 Observe standard precautions and blood borne pathogen standard and use any
personal safety equipment properly.
 Maintain professional boundaries.
 Follow all agency and facility policies.
 Don’t bring a lot of personal items in to a consumer’s home.
 Lock personal items in the truck of your car.
 If you have broken skin, cover all open areas with a band-aid.
 Let office or emergency contact know if your schedule changes.
 If the elder lives in an unsafe area, you may need to change your visit time.
 Car should be in good working condition. Keep gas tank above ½ full.
Module 2
Communication
Communication – An Exchange of Information.............................................................17

Listening to Understand.....................................................................................................18
Non–Verbal Communication................................................................................................19
Communication – An Exchange of Information
An Exchange of Information
Having effective communication skills is a job requirement of Direct Care Workers.

Communication is an essential aspect of every task a caregiver performs. You need to
know of any communication problems the person may have. The care plan should have
information regarding techniques that work best, or about the individual’s special
communication needs.
Verbal Communication
Verbal communication includes both what we say and how we say it. How information is
received and how a message is interpreted is affected by: Tone of voice – Volume of
voice - Speed of speech - Choice of words
Open and Closed Questions

Closed questions, also known as direct questions, can be answered with yes or no. This
is a good approach for people with speech problems such as aphasia, or during acute
distress. (“Did you eat today?”)
Open questions encourage further communication. (“What did you eat today?”) Open
questions can draw the person out and give you an opportunity to make important
observations about the person’s level of orientation.
The I Statement
Communication can break down easily at any point in the process, often due to
misunderstandings or hurt feelings. The way something is said can have more impact
than what is being said. The “I” statement is a very effective communication tool. It
allows the receiver to be clear about how she is understanding and affected by what is
being communicated. For example, “I feel angry when you say that,” rather than “You
make me angry when you say that.” The fact is no one makes us feel anything. We
cannot control what another says or does, but we can control our reaction/response.
Using the “I” statement also helps to keep the communication on the subject that is
being discussed, rather than feelings which can cause us to get off topic.
Subjective and Objective information

Subjective = something that is reported, not observed.
Objective = something you can see, hear, touch, smell.
Listening to Understand
Listening is not simply hearing and more than just being quiet or not interrupting. “Listening to
understand” means that the goal is to really get what the person is trying to convey. The
following are things you can do to help achieve that goal:
Listening Techniques Listening Examples
As you listen, repeat back or paraphrase what you have
heard. This trains you to listen closely and shows the
Listen and repeat speaker that you are paying attention.
Speaker: “I had my interview today”

Response: “Oh, you had your interview today”
One or two word prompts encourage the speaker to
continue to speak.
Encourage
Response: “Oh” or “Yes?” or “Um-hmm” “Go on”
Ask open–ended questions to encourage further
discussion of the topic
Ask for more
Ask: “What were some of the questions they asked
you in the interview?”
Ask closed questions that can be answered with yes, no,
or other single word answers, to clarify what you are
Direct/Closed hearing or encourage further thought and discussion
Questions
Ask: “How many people were there asking
questions?”
Clarify your understanding.
Clarify/Verify Speaker: “I’m glad I practiced before the interview”

Understanding Response: “So it sounds like the practice helped.”
Summarize any agreements or commitments that have

been mentioned, in order to clarify and verify
Summarize
Statement: “So you want to meet before the next
interview and practice again.”
Non-verbal cues Use positive body language, smile, lean in, affirmative
head nod, and provide other positive non-verbal cues.
Non–Verbal Communication
We communicate, even before we speak a word. Our Perception Influences Our
Reception! Perception = understanding of a situation through the senses, insight or
intuition.
Aspects of Non Verbal Communication:
Attitude/Intention Posture/Attentiveness
Facial Expressions General Appearance
Eye Contact Hand Movement/Gestures
Awareness of Personal Space Touching
Body Language = positive non-verbal messages can get across good feelings, and
encourage trust and more communication. A smile, nod, head tilt, gentle touch, leaning
toward the person, or eye contact, can send the message that you care and want to
listen. Behavior is communication. A person with impaired memory may not be able to
express themselves verbally, but their behavior can tell us a lot.
Written Communication = the use of words or symbols to convey information.

Factors that affect written communication: Neatness – Legibility – Spelling - Choice
of words – Length. Too much information can decrease understanding. The reader
may lose track of the main point or lose interest altogether.
Reporting Signs and Symptoms:
SIGNS: (Objective) Data that can be seen, heard, felt, smelled and measured.
SYMPTOMS: (Subjective) Data that is reported, not observed, by your senses.
Signs of a UTI might include small or large amounts of dark, strong smelling urine.
Symptom might include reported urgency, burning or pain with urination. Symptoms
are best reported in quotations: “She stated that…”
How we do something is as important as what we do. There are 3 indirect skills which
are part of every task that we perform:
*Safety – Infection control, body mechanics, awareness of what is around you.
*Client/Resident Rights – respecting privacy, supporting dignity, allowing choice.
*Communication – How you address the client/resident and how you interact.
Module 3
Documentation and Reporting
The Care Planning Process For Skilled Nursing Facility.............................................21

The Care Plan........................................................................................................................22
RECORD/DAILY FLOW SHEET..........................................................................................24
Accident/Incident Report Form......................................................................................26
The Care Planning Process For Skilled Nursing Facility
The Assessment
The Federal Nursing Home Reform Law mandates that a nursing home must help each resident
to “attain or maintain” his/her highest level of well being – physically, mentally and
emotionally. The first step in fulfilling this mandate is to perform a holistic, comprehensive
and interdisciplinary resident assessment. The Minimum Data Set (MDS) is an assessment
tool that nursing homes use to gather information about a resident. The assessment is
completed within 14 days of admission (7 days for Medicare residents) and at least once a
year thereafter. The MDS is reviewed every three months to monitor the residents condition
and to identify any changes The purpose of the MDS is to gather information about the
resident’s health, functional status and ability to perform activities of daily living (ADLs).
This in turn helps to determine the kind of help he/she will need and also to better
understand the reason for the difficulties a resident is having. The MDS process also
examines the resident’s routines, habits, activity preference and significant relationships.
This information helps nursing home staff to assist the resident to live more comfortably and
to feel more at home in the facility. Ultimately the MDS assists staff to set realistic goals
for the resident and to develop a comprehensive plan of care.
The Care Plan
The plan should be specific, stating what will be done, who will do it and when or how often it
will be done. When the assessment is completed, the information is analyzed and a plan of care
is developed to address all of the needs and concerns of the resident. The initial care plan
must be completed within 7 days after the MDS. The care plan will identify and address all of
the needs/problems of the resident and establish goals (measurable every three months by all
disciplines or more often if there is a significant status change).
The Care Conference
An interdisciplinary care conference will be scheduled every three months or more often if
needs/goals change. The resident and/or family members are invited to attend. The purpose
of the conference is to review the plan of care and the progress that has been made toward
the established goals. Another purpose of the meeting is to provide opportunity for the
resident and/or family members to voice any concerns and/or to ask any questions related to
care or life at the facility. CNAs should be involved in the review of the care plan and ideally
invited to attend.
The Care Plan
The planning of care is an on-going activity, not a one-time event. The care plan must
be regularly reviewed and up dated as needed to reflect the changing needs of the
people for whom we are providing care. The care plan is developed by the
interdisciplinary team, which means that all members of the heath care team
participate in the planning of care. The health care team includes:
Doctors - Nurses – Physical, Occupational, Speech Therapist - Social Worker

Nutritionist – Dietitian - Pharmacist – Psychologist – CNA/HHA – Family
The care planning process has five steps:
ASSESS – the person’s current condition, level of function and specific needs.
Establish a baseline. What is the status? What is needed? What is and what is not
working.
PLAN – Set goals to promote improvement, prevent decline and provide for comfort.
Determine what can be done to maintain or improve the condition. How will it get
done? Who will do it? When and how often? The goals should be clear and
measurable and the plan should include a time line for measuring progress.
IMPLEMENT – Putting the plan into action. Monitoring, reporting and documenting
progress toward goals.
EVALUATE – Check in. What is the status now? How is the plan working? Revisit the
goal/s, measure the progress. Is the goal still realistic?
MODIFY – Adjust or change the plan. Set new goals, or new timelines.
When you fail to plan, you plan to fail.
Documentation and Medical Record
Observing, reporting and recording are an important part of a direct care workers job in any
care setting. Each facility, agency group or private home will have its own specific rules and
routines for documentation, including the abbreviations that are allowed.
In all cases documentation should be considered as a formal communication. In many cases the
record is considered a legal document. Information should reflect what really happened and
when, in order to give an accurate accounting of the person's condition and needs as well as
the care given.
Documentation also serves as a tool for reimbursement/billing. Medicare, Medicaid and private
insurers rely on documentation to justify payment for services. In accurate information may
be considered fraud.
There is an saying in health care, "If it isn't documented, it hasn't been done"
A few guidelines to follow:

Timeliness:
·It is generally best to document at the end of a shift.
·Don't assume that you will remember later. You may want to carry a small pad of paper to
make notes as you go along.
·Never chart "in advance":
·Always date, initial or sign anything that you add to the record.
·Always report any urgent concerns immediately.
Accuracy:
·Maintain accurate and truthful records by recording only factual information and
observations
·Stick to the facts. Objective information is best.
·Only document your own actions, not others
·When recording statements made by another person, including the care recipient, use
quotation marks.
·Don't use pencil or something that can be smudged easily. Permanent ink pen is best.
·Make entries short and concise, but not so short that you don't mention something
important or useful.
Errors and Legalities:

·If after completing an entry you feel the need to add information, or clarify a point, write
the date and the additional comments with the word "addendum".
·Any changes or mistakes on an entry must be clearly noted. Never erase, scribble over, or
use white out. A single line through an incorrect entry with date, and initials is most
widely used.
·Don't alter anyone else's documentation. If you think it's wrong, see your supervisor or
the responsible person about it.
·
RECORD/DAILY FLOW SHEET
Resident Name: ______________________________________________________________________________

Write correct code (I = Independent; A = Assisted; D = Dependent) in the box for the day and skill you performed.
Place your initials at the bottom of the sheet in the box for the date and shift you performed the skills. Initial each page where you performed a skill.
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Temperature
Pulse
Respiration
Weight
DIET - % consumed
I – Independent 11-7
A – Assisted 7-3
D – Dependent 3-11
POSITIONING
A – Assisted 7-3
TRANSFER
A – Assisted 7-3
NAIL CARE
A – Assisted 7-3
BATHING
A – Assisted 7-3
HAIR CARE
A – Assisted 7-3
ROM EXERCISES
A – Assisted 7-3
INITIALS
11-7
7-3
3-11
RECORD/DAILY FLOW SHEET

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 26
Resident Name: ______________________________________________________________________________
Write correct code (I = Independent; A = Assisted; D = Dependent) in the box for the day and skill you performed.
Place your initials at the bottom of the sheet in the box for the date and shift you performed the skills. Initial each page where you performed a skill.
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ORAL HYGIENE
A – Assisted 7-3
DRESSING
A – Assisted 7-3
COMMODE
A – Assisted 7-3
PERINEAL CARE
A – Assisted 7-3
SKIN CARE
A – Assisted 7-3
BED PAN
A – Assisted 7-3
INITIALS
11-7
7-3
3-11
Nurse Aide Signature and Initials: _________________________________________________________
Accident/Incident Report Form
(Complete this form as soon after incident/accident as possible)
Date of incident: _______________ Time: ________ AM/PM
Name of person reporting:
Phone Number(s):
Was anyone other than reporter involved? (Circle one) YES NO
Name of others involved: __________________________________________

_____________________________________________________________
Phone Number(s):________________________________________________
Details of incident/accident:
(If more space is needed continue on back)
Was medical attention required/received? (Circle one) YES NO
Explain treatment received:
Physician/hospital Name:
Signature of reporter: _____________________________Date____________
Module 4
Infection Control
Hand Washing..................................................................................................................28
Introduction to Infection Control.............................................................................29
Signs And Symptoms Of Infection...........................................................................30
Precautions.......................................................................................................................31
Basic Rules of Bed-Making...........................................................................................32
Public Health Fact Sheet: Clostridium difficile.....................................................33
Public Health Fact Sheet: MRSA...............................................................................36
Public Health Fact Sheet: HIV...................................................................................39
Hand Washing
Introduction to Infection Control

Preventing the spread of infection is an important job responsibility of a direct care
worker. Infection control is embedded in every task that a direct caregiver performs.
Following infection control standards protects both the person receiving care and the
caregiver.
Micro-organisms (Microbes) = Small organism that are everywhere, but seen only under a
microscope. Common types of microbes include: Bacteria, Fungi, Viruses and Normal
Flora, which grows in the respiratory tract, intestines and on skin.
Pathogen = Microbes that cause infection.
Non-Pathogen = Microbes that do not cause infection.
Infection = A disease caused by the invasion and growth of microbes in the body.
Types of Infection
* Local Infection = In a certain location of the body.
* Systemic Infection = Travels through the bloodstream, throughout the body.
* Nosocomial = Healthcare Associated (HAIs) Infection = Infection acquired in a
health care setting.
Source = A pathogen that causes disease.

Reservoir = A place for a pathogen to grow – a warm, dark, moist place is best.
Portal of Exit = Any body opening that allows the pathogen to leave.
Mode of Transmission = How the pathogen travels.
Portal of Entrance = Any body opening that allows pathogens to enter.
Susceptible Host = A person at risk for infection.
Signs And Symptoms Of Infection
The immune system helps the body to fight infection. When a harmful pathogen
enters the body, the immune system will go to work to attack the pathogen.
Sometimes the pathogens grow too fast, or are too strong for the immune system
and an infection will grow.
Local infections are in a specific location, such as an ear infection, an infected

tooth, or an infected cut. An infection can spread through the blood. This is
called a systemic infection (blood poisoning). A systemic infection is very serious
and can be life threatening. Common signs and symptoms of infection include:
* Unsteady/Falls – Poor balance

* TIRED – low energy, fatigue, sleepy, weakness
* FEVER – can be low or can spike high
* CHILLS – can’t get warm.
* PAIN – burning, aching, tenderness
* LOSS OF APPETITE – not hungry, food does not sit well.
* NAUSEA – could include vomiting
* SKIN REDNESS – rash, itching, hot to the touch
* SWELLING – puffy, stiffness
* PUS – yellowish thick, mucus drainage
* CONGESTION – runny nose, cough
* BEHAVIOR CHANGE – irritability, agitation, confused, weepy, disorientation
* CONFUSION – foggy, unfocused
Elders are at higher risk for infection. They may only have
moderate symptoms. Even minor changes should be closely
monitored and reported.
Precautions
Medical Asepsis = clean technique is the practice used to maintain a clean environment.
Sterile technique is used to keep an area free of all microbes.
Precautions are used by health care workers to prevent the spread of infections and to
protect workers against exposure to contagious conditions.
Standard Precautions = guidelines set by the (CDC) Center for Disease Control for the
proper use of Personal Protective Equipment (PPE) to protect against exposure to body
fluids, also known as Bloodborne Pathogens. Standard precautions are used with everyone,
regardless of their health status, whenever exposure is possible. The guidelines include
proper handwashing before and after use of PPE and proper disposal of any contaminated
linens, supplies and waste.
There are additional types of precautions that may be used. These are called:
Modes of Transmission:
 Airborne – Germs that travel through the air
 Droplet – Coughing, sneezing, talking; droplets only stay in the air a few minutes.
 Contact - Direct touch
 Indirect – Touching contaminated surfaces
 Vector – Transmitted by animals
PPE includes Gloves, Gowns, Masks, goggles and face shields. There are proper ways to
put on (Don) and take off (Doff) PPE and a specific order and techique for donning and
doffing each item in order to prevent contamination/exposure. Always discard PPE in
appropriate trash receptacle.
DONNING PPE REMOVING PPE

Gown Gloves
Mask Eye-wear/goggles
Eye-wear/goggles Gown
Gloves Mask
OSHA = Occupation Safety and Health Administration sets and enforces workplace
safety and health standards. Under OSHA, employers are required to provide their
employees with a safe work place and where there is occupational exposure, the employer
shall provide, at no cost to the employee, appropriate PPE and having for the proper use.
People with dementia may not or cannot protect themselves from germs.
We must do it for them.
Basic Rules of Bed-Making
 Beds should be made every day and changed at least weekly
 A clean, dry, wrinkle-free bed helps prevent skin problems
 Handle soiled linen according to care plan. Follow standard precautions
 Do not shake linens in the air
 Hold clean and dirty linens away from your body
 Gather all clean linens before you begin
 Remove soiled linen one piece at a time, rolling linen away from you
 Launder soiled linen promptly
 Wash hands after handling soiled linens and before handling clean linens
 Do not lean over bed. Make bed one side at a time
CLOSED BED - When the person is up for the day, linens are pulled up to the top
of the bed.
OPEN BED - When the person is out of bed, and expected to get back in to bed.
Linens are fan-folded to the bottom of the bed in order to allow the person to pull
covers up independently.
Public Health Fact Sheet: Clostridium difficile
What is Clostridium difficile infection?

Clostridium difficile infection also known as “C. diff”, is a diarrheal illness caused by the
germ (a bacterium) Clostridium difficile. C. difficile can be found in the soil but it is also
commonly found in the hospital environment. It can be found in the stool of people with
infection and also in the stool of people without symptoms (carriers). Most cases of C.
difficile happen in patients who are taking or have taken antibiotics and who have been
exposed to healthcare settings. Antibiotics can destroy the “good” bacteria in the
intestines allowing C. difficile to grow.
What are the symptoms of infection?

The most common symptoms are watery diarrhea (usually 10 or more bowel movements per
day which can contain blood or mucous), fever, loss of appetite, nausea, and abdominal
(stomach) pain and tenderness. It is also possible to carry
C. difficile in the bowel and have no symptoms.
How is C. difficile spread?

C. difficile can form spores which can exist and remain infectious for a very long time.
These spores are not killed by temperatures or other things that kill bacteria that do not
form spores. C. difficile is spread from person-to-person. Spores from C. difficile can be
found in many environments, especially in healthcare facilities on bed rails, light switches,
and medical equipment. They can also be carried on the hands of healthcare providers
after caring for a patient who has C. difficile. Improper hand washing and incomplete
environmental cleaning of hospital rooms and bathrooms can put individuals in these
settings at risk of getting the infection.
Who is most at risk of C. difficile infection?

Since spores from this germ can live outside the body for a very long time, nursing homes
and hospitals have become common places for the elderly and patients taking antibiotics to
get this infection. Child care facilities have also become places where C. difficile can be a
problem. This germ can be found in the stools of healthy newborns and young infants
without causing infection. People with prolonged exposure in any of these settings or in
contact with a person with C. difficile infection are at higher risk of getting C. difficile.
It mostly affects people taking antibiotics, but is also more likely to affect the elderly
and people with bowel disease or other medical conditions. It is less likely to be a problem
in children.
How is C. difficile diagnosed?

Your healthcare provider must examine you and send your stool sample to a laboratory.
The laboratory then tests the sample for the presence of C. difficile or the toxins
(poisons) the bacteria produce. It is the toxins that cause the damage in the intestines.
How is C. difficile infection treated?

In most cases infection with C. difficile can be treated with certain antibiotics. C.
difficile can recur, however, after treatment ends. In very rare cases serious infection
can result and surgery may be required to remove part of the intestines.
How can you prevent C. difficile infection?

 Soap and water works the best against C. difficile. Always wash your hands
thoroughly with soap and water before eating or handling food and after
using the bathroom.
 Make sure all doctors, nurses, and other healthcare providers wash their
hands with soap and water or with an alcohol-based hand sanitizer before
and after caring for you. If you do not believe your healthcare provider has
washed their hands, please ask them to do so.
 Only take antibiotics as prescribed by your healthcare provider.
 If you are taking care of someone who has C. difficile or any kind of diarrhea, scrub
your hands with plenty of soap and water after cleaning the bathroom, helping the
person use the toilet, or changing diapers, soiled clothes or soiled sheets.
 Disinfect surfaces that may have been contaminated by an individual with diarrhea
or any other symptoms of C. difficile. Use a disinfectant with “sporicidal” on its
label or a fresh 1:10 dilution of household bleach and water. These will kill C.
difficile spores. However, keep in mind that bleach solutions must be handled with
care as they can irritate your skin, eyes, nose and respiratory secretions. Use them
in a well ventilated area.
What are hospitals and other facilities doing to prevent the spread
of C. difficile?
To prevent transmission of C. difficile, hospitals and long-term care facilities have
infection control measures in place.
 Doctors, nurses, and other healthcare providers should regularly wash their hands
with soap and water before and after caring for every patient. They may also wear
medical gowns and gloves while caring for patients with C. difficile.
 All rooms and bathrooms in hospitals and long term care facilities should be
thoroughly cleaned on a regular basis and all waste should always be properly
handled and disposed of.
 Contact with infected patients should be limited. Whenever possible, patients with
C. difficile should have their own room or only share a room if the other patient
also is infected with C. difficile. Hospitalized patients with C. difficile should avoid
common areas in the facility as much as possible. Visitors may be asked to wear
protective gowns and gloves. Children in daycare who are infected with C. difficile
may also be excluded while they have active diarrhea in order to reduce
transmission to the other children.
Where can you get more information?

 Your doctor, nurse or health care clinic.
 The Centers for Disease Control and Prevention (CDC) website at:
http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html
 Your local board of health (listed in the telephone directory under “government”).
 The Massachusetts Department of Public Health (MDPH), Division of Epidemiology

and Immunization at (617) 983-6800 or toll-free at (888) 658-2850, or on the
MDPH website at http://www.mass.gov/dph
Public Health Fact Sheet: MRSA
What is MRSA?
MRSA (methicillin-resistant Staphylococcus aureus) is a kind of bacteria that is resistant

to some kinds of antibiotics. To understand MRSA it is helpful to learn about
Staphylococcus aureus bacteria, often called “staph,” because MRSA is a kind of staph.
What are staph?
Staph are bacteria commonly carried on the skin or in the nose of healthy people. About
25-30% of the U.S. population carry staph on their bodies at any time.
Do staph always make people sick?
No. Many people carry staph in their nose or on their skin for a period of time and
do not know they are carrying them. They do not have skin infections. They do not
have any other signs or symptoms of illness. This is called “colonization.”
Sometimes, though, staph can cause an infection, especially pimples, boils and other
problems with the skin. These infections often contain pus, and may feel itchy and
warm. Occasionally, staph cause more serious infections.
How are staph spread?
Staph are spread by direct skin-to-skin contact, such as shaking hands, wrestling, or
direct contact with the skin of another person. Staph are also spread by contact with
items that have been touched by people with staph, like towels shared after bathing and
drying off, or shared athletic equipment in the gym or on the field. Staph infections start
when staph get into a cut, scrape or other break in the skin. People who have skin
infections—painful, swollen pimples, boils, and rashes, for example—should be very careful
to avoid spreading their infection to others.
Is MRSA different from other staph?
Yes. MRSA is different from other staph because it cannot be treated with some
antibiotics. When antibiotics are needed to treat a MRSA infection, the right
antibiotic must be used. If the right antibiotic is not used, the treatment may not work.
MRSA is just like other staph in almost every other way:
• MRSA can be carried on the skin or in the nose of healthy people, and usually not cause
an infection or make them sick.
• It can cause minor skin infections that go away without any special medical treatment.
• It is spread the same way as other staph.
• The symptoms are the same as other staph infections.
What are the symptoms of an infection caused by staph?
Pimples, rashes, pus-filled boils, especially when warm, painful, red or swollen, can mean
that you have a staph or MRSA skin infection. Occasionally, staph can also cause more
serious problems such as surgical wound infections, bloodstream infections and pneumonia.
The symptoms could include high fever, swelling, heat
and pain around a wound, headache, fatigue and others.
What should I do if I think I have a staph skin infection?
Keep the area clean and dry. See your doctor, especially if the infection is large, painful,
warm to the touch, or does not heal by itself.
How will my doctor know if I have a MRSA infection?
The only way to tell the difference between MRSA and other staph infections is with lab
tests. Lab tests will also help your doctor decide which antibiotic should be used for
treatment, if antibiotic treatment is necessary. Your doctor will usually take a sample on a
swab (like a Q-tip) from the infected area. The sample will be sent to a laboratory to see
if the infection is caused by staph. Blood and other body fluids can also be tested for
staph.
How are MRSA infections treated?
Most MRSA skin infections are treated by good wound and skin care: keeping the
area clean and dry, washing your hands after caring for the area, carefully
disposing of any bandages, and allowing your body to heal. Sometimes treatment
requires the use of antibiotics. Lab tests help your doctor decide which antibiotic
should be used for treatment, if antibiotic treatment is necessary. If antibiotics
are prescribed, it is important to use the medication as directed unless your
doctor tells you to stop. If the infection has not improved within a few days after
seeing your doctor, contact your doctor again.
How can I prevent a staph infection?
• Regular handwashing is the best way to prevent getting and spreading staph,
including MRSA. Keep your hands clean by washing them frequently with soap and
warm water or use an alcohol-based hand sanitizer, especially after direct contact
with another person’s skin.
• Keep cuts and scrapes clean and covered with a bandage until they have healed.
• Avoid contact with other people’s wounds or bandages.
• Avoid sharing personal items such as towels, washcloths, toothbrushes and

razors. Sharing these items may transfer staph from one person to another.
• Keep your skin healthy, and avoid getting dry, cracked skin, especially during the
winter. Healthy skin helps to keep the staph on the surface of your skin from
causing an infection underneath your skin.
• Contact your doctor if you have a skin infection that does not improve.
For more information about MRSA, visit the

MDPH website at www.mass.gov/dph
Public Health Fact Sheet: HIV
What is HIV?
HIV (Human Immunodeficiency Virus) is caused by a virus that attacks your body and
makes it hard for you to fight off other infections. HIV is the virus that causes AIDS
(Acquired Immune Deficiency Syndrome), a condition where your body becomes unable to
protect itself from certain kinds of infections. This means that people with AIDS can get
diseases which a healthy person's body would normally fight off easily. Once you have the
HIV virus in your body, it becomes easier for you to get sick from other things. A health
care provider can tell from testing your blood how much virus you have in your body and
how hard it may be for your body to protect itself from other germs. When your body
gets too weak to fight off other infections, a health care provider may say that you have
AIDS.
How do you get HIV?
If you have anal sex, vaginal sex, or oral sex without a condom with someone who has it,
you can get it. Some kinds of sex may be riskier than others (e.g. oral sex is lower risk).
You can also get it from sharing needles or works with someone who has the virus. It is
passed through body fluids (like blood, vaginal fluid or semen). It can also be passed from
mother to baby during birth or breastfeeding. You can’t get it from:
• insect bites
• kissing or hugging
• shaking hands
• sharing food or using the same dish
• sitting on public toilets
How do you know you have it?
Many people don’t know they have HIV. You may not have symptoms until your body gets so
weak that you get sick from something else. You may have:
• small sores, blisters, bumps or a rash

• a sore throat
• chills or sweats
• diarrhea
• a fever or swollen glands
• weight loss
The only way to know if you have HIV is to get tested.

What is the test like?
A doctor, nurse or testing counselor will usually take a sample of blood from your fingeror
from your arm or they may swab the inside of your mouth.
How is HIV treated?
There is no cure for HIV or AIDS. Medicines can help reduce the amount of virus in the
body. If you have HIV, talk with your health care provider about how you can stay healthy
and live longer with the disease.
What can you do to protect yourself?
• You can choose not to have sex

• You can reduce your number of partners if you choose to have sex
• You can use condoms when you have sex
• You can talk with your partner(s) about STDs
• You can avoid sharing needles or other works when using drugs
• You can talk with your health care provider and get tested
To find out more about HIV or AIDS or for information about where you can go to get
tested, call (800) 235-2331 or visit www.mass.gov/dph/aids
QUESTIONS AND ANSWERS ABOUT
Methicillin-resistant Staphylococcus aureus (MRSA)
What is MRSA?
MRSA is a kind of bacteria that is resistant to some kinds of antibiotics. To understand MRSA it is helpful
to learn about Staphylococcus aureus bacteria, often called “staph,” because MRSA is a kind of staph.
What is staph?
Staph is a bacteria commonly carried on the skin or in the nose of healthy people. About 25-30% of the
U.S. population carries staph on their bodies at any time.
Does staph always make people sick?

No. Many people carry staph in their nose or on their skin for a period of time and do not know they are
carrying them. They do not have skin infections. They do not have any other signs or symptoms of
illness. This is called “colonization.”
Sometimes, though, staph can cause an infection, especially pimples, boils and other problems with the
skin. These infections often contain pus, and may feel itchy and warm. Occasionally, staph cause more
serious infections.
How is staph spread?

Staph are spread by direct skin-to-skin contact, such as shaking hands, wrestling, or other direct contact
with the skin of another person. Staph are also spread by contact with items that have been touched by
people with staph, like towels shared after bathing and drying off, or shared athletic equipment in the
gym or on the field. Staph infections start when staph gets into a cut, scrape or other break in the skin.
People who have skin infections—painful, swollen pimples, boils, and rashes, for example—should be
very careful to avoid spreading their infection to others.
Is MRSA different from other staph?

Yes. MRSA is different from other staph because it cannot be treated with some antibiotics. When
antibiotics are needed to treat a MRSA infection, the right antibiotic must be used. If the right antibiotic
is not used, the treatment may not work. MRSA is just like other staph in almost every other way:
• MRSA can be carried on the skin or in the nose of healthy people, and usually not cause an infection
or make them sick.
• It can cause minor skin infections that go away without any special medical treatment.
• It is spread the same way as other staph.

• The symptoms are the same as other staph infections.
What are the symptoms of an infection caused by staph?

Pimples, rashes, pus-filled boils, especially when warm, painful, red or swollen, can mean that you have
a staph or MRSA skin infection. Occasionally, staph can also cause more serious problems such as
surgical wound infections, bloodstream infections and pneumonia. The symptoms could include high
fever, swelling, heat and pain around a wound, headache, fatigue and others.
What should I do if I think I have a staph skin infection?

Keep the area clean and dry. See your doctor, especially if the infection is large, painful, warm to the
touch, or does not heal by itself.
How will my doctor know if I have a MRSA infection?

The only way to tell the difference between MRSA and other staph infections is with lab tests. Lab tests
will also help your doctor decide which antibiotic should be used for treatment, if antibiotic treatment is
necessary.
Your doctor will usually take a sample on a swab (like a Q-tip) from the infected area. The sample will be
sent to a laboratory to see if the infection is caused by staph. Blood and other body fluids can also be
tested for staph.
How are MRSA infections treated?

Most MRSA skin infections are treated by good wound and skin care: keeping the area clean and dry,
washing your hands after caring for the area, carefully disposing of any bandages, and allowing your
body to heal. Sometimes treatment requires the use of antibiotics. Lab tests help your doctor decide
which antibiotic should be used for treatment, if antibiotic treatment is necessary. If antibiotics are
prescribed, it is important to use the medication as directed unless your doctor tells you to stop. If the
infection has not improved within a few days after seeing your doctor, contact your doctor again.
How can I prevent a staph infection?

• Regular hand washing is the best way to prevent getting and spreading staph, including MRSA. Keep
your hands clean by washing them frequently with soap and warm water or use an alcohol-based hand
sanitizer, especially after direct contact with another person’s skin.
• Keep cuts and scrapes clean and covered with a bandage until they have healed.
• Avoid contact with other people’s wounds or bandages.
• Avoid sharing personal items such as towels, washcloths, toothbrushes and razors. Sharing these items
may transfer staph from one person to another.
• Keep your skin healthy, and avoid getting dry, cracked skin, especially during the winter. Healthy skin
helps to keep the staph on the surface of your skin from causing an infection underneath your skin.
• Contact your doctor if you have a skin infection that does not improve.
For more information about MRSA, visit the MDPH

website at: www.mass.gov/dph
Module 5
Safety and Emergencies

Situations That Are Considered to be Emergencies............................................52
Responding To An Emergency.....................................................................................56
What To Do In A Fire...................................................................................................59
Handling Hazardous Substances................................................................................60
Safety
As a Nursing Assistant you have a great deal of responsibility for the health and
well-being of the people for whom you provide care. However, your first
responsibility is always to your own well-being. You can’t give water from a dry
well.
An important key to safety is the understanding and management of the risk

factors involved. Risk factor = something that is likely to increase the chances
that a certain event or condition will happen.
Two Aspects of Safety:

Prevention: To keep from happening, to stop
Preparedness: To anticipate, to plan, to make ready
Five Areas of Safety:

1. Personal Safety
2. Safety of the Person Receiving Care
3. Environmental Safety
4. Safe use of Equipment, Devices, Appliances
5. Emergency Preparedness
In order to provide safe and effective care, it is important to understand:

 The goals of the Care Plan
 The consumer’s Baseline = current condition, abilities, disabilities.
 Risk factors involved
 Cultural factors
NOTE: Home Care Aides do not make any changes in a consumer’s home, diet
routine or lifestyle without direction from, consumer, supervisor, responsible
person or emergency contact.
Every individual has the right to live the way they choose; this includes taking
risks.
Identifying and reporting any situations or conditions that seem less than safe is
an important job responsibility of an HHA.
Always be clear about who to report to and how to contact that person.
Remember that your own safety comes first!
Guidelines for Personal Safety:
 Maintain good hydration. Drink plenty of water.
 Get enough rest and nourishment.
 Perform only tasks that are within your job description.
 Accept only the tasks you feel confident performing. Request assistance
with any task you are unsure of.
 Always follow the care plan.
 Don’t rush.
 Ask question to clarify anything you don’t understand.
 Use proper body mechanics.
 Request assistance with care or transfer as needed.
 Observe standard precautions and blood borne pathogen standard and use
any personal safety equipment properly.
 Maintain professional boundaries.
 Follow all agency and facility policies.
 Don’t bring a lot of personal items in to a consumer’s home.
 Lock personal items in the trunk of your car.
 If you have broken skin, cover all open areas with a band-aid.
 Let office or emergency contact know if your schedule changes.
 If the elder lives in an unsafe area, you may need to change your visit time.
 Car should be in good working condition. Keep gas tank above ½ full.
Communicating Concerns in Home Care
As a Home Care Aide, you will see many different types of clients in a variety of
home settings. Generally you will be working unsupervised in the client's home. You
may be the only person aware of a health or safety concern.
Many factors contribute to safety in the home, for example the time of year. Snow
removal/ lawn care. Older homes generally have more safety concerns than a newer
home. Location of the home may also be an issue.
Communication (documentation and reporting) is an important responsibility of a
Home Care Aide. It is essential that you know what to communicate, in what form
and to whom you should report.
Things that you need to know prior to starting a case:
 Who is the emergency Contact/who to report to?

 Who is responsible for medications/care plan
 Who else is involved in the case
 When to call 911
 What health concerns are being monitoring
 What is the backup plan
Some Situations Require Immediate Attention.
If any of these situations occur during your visit call your supervisor or the
client's responsible person immediately:
 Witnessed/un-witnessed falls
 No food or money to buy food or Medications
 EMT's could not fit a stretcher in their home
 Client doesn't answer the door or is not home at a scheduled visit
 Client asks you to leave early
 Client expressing suicidal thought
 Client refuses personal care
 Client has no cleaning supplies
 Client asks you to complete a task that's beyond your job description
 Suspected sexual, emotional, spiritual, physical or financial abuse
 Personal Response System not working
 Change in physical/mental status
 Inappropriate home temperature
 No electricity
 Environmental safety concern
Home Safety Check List
As a health care worker, you encounter potentially hazardous situations every day.
Because you are working in the homes of patients, you have less control over the
working environment. You should be aware of potential hazards and know how to
handle and avoid them. This safety check list will help to identify home hazards.
Outdoors-
o Be aware of uneven sidewalks entering the home.
o Have handrails on both sides of stairs.
o Keep all walk ways and stairs free of clutter; rock, ice and snow.
o Have adequate outside lighting.
o Is the snow removed from the drive way, and walk way.
o Could an ambulance enter the drive way.
Kitchen-
o Maintain well lit room
o Remove scatter rugs
o Wipe up spills immediately
o Have an A-B-C fire extinguisher in kitchen.
o Keep stove free of grease and have pot holders within easy
reach,
o Appliances unplugged when not in use.
Basement-
o Are the cellar stairs stable (in good working order)., are there
railings in place
o Remove clutter from stairs.
o Are there carbon monoxide detectors1 in the home. They will
need to be installed 5feet from the floor.
o Keep area well lit.
Bathroom-
o Maintain a well it room
o Are grab bars hand rails needed or in need of repair.
1
If an elder does not have working smoke or Carbon monoxide detectors, they can call the fire department in the
town they live in for assistance.
o Non-skid surface in the tub
o Raised toilet seat or need one, bed side commode needed for
night use.
o Water temperature less than 120 degrees.
o Non-skid mat beside the tub
Bathroom -
o Does the person need a tub bench.
o Does the person need a hand held shower.
o Have a night light in use.
Living Room, Dining Room -
o Maintain a well lit room.
o Be careful of area rugs, may need to tape down.
o Keep electrical and cords away from the walk ways.
o Use high couches or chairs for easy sitting and standing.
o Avoid clutter around inside walk ways.
Smoke Detectors -
o Minimum one per floor. Need to be on the ceiling NOT WALLS.
o Replace batteries 2x a year.
o Test each one monthly.
o Carbon Monoxide detector should be installed on every floor of your home.
These can be installed on the wall 5 feet above from the floor.
Bed Room -
o Make sure bed is not too high, can the persons feet touch the floor. Does
the person need a hospital bed.
o Utilize night light or monitor.
o Keep phone or health watch button near the bed during the night.
o May need a bedside commode or urinal for night use.
Miscellaneous Information -
o Watch out for cats and dogs and their toys.
o Visit your MD regularly.
o See podiatrist regularly. Sore feet can cause you to fall.
o To avoid dizziness when first getting out of bed, have the person sit on the
edge of the bed for 1-2 minutes before standing.
o Keep an updated File of Life on your fridge-Review person’s medications
every 6 months.
Safety Measures for Tub Baths and Showers
 Clean the tub/shower before and after use.

 Check all safety equipment, hand rails, grab bars, lifts, tub bench,
rubber mat. Report any malfunctions. — body alarms
 Follow the care plan
 Wipe up spills promptly.
 Cover the person for warmth and privacy. The person may want to
remain covered during bathing.
 Place needed items within persons reach.
 Be sure persons use grab bars or hand rails for entering and exiting
the bath. Towel bars are made to hold towel not people. Report if grab
bars are needed.
 Turn cold water on first; then hot water. Turn hot water off first;
then cold water.
 When adjusting water temperature, always direct water away for the
person.
 Fill the tub before the person gets into it.
 Drain the tub before the person gets out of the tub. Cover them for
privacy and warmth.
 Keep the water on the person during the entire shower. You can wet
towels and keep them over the person shoulders during tub baths and
showers to ensure their warmth.
 AVOID BATH OILS! They make bathroom surfaces slippery.
 DO NOT leave weak or unsteady persons unattended.
 Stay within hearing distance if the person can be left alone. Can give
them a bell if at home or the call bell in facility.
 Household water temperature should be less than 120 degrees.
Situations That Are Considered to be Emergencies
ALLERGIC REACTIONS - Can be to food or bee stings. You may observe:
 Trouble breathing
 Feeling of tightness in the chest and throat
 Swelling of the face, neck, and tongue
 Rash, hives, dizziness, or confusion
People who know that they are allergic may have a special kit.
WHAT TO DO: If the person has trouble breathing - call 911. If they have a kit,
use the kit
CHEST PAIN OR PRESSURE - Most people who die of a heart attack die within 2
hours of onset of symptoms. Recognizing the signs of potential heart attack and
getting prompt help can save lives! You may observe:
 Chest pain, heaviness (“an elephant sitting on the chest”) not relieved by
rest, changed position, or medication. Pain may radiate to arm, neck, or jaw
 Shortness of breath
 Nausea and/or vomiting
 Sweating or change in skin appearance
 Dizziness or unconsciousness
ACHE, HEARTBURN or INDIGESTION - may occur more in women, elderly and

diabetics.
WHAT TO DO: Call 911, stay with client, make comfortable - adjust position, prop
up head, loosen clothing, stay calm.
HEAD, NECK, AND BACK INJURIES - Injuries to the head, neck, or back
account for only a small percentage of all injuries (according to the Red Cross), but
they are the cause of more than half of injury-related deaths.
SIGNS OF HEAD, NECK AND BACK INJURIES ARE OFTEN SLOW TO

DEVELOP AND ARE NOT ALWAYS OBVIOUIS AT FIRST. Always suspect a
head, neck, or back injury if:
 There’s been a fall greater than the person’s height or if elderly
 A diving injury
 A person is found unconscious for unknown reasons
 Any injury where a person’s helmet is broken
 Any known lightning strike
Signs of this type of injury:
 Changes in consciousness, loss of balance, seizures
 Sever pain to head, neck, or back
 Tingling or loss of sensation anywhere on body
 Loss of mobility of a body part
 Unusual bumps or depressions on head or spine
 Blood or other fluids draining from ears
 Heavy external bleeding
 Impaired breathing or vision
 Nausea or vomiting or persistent headache
WHAT TO DO: Call 911! Do NOT move person unless absolutely necessary. Stay
with the person until help arrives
SUDDEN ILLNESS - Many types of sudden illnesses often have similar signs.
Usually you will not know what exactly is going on, but you can still help. Call 911
when:
 There is a chance in consciousness or losing consciousness
 Difficulty breathing
 Chest pains or pressure
 Abdominal pain or pressure
 Person is vomiting or passing blood
 Slurring speech, severe headache or seizures
Some causes of sudden illness:
 Diabetic Reactions
 Cardiac Episodes
 Seizures Disorders
 Acute Abdomen
 Stroke
 Fainting
FIRST AID
Animal Bites - if bleeding is minor, WEAR GLOVES - wash wound with soap and
water, control bleeding, and apply antibiotic ointment and dressing. Get medical
attention if the wound bleeds severely, appears to require sutures, or the animal is
suspected of having rabies. May need to contact Animal Control.
Burns - are caused by heat, chemicals, electricity, or radiation. Superficial burns

(first degree) - cool burn with lots of cool water. DO NOT USE ICE OR ICE
WATER on small superficial burns. Can apply soaked towel or cloth. Keep cloth
cool by adding more cool water. Cover burn with sterile dressing to prevent
infection.
CALL 911 FOR BURNS WHEN:

 There’s trouble breathing
 Burns covers more than one body part or are on head, neck, feet or genitals
 Children or elderly unless they are very minor
 Burns result from chemicals, explosions, or electricity
Minor wounds - A wound is an injury to the skin and soft tissue beneath it. Damage
to blood vessels cause bleeding. USE GLOVES WHEN CARING FOR WOUNDS
TO PREVENT DISEASE TRANSMISSION!!! For abrasions and minor cuts - wash
wound gently with soap and water. Control bleeding and apply antibiotic ointment
and clean dressing.
CALL 911 or SEEK MEDICAL ATTENTION FOR WOUNDS WHEN:

 Bleeding can’t be stopped - apply additional dressings. DO NOT TAKE OFF
EXISTING DRESSINGS
 Apply pressure to nearby artery until help arrives
 Wounds that show muscle or bone, or involve joints are deep and require
suture, or involve hands and feet
 Human bites
 Any wound that looks like it might leave a scar – especially on the face
 Skin or body parts have been partially or completely torn away
Bruises - apply ice or cold pack to the bruise to control pain and swelling. Place a
cloth between the person’s skin and the cold source to prevent injury to the tissue.
Nosebleed - have person lean slightly forward, pinch the nose shut for
approximately 10 minutes. Apply ice pack. If still bleeding, apply pressure on
upper lip just beneath the nose. If it STILL doesn’t stop, seek medical attention.
Dislocations/broken bones - Only a trained professional can tell the difference

between a sprain, fracture, or dislocation. You do not need to know what kind of
injury it is to help.
SIGNS: Pain, bruising, and swelling

 Apply ice or cold pack with cloth between the cold source and the skin
 AVOID MOVEMENT or activity that causes pain
 IF SERIOUS INJURY IS SUSPECTED: CALL 911
 If an imbedded object - call 911. Keep person still. DO NOT MOVE
OBJECT!!! Place bulky dressing around object to support staying in place.
Seizures - Protect person from injury. DO NOT restrain or attempt to place

anything in the person’s mouth. DO NOT leave person alone. Check for breathing,
and call 911.
Fainting - May indicate a more serious condition. CALL 911. Elevate legs 8-12
inches if injury is not suspected. Loosen any tight clothing. CHECK breathing. DO
NOT give anything to eat or drink.
Choking Adult (Conscious) - Clutching throat. Unable to speak, cough forcefully, or

breathe. High pitched wheeze. CALL 911!!! Place thumb side of fist against middle
of abdomen just above the navel. Grasp fist with other hand. Give quick upward
thrusts. Repeat until object is coughed up and person breathes on own or becomes
unconscious.
Choking Adult (Unconscious) - If person becomes unconscious, look for object in

mouth. If seen, remove with your fingers. IF trained in CPR, begin CPR. If not,
wait with person until help arrives.
Choking Small Child (Conscious) - Turn small child upside down to dislodge object.
Give 4 sharp blows between shoulder blades. Repeat if necessary. CALL 911
Electric shock - Shut off source of electricity. If not possible, separate person
from electrical source using loop of rubber, cloth, dry wood, or leather belt. CALL
911 and stay with person until help arrives.
Heat Exhaustion - If person is conscious, move person to cool place. Give cool
fluids. Loosen or remove perspiration soaked clothing. Apply cool, wet clothes to
skin.
Poison Ingested- CALL 911 or call Poison Control (1-888-222-1222), stay with
person until help arrives.
Responding To An Emergency
Emergencies can’t always be avoided. It is likely that at some time during your life
or your work that you will be witness to an emergency or be required to provide
first aid. It can be frightening or confusing. STAY CALM!! You can help!!
Getting help quickly is often the single most important thing you can do.
Call 911 when:
 The person is unconscious
 Has trouble breathing or is breathing in a strange way
 Has chest pain or pressure
 Is bleeding severely
 Has severe pain or pressure in the abdomen and it doesn’t go away
 Is vomiting or passing blood
 Has injuries to the head, neck, or back
 Has possible broken bones
 Has fallen and can’t get up
 Shows signs of having had a stroke
ALSO CALL FOR: fire, downed electrical wires, vehicle collision, presence of
poisonous gas, or when a person suddenly becomes disoriented.
Use a land line whenever possible to call 911.
IF THE PERSON DOES NOT WANT 911 TO BE CALLED? CALL ANYWAY!!

Tell the person that they can refuse treatment, and will not have to pay for the
ambulance if they don’t go in it. The EMS workers will be able to assess the
situation and often convince the person to accept treatment.
Always complete an Incident/Accident form or report.
The Recovery Position
This position is used after an emergency such as fainting,

seizure or fall. The recovery position is a side lying position
which keeps the airway open and prevents aspiration.
HAND SUPPORTS HEAD
KNEE STOPS BODY FROM

ROLLING ONTO
STOMACH
The person is positioned on their left side, to allow any fluids, mucus, and
vomitus to drain from the mouth and to keeps the head, neck and spine in
proper alignment.
The recovery position is used when the person is breathing and has a
pulse but is NOT responding. DO NOT USE the recovery position if you
suspect head/neck/back injury. It may be necessary to activate the
EMS system or follow the agency's emergency policy.
What To Do In A Fire
R- Rescue
Rescue person in immediate danger. Assist
them to a safe place
A- Alarm
Call 911. Pull building alarm if there is one.
C- Confine
Close doors and windows to confine the fire.
Turn off oxygen and electrical appliances.
E- Extinguish
If you can, put the fire out. For small fires,
use a fire extinguisher if you have one
Handling Hazardous Substances
A hazardous substance is any chemical that can cause harm. Substances that
CNAs and HHAs commonly handle -- such as household cleaners and personal
hygiene products -- are perfectly safe when used properly. However, the same
products may become hazardous under certain circumstances such as:
* When ingested
* When inhaled
* If it gets in the eye
* When mixed with other substances
* When stored improperly
* When expired
By law all hazardous substances must have important safety information on the
label and a phone number to call for more information about the contents of the
product.
Every hazardous substance must have a MSDS (Material Safety Data Sheet).
That can be available upon request. The MSDS provides detailed information about
the hazards of the substance.
The Occupational Safety and Health Administration (OSHA) mandates that all
employees have a right to know about the hazardous substances that they may
come in to contact with in the course of their work. OSHA requires that all
employers have a Hazard Communication program that includes:
* Container labeling
* MSDSs
* Employee training
This is not true of home care. In home care you are in a client’s home and you will
be using products that they have. However, you still have the right to know.
White vinegar mixed with water makes a good, safe household disinfectant.
Use a 3 to 1 ratio: 1 cup white vinegar with 3 cups of water.
Bleach also can be mixed with water to make a disinfectant.

1 part bleach and 10 parts water.
Module 6
Human Growth and Development
Culture...............................................................................................................................62
Basic Human Needs – Maslow’s Hierarchy...............................................................63
Human Growth and Development................................................................................64
Stages of Growth and Development..........................................................................65
Erik Erikson’s Stages of Psychosocial Development.............................................66
The Aging Process..........................................................................................................66
Physical Changes Common to the Aging Process....................................................67
The Stages of Grief......................................................................................................69
Culture
Culture = the distinct way that people live. Culture influences what a person
perceives as “normal” or “the right way” to do things.
Cultural influences can come from the ethnic background or country a person is
from, their religion, a group that they are a part of, where they work, go to school,
or even their interest and hobbies. Culture can affect:
o Life style
o Beliefs
o Language
o Traditions
o Customs
o Food
o Family roles and interactions
o Social behaviors
o Religion
o Beliefs about health care
Culture can affect communication. For example, in some cultures making eye
contact with an elder is considered to be disrespectful; in ours it is a sign of
respect. As a caregiver it is good to learn about the culture of the person you are
caring for. Be open and curious and always hold the person and their culture in
positive regard.
When cultural differences create challenges, speak with your supervisor.
Basic Human Needs
Described by Abraham Maslow as a Hierarchy
Growth= Measurable physical changes
Experiencing
Selfpersonal
potential, living to the
Actualization
limit of one’s capacity.
Development= Changes in mental, emotional and social functions
Growth and development occurs in stages

Each stage is the basis for the next
Each stage has its own developmental tasks
Every stage affects the whole person
Holistic = A concept that considers the whole person
 Physical Health
 Mental Health
 Emotional Stability
 Social/Spiritual Well-being
Many factors such as the following can influence and effect the growth and
development of a person:
 Environmental Factors
 Health
 Relationships
 Past experiences
 Culture
 Beliefs
 Economics
Each stage of growth and development relates to and depends upon the stage
before. No developmental task can be skipped.
Stages of Growth and Development
Infancy (Birth to 1 year)
 Learning to walk
 Learning to eat solid food
 Beginning to talk and communicate with others
 Beginning to have emotional relationships with parents and siblings
 Developing stable sleep and feeding patterns.
Toddlerhood (1 to 3 years)
 Tolerating separation from primary caregiver
 Gaining control of bowel and bladder function
 Using words to communicate
 Becoming less dependent on the primary caregiver
Preschool (3 to 6 years)
 Increasing ability to communicate and understand others
 Performing self-care activities
 Learning gender differences and developing sexual modesty
 Learning right from wrong and good from bad
 Learning to play with others
 Developing family relationships
School Age (6 to 9 or 10 Years)
 Developing the social and physical skills needed for playing games
 Learning to get along with children of the same age and background
 Learning gender appropriate behaviors and attitudes
 Learning basic reading, writing, and arithmetic skills
 Developing a conscience and morals
 Developing a good feeling and attitude about oneself
 Entering the world of peer groups, games, and learning
Adolescence (12 to 18 Years)
 Accepting changes in the body and appearance
 Developing appropriate relationships with peers
 Accepting the male or female role appropriate for one’s age
 Becoming independent from parents and adults
 Developing morals, attitudes, and values needed to function in society
 rapid growth and physical and social maturity
 puberty
Young Adulthood (18 to 40 Years)
 Choosing an education and career
 Selecting and learning to live with a partner
 Becoming a parent and raising children
 Becoming self sufficient
Middle Adulthood (40 to 65 Years)
 Adjusting to physical changes
 Having grown children
 Developing leisure-time activities
 Adjusting to aging parents
Late Adulthood (65 Years and Older)
 Adjusting to decreasing strength and loss of health
 Adjust to retirement and reduced income
 Coping with partner’s death
 Developing new friends and relationships
 Preparing for one’s own death
Erik Erikson’s Stages of Psychosocial Development

Erikson’s theory is that at each stage of life, we are faced with developmental
tasks or challenges. Successful completion of each task/challenge leads to
continued growth and a healthy personality. Challenges/tasks not successfully
completed may reappear as problems later in life. For example, someone whose
needs were not well attended to in the 1st year of life may be fearful in later life.
In his 90s, Mr. Erikson added the achievement of wisdom as the ultimate stage of
emotional maturation.
Stage Issue Favorable Outcome Unfavorable Outcome

Challenge
1st Year of Life Trust Vs. Mistrust Faith in the environment Suspicion, fear of future
Hope and future events events
2nd Year Autonomy Vs. Doubt A sense of self-control Feelings of shame and self-
Will and adequacy doubt
3 – 5 years Initiative Vs. Guilt Ability to be a self- A sense of guilt and inadequacy
Purpose starter, to initiate one’s to be on one’s own
own activities
6 year to puberty Industry Vs. Inferiority Ability to learn how A sense of inferiority at
Competence things work, to understanding and organizing
understand and organize
Adolescence Identity Vs. Confusion Seeing oneself as a unique Confusion over who and what
Fidelity and integrated person one really is
Early Adulthood Intimacy Vs. Isolation Ability to make Inability to form affectionate
Love commitments to others, relationships
to love
Middle Age Generatively Vs. Self- Concern for family and Concern only for self, one’s own
Care absorption society in general well-being and prosperity
Aging Years Integrity Vs. Despair A sense of integrity and Dissatisfaction with life,
Wisdom fulfillment, willing to face despair over prospect of death
death
The Aging Process

If given a choice, growing to old age is the option most of us would choose, but few
of us look forward to it.
Abraham Joshua-Heschel put it this way: “Old age is something we all want to
attain. However, once attained we consider it a defeat, a form of capital
punishment. In enabling us to reach old age, medical science may think that it gave
us a blessing; however we continue to act as if it were a disease.”
We are a very youth oriented culture, but that is changing; this is due to the post-
World War II baby boom = Between 1946 and 1964, 78.3 million babies were born.
The baby boomers are aging.
Currently the fastest growing segment of the population is over 80 years old.
People are living longer than ever before. In 1930 human life expectancy was 59
years old. In 1965 it was 70. Today 80% of people in this country can expect to
live 80 years.
The baby boomers are aging. As a result of these changes, we now have new age
group definitions: the “young old” are people ages 65-80. People over 80 are the
“old-old”
No two individuals age alike. There is a wide range of “normal” aging

characteristics. A person’s physical, psycho–social, environmental, and family
histories influence how they age.
Although people often develop chronic health conditions, disabilities or disease as

they age, disease is not a normal part of aging. This means that if all goes well one
will die healthy.
There are common functional changes that occur with age. How we adjust to the
body system’s decline and psychosocial changes impacts how we age. Our own
attitudes towards aging may be the biggest influence in how well we age.
Healthy aging requires adjusting to declining abilities and decreased independence,

dealing with change and losses, and accepting support.
Physical Changes Common to the Aging Process
Aging is a very individual process. No two people age exactly the same. Genetics, personal
health history, life style, diet, activity, stress level, environment and attitude toward aging
are important factors in how a body ages.
People are staying healthy and living longer than ever before. However, even in the
healthiest of people, body system functions slow down, energy level and body efficiency
declines as the body ages. Generally these changes occur slowly and gradually over time.
People adapt, adjust and make changes in their lifestyle and activities of daily living to
accommodate these changes, often without conscious awareness of the decline.
The following is a list, by body system, of common age related changes. Not all people
experience all of the below-listed changes:
CARDIOVASCULAR SYSTEM:
 Heart muscle weakens, pumps with less force, increase fatigue may occur
 Arteries narrow and are less elastic
 Less blood flows through narrowed arteries
 Weakened heart works harder to pump blood through narrowed vessels
 Fluid retention may occur
INTEGUMENTARY (SKIN) SYSTEM:

 Skin becomes less elastic and loses its strength
 Brown spots (age spots or liver spots)
 Fewer blood vessels
 Fewer nerve endings can result in decreased sensitivity to pain
 Fatty tissue layer is lost
 Skin thins and sags, becomes fragile, and wrinkles appear
 Decreased secretion of oil and sweat glands may result in dry skin and itching
 Decreased sensitivity to heat and cold
 Nails become thick and tough
 Whitening/graying, loss/thinning, drier hair - Facial hair for some women
DIGESTION SYSTEM:
 Decreased saliva production may result in diminished swallowing capacity
 Loss of teeth
 Decreased appetite may result in decreased nutritional intake
 Slower digestion due to decreased secretion of digestive juices
 Difficulty digesting fried and fatty foods
 Decreased peristalsis causing flatulence and constipation.
Physical Changes Common to the Aging Process – Continued
NERVOUS SYSTEM:
 Slower nerve conduction
 Reduced blood flow to brain
 Reflexes and response time slow
 Decrease in short term memory, which may result in forgetfulness
 Sleep patterns change, sleep periods are shorter
 Smell and taste decreases
 Less tear secretions
 Pupils less responsive to light
 Decreased vision especially at night or dark rooms
 Problems seeing green and blue colors
 Eardrums atrophy resulting in changes in auditory nerve and hearing loss
 Decreased ear wax secretion
 Reduced sensitivity to hot, cold and/or pain
MUSCULOSKELETAL SYSTEM:
 Muscle atrophy resulting in decreased range of motion, flexibility and strength
 Bone mass and strength decreases
 Bones may become brittle; can break easily
 Vertebrae shorten resulting in gradual loss of height
 Joints may become flexed, stiff and/or painful
RESPIRATORY SYSTEM:
 Respiratory muscles weaken, resulting in decreased strength for coughing
 Lung tissue become less elastic
 Shortness of breath with exercise may occur
 Higher risk for respiratory infection
URINARY SYSTEM:
 Reduced blood supply to kidneys
 Kidney atrophy
 Bladder muscles weaken
 Urinary frequency and/or urgency may occur
 Urinary incontinence may occur
 Nighttime urination may occur
The Stages of Grief
Elisabeth Kubler-Ross was a pioneer in the field of hospice care. She identified five
different stages of grief, a process by which people cope when diagnosed with a
terminal illness. Today we use these stages as a guideline to understand the grieving
process.
The grieving process is highly personal and should not be rushed or judged. Certainly
the Five Stages are not an exact science. They are simply a guide to understanding a
person’s behavior. Some people reach acceptance very easily, while others struggle
with depression or anger for a long time. It is also important to note that the Five
Stages are not always a linear process. Often individuals coping with loss have good
days, not so good days, and bad days. They may move back and forth between these
Stages:
o Denial- Often an initial feeling. Shock, disbelief, unable to grasp the reality
of the situation/diagnosis. Sometimes unwillingness to believe: “This can’t be
happening” “Everything will be fine” “The Doctor is wrong”
o Anger- This reaction can be very intense. Anger may come in sharp
emotional outbursts, rage, or in sustained dark moods. The person may blame or
resent others, a situation, him/herself or even God. “Why me” “It’s not fair”
o Bargaining- For some this may be bargaining with God for a little more time
or another chance or with the doctor for more test or treatment. This process
is usually private. “I’ll do anything, if only …”
o Depression- This reaction is marked by a deep sadness. Sometimes a very

flat affect and withdrawal from others. The person mourns things that are
lost. “I don’t care about anything”
o Acceptance- The person who has reached acceptance is generally calm and
at peace. They no longer fight the reality of their situation. They may be
planning their funeral, or writing their will.
Module 7
Elder Rights and Abuse Reporting
Rights of Nursing and Rest Home Residents..........................................................72

What Do You See? – a poem........................................................................................73
Reflections on the Importance of Stuff.................................................................74
Elder Abuse Law.............................................................................................................75
Types of Abuse...............................................................................................................77
Frequently Asked Questions About the Elder Abuse Law..................................78
Self-Neglect Identifiers.............................................................................................79
Western Mass Elder Abuse Information.................................................................80
Agency/Town List...........................................................................................................81
Rights of Nursing and Rest Home Residents
Residents of nursing and rest homes have rights. The following is a list of some of
those rights:
 To be treated with dignity and respect
 To privacy and to confidentiality
 To be free from physical and chemical restraints
 To send and to receive their mail unopened
 To participate in arranging their personal care plans
 To refuse treatment of medication
 To manage their personal and financial affairs
 To present grievances to facility staff
 To have choices regarding menu and meal time
 To present concerns to an Ombudsman
 To participate in meaningful activities
For more information about residents’ rights contact your local Ombudsman:
Franklin County – (413) 773-5555

Hampshire County Highland Valley Elder Services – (413) 586-2000
Department of Public Health - Elder Abuse Hotline - 1-800-922-2275
Disabled Person Protection Commission - 1-800-426-9009
Office of Elder Affairs State Long Term Care Ombudsman Program

One Ashburton Place, Room #517, Boston, MA 02108
(617) 727-7750 or Toll Free: 1-800-882-2003
What Do You See?
A poem written by an anonymous nursing home resident
What do you see; tell me what do you see? What are you thinking when you’re
looking at me? A crabby old woman, with faraway eyes? Who seem not to notice
things that you do, and forever is losing a stocking or shoe? Is that what you’re
thinking? Is that what you see? Then open your eyes, for you’re not seeing me.
I’ll tell you who I am as I sit here so still, as I rise at your bidding and eat at your
will. I’m a small child of ten, with a father and mother, brothers and sister, who
love one another.
A young girl of sixteen, with wings on her feet, dreaming that soon her true
sweetheart she’ll meet.
A bride at just twenty – my heart gives a leap, remembering the vows that I
promised to keep
At twenty-five now, I have babies of my own, who need me to build a secure happy
home
A woman of thirty, my children grow fast, at forty, my young sons have grown and
are gone, but my man’s beside me to see I don’t mourn
At fifty once more, babies play round my knee, again we know children, my loved
ones and me
Dark days are upon me, my husband is dead; I look at the future, I shudder with
dread
For my children are busy with lives of their own, and I think of the years and the
love that I’ve known
I’m an old woman now – grace and vigor depart, but thousands of memories still live
in my heart. Inside it you see a young girl still dwells, and now and again my tired
heart swells
I remember the joys, I remember the pain, and I’m loving and living all over again.
So open your eyes please open and see, not a crabby old woman, look close … and
see me!!
Remember this poem next time that you meet an older person.
Reflections on the Importance of Stuff
Many of our belongings have meaning to us beyond their monetary value or use. Our
possessions are a big part of our identity. Some things have sentimental value to us. In
some cases where we got it is more important than what it is. “One person’s trash is
another person’s treasure.”
In this culture, most of us love stuff. We engage in retail therapy to lift our spirits when
we’re down, to celebrate something wonderful, or to treat ourselves for a job well done.
We devote a large amount of our time to decorating and caring for our homes. The
clothing and accessories we wear can communicate our individuality and help us to express
our identity to the world.
Take a few minutes to complete this Personal Belongings Inventory
How many pairs of shoes do you own? ______ Which is your favorite?_____________________
Do you have a favorite set of sheets? _____Why do you like them?_______________________
Which room in your home do you like the best? ______________ Why?___________________
Do you have a favorite sweater?___________________ How old is it? ___________________
Where did you get it? ________________________________________________________
Name something that you keep because someone special gave it to you: ____________________
Do you collect anything? ____ What?_____________________________________________
How many do you have? _________________
What is the item you have had the longest? _________________________________________
Do you own anything valuable? ___________________________________________________
If you had to select only ten items to keep safe how would you decide?
1. _________________________________ 6. ___________________________________
2. ________________________________ 7. ___________________________________
3. _________________________________ 8.____________________________________
4. _________________________________ 9. ___________________________________
5. _________________________________ 10.___________________________________
Elder Abuse Law
The Elder Abuse Law:
 Massachusetts General Law, Chapter 19A: Sets forth definition of elder abuse and
the provisions governing the Elder Protective Services Program.
 The Executive Office of Elder Affairs is responsible for coordinating the

development of a statewide system for Elder Abuse Reporting and the Elder Abuse
Protective Services Program. The Executive Office has developed regulations for
the Protective Services Program to carry out the law.
 The following agencies investigate reports of elder abuse in your area, so that you
can make a Protective Service Report to the appropriate local agency:
 Franklin County Home Care, 330 Montague City Road, Turners Falls (413)
773-5555
 Greater Springfield Senior Services, 66 Industry Ave., Suite 9, Springfield.

(413) 781-8800
 Highland Valley Elder Services, 320 Riverside Drive, Suite B, Northampton.

(413) 586-2000
 The state Elder Abuse Hotline will take reports of abuse on a 24 hour per day,
seven-day per week basis. The hotline number is 1-800-922-7725.
For purpose of the law:
 Act or Omission, which results in serious physical or emotional injury of an elder or

financial exploitation of an elder. Also includes self-neglect.
 Elder is defined as an individual who is 60 years of age or older.
Elder Protective Services
Program Philosophies
The Elder Protective Services Program embodies the three principles articulated
below:
The overall program philosophy recognizes the elder’s right to self-

determination thereby balancing individual autonomy with its mandate to
provide protection. Protective Services aim to involve the older to the
greatest feasible extent in decisions which affect them, providing services
only with the consent of the elder and with the least possible intrusion into
their life.
Least Restrictive Intervention
EPS seeks to provide services which will have the least disruption and intrusion
into the elder’s life while still alleviating the abuse.
Self-Determination
EPS aims to serve the best interests of the elder. The elder is in charge of
decision-making unless they delegate this responsibility or court-authorizes
another to do so.
Freedom Over Safety
Freedom is more important than safety. This means elders can choose to live in
harm or even self-destructively provided they are competent to choose, do not
harm others and commit no crime.
Types of Abuse
 Self-Neglect: Failure, inability or resistance to provide for oneself, or one

or more of the necessities essential for physical & emotional well-being.
Elder may not be safe to remain in the community without addressing these
needs.
 Physical Abuse: Non-accidental infliction of serious physical injury or threat
of serious physical injury.
 Sexual Abuse: Sexual assault, rape, sexual misuse, or sexual exploitation or
threats of sexual abuse.
 Emotional Abuse: Non-accidental infliction of serious emotional injury to
elder.
 Neglect: Failure or refusal by caretaker to provide one or more of the
necessities essential for the physical well-being of elder which has resulted
in or where there is substantial reason to believe that such failure or refusal
will immediately results in serious physical harm to an elder.
 Financial Exploitation: Non-accidental act or omission by another person
without the consent of the elder causing substantial monetary or property
loss to elder or substantial monetary or property gain to the other person
which gain would observe benefit the elder. Financial exploitation may result
from consent obtained as a result of misrepresentation, undue influence,
coercion or threat of force by another person.
You should report if there is reasonable cause to believe that an abusive act
probably took place or an abusive condition probably exists, that an elder is being
neglected by a caregiver or is neglectful of their own needs and if you believe that
an elder may have died as a result of a reportable condition.
All persons are encouraged to make a report if they have a reasonable suspicion
that abuse or neglect has occurred. Home Health Aides are mandated reporters
of elder abuse, which means you are required to report it if you think an abusive
act or condition.
To report suspected abuse of persons with disabilities, call:
Disabled Persons Protection Commission (DPPC) 1-800-426-9009
Frequently Asked Questions About the Elder Abuse Law
How long will it take Elder Protective Services to see an elder?
All referrals are evaluated based on information provided to the agency. If it appears
that the elder has an acute situation which needs immediate attention, the situation will be
assessed on the day of the report. In situations where there is no apparent immediate
serious risk to the elder, she/he will be contacted within 5 calendar days.
I made a report and nothing has been done! Can’t you get the elder out of
there?
When a report is made, the Protective Service Worker will attempt to investigate all
allegations. If a report of abuse or self-neglect is sustained, Protective Services will be
offered to the elder. Services include but are not limited to the following: referral to
various services, assistance with other living arrangements, safety planning, family
intervention and legal assistance. Services provided do not always offer an immediate
solution, but do reflect the speed at which an elder feels he or she can attempt change.
Elders, if mentally competent, retain the right to refuse services and sometimes they may
choose to do so.
What if an elder is not competent and cannot make decisions on his/her own?
Competency is a legal term which is determined by a court of law. If there are concerns
about an elder’s competency, the following is the process that is reviewed:
1. Is the Elder at serious risk of further abuse, neglect or self-neglect?

2. What is the elder’s ability to understand his/her situation?
3. Is the elder refusing protective service intervention?
After assessing the questions listed the Protective Service Program will:
 First try to enlist the cooperation and support of family, professionals and others
in providing assistance to alleviate the problem or concern.
 If the elder remains at serious risk and clearly is not understanding his/her
situation, the Elder Protective Service Program may pursue a formal competency
evaluation and legal intervention, in the form of a guardianship or conservatorship,
to bring about change in the elder’s situation in order to alleviate the abuse or self
neglect.
Self-Neglect Identifiers
Presenting Problems Contributing Factors
A. Housing: (Shelter): I. Mental Health:
1. Behavior problems jeopardize housing or there are 1. Elder displays symptoms of mental illness (diagnosed or not) which have
threats to evict occasional impact of functioning level
2. Eviction in process or current living situation is short 2. Elder displays symptoms on mental illness which have regular impact on
term or inappropriate functioning
3. Elder is homeless or eviction is imminent with 3. Elder displays symptoms of mental illness which pose a immediate threat or
appropriate shelter available risk of harm to self or others
B. Housing (physical environment) J. Dementia:
1. Home is extremely cluttered and poses some ambulation 1. Elder has some memory loss of confusion which has a slight impact on daily
problems; some level of disrepair functioning, but usually meets basic needs
2. Serious disrepair; unsanitary condition/infestation 2. Elder has regular periods of memory loss or confusion which has a significant
3. No heat/utilities, fire hazards, property is condemnable impact on daily functioning; ability to meet or obtain assistance for basic
need is inconsistent
1. Elder has severe memory loss or confusion and demonstrates little or no
ability to function independently or meet basic needs
C. Nutrition K. Cognition/Judgment
1. Inadequate diet or the diet poses a threat to elder’s 1. Elder displays little or no awareness of risks, choice and possible
health consequences, which has had minimal impact on functioning level or on safety
2. Not eating regularly or appropriately with significant of self or others
impact on health 2. Elder displays little or no awareness of risk, choices and possible
3. Dehydrated/malnourished; indicators or diagnosis of consequence, with significant impact on functioning level or on safety to self
failure to thrive and others
3. Elder displays little or no awareness of risks, choices and possible
consequences, with severe and/or immediate impact on functioning level on
safety of self or others
D. Financial: L. Cultural/Ethnic/Linguistic:
1. Difficulty managing finances 1. C/E/L issues pose an intermittent or minor problem for elder in accessing
2. Inadequate income, failure to appropriately use assistance
resources, or unable to manage finances consistently 2. C/E/L issues pose a regular problem for elder in accessing assistance
3. Essential bills are not paid, elder threatened with 4. C/E/L issues pose a serious problem for elder in accessing assistance
impoverishment
E. Medical Noncompliance: M. Social Isolation:
1. Elder does not receive medical care for chronic, non- 1. Social contacts are very limited; elder experiences discomfort with social
life threatening condition with minimal impact settings
2. Elder does not follow through with medical care/ 2. Social contacts are inconsistent and/or have negative impact on elder
medications with significant impact 3. Social contacts are nonexistent or inappropriate & have negative impact on
3. Elder does not seek or accept medical care for acute of elders
life threatening conditions
F. Personal Care: N. Medical/Physical:
1. Elder does not bathe or change clothes consistently 1. Medical/physical limitations pose an intermittent or minor problem for elder
2. Elder is dirty with offensive odor, and/or in meeting needs
inappropriately dressed 2. M/PL pose a regular problem for elder in accessing assistance
3. Elder has skin breakdown or infections 3. M/PL pose a serious problem for elder in accessing assistance
G. Personal Safety: O. Sensory Disabilities:
1. Behavior is potential threat to health and/or safety 1. Hearing/vision/speech impairment pose an intermittent or minor problem for
2. Behavior presents significant threat to health and/or elder in meeting needs
safety with some impact having occurred 2. H/V/S pose a regular problem for elder in accessing assistance
3. Behavior has had a severe impact on elder, requiring 3. H/V/S pose a serious problem for elder in accessing assistance
immediate intervention by others
H. Substance Abuse: P. Variability Issues
1. Elder’s use of drugs or alcohol has slight impact on 1. Time of day, month, or year creates an intermittent or minor problem for
functioning level elder in meeting needs
1. Elder’s use of drugs or alcohol has significant impact on 2. Time of day, month or year creates a serious problem for elder in accessing
functioning level assistance
2. Elder’s use of drugs or alcohol has severe impact on
functioning level
Western Mass Elder Abuse Law Mandated Reporting
Highland Valley Elder In 1983, Massachusetts mandatory Under the elder abuse statue,
reporting law went into effect. the following individuals are
Services, Inc.
This law required certain mandated to report if there
320 Riverside Drive
professionals to report suspected is reasonable cause to believe
Northampton, MA 01060
serious occurrences of elder that an elderly person is
(413) 586-2000 abuse, neglect and financial suffering from, or has died as
exploitation. The law provides for a result of a reportable
Elder Services of cases of elder abuse to be handled condition: any physician,
Berkshire County, Inc. by social service professionals and medical intern, dentist, nurse,
66 Wendell Avenue not the criminal justice system. family counselor, probation
Pittsfield, MA 01201 Protective services staff are officer, police officer, social
(413) 499-0524 sensitive to the needs of the worker, firefighter, EMT,
elderly and make every effort to licensed psychologist,
Franklin County Home Care maintain the elders in their own registered therapist and
330 Montague City Road homes with appropriate services, occupational therapist,
support and with respect for the osteopath, pediatrician,
Turners Falls, MA 01376
elder’s rights to accept or reject coroner, and directors of
(413) 773-5555
services as he/she chooses. In licensed home health aide or
addition to the local protective homemaker provider agencies.
Greater Springfield Senior
services agencies for each area,
Services, Inc. there is a state-wide Elder Abuse
66 Industry Avenue Hotline (1-800-922-2275) for
Springfield, MA 01104 emergencies outside of normal
(413) 781-8800 office hours.
How to Report Suspected Abuse

If you have a reasonable cause to believe that an elder is being abused or exploited:
1. Make a VERBAL report to the locally designated agency of to the Elder Abuse
Hotline (nights, holidays, weekends) 1-800-922-2275
2. A written report must be forwarded to the protective service agency within 48
hours of the verbal report
Information necessary:
 Name of elder
 Permanent address and current location of elder
 Phone Number
 Exact age of elder
 Identity and address/location of alleged perpetrator
 Detailed description of nature of abuse
 Others who may have knowledge of elder
 How best to contact elder
Agency/Town List
Franklin County Home Greater Springfield Highland Valley Elder
Care Senior Services Services
330 Montague City Road 66 Industry Ave., Suite 320 Riverside Dr, Suite
Turners Falls, MA 9 B
(413) 773-5555 Springfield, MA Northampton, MA
(413) 781-8800 (413) 586-2000
Ashfield Agawam Amherst
Athol Belchertown Blandford
Bernardston Brimfield Chester
Buckland Chicopee Chesterfield
Charlemont East Longmeadow Cummington
Colrain Feeding hills Easthampton
Conway Granby Florence
Deerfield Hampden Goshen
Erving Holland Granville
Gill Holyoke Hadley
Greenfield Longmeadow Huntington
Hawley Ludlow Middlefield
Leverett Monson Montgomery
Leyden Palmer Northampton
Monroe South Hadley Pelham
Montague Springfield Plainfield
New Salem Wales Russell
Northfield Ware Southampton
Orange West Springfield Southwick
Petersham Wilbraham Tolland
Philipston Westfield
Rowe Westhampton
Royalston Williamsburg
Shelburne Worthington
Shutesbury
Sunderland
Warwick
Wendell
Whately
Module 8
Cardio-Respiratory System
The Circulatory System................................................................................................83

Pulse Chart.......................................................................................................................84
Cardiovascular Disorders.............................................................................................85
Signs and Symptoms of a Heart Attack..................................................................86
Cholesterol: What do the Numbers Mean?.............................................................87
The Respiratory System..............................................................................................88
Disorders Of The Respiratory System....................................................................89
The Circulatory System
The circulatory system is made up of the heart, blood and blood vessels.
The functions of the system are:
 Blood carries food, oxygen and other substances to the cells.
 Blood removes waste products from cells.
 The system produces and carries cells that defend the body from microbes
that cause disease.
 Blood helps regulate body temperature. Blood carries heat from muscles to
other body parts. Blood vessels in skin dilate to cool the body and they
constrict to retain heat.
The heart is a muscle. It has four chambers. The heart pumps blood to the lungs
for fresh oxygen, delivers the freshly oxygenated blood throughout the body to
the tissues and cells, carries carbon dioxide and waste products out of the cells
and returns to the heart for fresh oxygen. The heart has two actions:
 Systole – The heart contracts and pumps blood through the vessels.
 Diastole – The resting phase. The heart chamber fills with blood.
Blood flows through three groups of blood vessels:

 Arteries – carry oxygen-rich blood away from the heart.
 Capillaries – are very tiny vessels. Food, oxygen and other substances pass
through the capillaries in to the cells.
 Veins – return blood to the heart. Venous blood is dark red because it has
little oxygen and lots of carbon dioxide.
The blood consists of blood cells, plasma and platelets:

 Red blood cells contain hemoglobin, which gives it the red color. As the
blood circulates through the lungs, the hemoglobin picks up oxygen and
carries it to the cells.
 Plasma is mostly water. It carries substances that the body needs to
function (proteins, fats, carbohydrates, hormones and other chemicals).
 White blood cells have no color. They are produced by the bone marrow.
At the first sign of infection, white blood cells rush to the site and multiply
rapidly to help fight the infection.
 Platelets are needed for blood clotting. They are also produced in the bone
marrow.
Pulse Chart
Cardiovascular Disorders
Hypertension = High Blood Pressure can lead to heart disease, stroke, kidney
failure and blindness. Signs and symptoms such as headaches, dizziness, blurred
vision, nose bleeds develop over time. Historically men are at greater risk of high
blood pressure. However, women are catching up, primarily due to their increase of
other risk factors. The older we get the higher our risk. African-Americans are at
higher risk than whites, and individuals with a family history of cardiovascular
disorders are at greater risk than someone without. In many cases hypertension
can be managed with medication. The following risk factors can be controlled and
decreased through life style changes, such as low fat/low sodium diet, exercise,
stress management and decreased use of alcohol, tobacco and caffeine:
 Family history
 Being overweight
 Stress
 Smoking
 High sodium diet
 Excessive alcohol consumption
 Lack of exercise
 Atherosclerosis
Coronary Artery Disease (CAD) occurs when one or more of the coronary arteries
narrow, causing the heart muscle to get less blood. The most common cause is
atherosclerosis, also known as hardening of the arteries, which is a buildup of fatty
deposits on the artery walls. The risk factors are the same as hypertension, but
also include diabetes.
One major complication of CAD is Peripheral Artery Disease (PAD), a narrowing of

arteries in the leg, which results in decreased blood flow. Signs and symptoms
include pain or cramping in the leg when exercising, a marked decrease in
temperature in the foot of one leg and pale or purplish color of the foot. Generally
symptoms do not arise until an artery is 60% blocked.
Another complication of CAD is Angina Pectoris, which is pain, tightness or

pressure in the chest that occurs when the heart needs more oxygen, generally
caused by stress, exertion, over eating, over excitement or exposure to hot or cold
temperatures. People with angina commonly carry nitroglycerin tablets. This very
small tablet is placed under the tongue where it is quickly absorbed in to the blood
stream. If chest pain is not relieved by nitroglycerine the person may be having a
Myocardial Infarction, commonly known as a heart attack, which means that
blood flow to the heart is suddenly blocked and part of the heart muscle will die
without immediate emergency medical care.
Signs and Symptoms of a Heart Attack Include:

 Sudden severe chest pain (generally on the left side)
 Pain radiates to arm, neck, or jaw
 Severe indigestion or nausea
 Apprehension or feeling of doom
 Perspiration and cold clammy skin
 Dizziness
 Low blood pressure
 Pale or grayish skin color
 Shortness of breath
Congestive Heart Failure
Congestive Heart Failure (CHF) is a common chronic health problem of the

elderly. CHF occurs when the right or left side of the heart cannot pump blood
normally, generally due to a weakened or damaged heart muscle or valve. With CHF
the blood backs up and tissue congestion occurs.
When the left side of the heart cannot pump normally the blood backs up in to the
lungs causing congestion, coughing, gurgling sounds and shortness of breath. When
the right side of the heart cannot pump normally the blood backs up into the
venous system causing feet and ankles to swell, as well as liver and abdominal
congestion.
With CHF all of the body’s organs receive less blood flow. Signs and symptoms
occur from the effects of decreased blood flow to the organs. Poor blood flow to
the:
 Brain may cause dizziness, confusion and fainting.

 Kidneys will produce less urine
 Liver will not function properly
 Skin will become pale or purplish
 Heart may drop the blood pressure
Cholesterol: What do the Numbers Mean?
Cholesterol and triglyceride levels are measured as milligrams (mg) per deciliter
(dL) of blood. Below are the levels that the National Heart Lung & Blood Institute
deems as too high, too low, borderline, and good.
Total Cholesterol
Less than 200 mg/dL Good 240 mg/dL and above High
200-239 mg/dL Borderline
High
LDL Cholesterol
Less than 100 mg/dL Good 160-189 mg/dL High
100-129 mg/dL Near Optimal 190 mg/dL and above Very High
High
HDL Cholesterol
Less than 40 mg/dL Too Low 60 mg/dL and above Good
Triglycerides
Less than 150 mg/dL Optimal 200 mg/dL and above High
High
The Respiratory System
The function of the respiratory system is to bring oxygen in to the body, to
distribute oxygen in the body and to rid the body of carbon dioxide by inhalation
and exhalation.
RespiratoryTract
Nose – Air enters
Pharynx – throat
Epiglottis - lid over the esophagus. During inhalation, it lifts up to let air pass.
Trachea divides into: Right bronchus, Left bronchus
Bronchi enter the lungs and branch, dividing many times to create bronchioles
Bronchioles subdivide into alveoli
Respiration
= Inhalation and exhalation. Air enters the nose and winds up in the alveoli, where
oxygen and carbon dioxide are exchanged between the alveoli and capillaries.
The lungs are separated from the abdomen by the diaphragm, a muscle that aids in
breathing.
Pleura cover each lung. It’s a double sac in which one is attached to the lung, the
other to the chest wall. They secrete a fluid that keeps the pleura from rubbing
together.
Ribs, sternum and vertebrae protect the lungs.
Disorders Of The Respiratory System
COPD: Chronic Obstruction Pulmonary Disease
Chronic Bronchitis: an inflammation of the bronchi. Symptoms include frequent

infections with coughing, excess mucus production, shortness of breath. The
inflammation causes irritation, which obstructs the flow of oxygen to the lungs.
RX Treatment = Removing the irritant (usually smoking), oxygen, inhaled
medications, and breathing exercises.
Asthma: an allergic reaction where the airways narrow causing shortness of

breath. Allergies and emotional stress can trigger episode and they can become life
threatening. Symptoms include wheezing and coughing, rapid pulse and, sweating.
Treatment = inhaled medication.
Emphysema: affects the alveoli. They enlarge and become less elastic. They don’t
expand and shrink normally with inhalation and exhalation. Air gets trapped there
and is not exhaled. Breathing is easier when the person is sitting upright and
slightly forward. Cause is usually smoking. 20% of smokers get it. The first sign
occurs with exhalation, but over time it occurs at rest too. Treatment = oxygen,
exercise (pulmonary rehab) breathing exercises, and meds.
Pneumonia: inflammation and infection of the lung tissue. Types: aspiration, viral,
bacterial. Symptoms are fever, chills, painful cough, chest pain on breathing, and
rapid pulse. Mucus is thick and colored green, yellow, or rust. Treatment =
antibiotics, antiviral, increased fluids to thin mucus and to prevent dehydration.
Oxygen may be ordered. Position in semi-fowlers to ease breathing. Precautions
must be taken to prevent spread.
Tuberculosis (TB): is a bacterial infection in the lungs. It is spread by airborne

droplets by coughing, sneezing and singing. Person nearby can inhale the bacteria.
Symptoms include fatigue, loss of appetite, weight loss, fever, and night sweats,
gradual increase in cough and sputum production over time. Chest pain occurs.
Treatment = medication, oxygen
Module 9
Taking and Recording Vital Signs

Taking and Recording Pulse and Respiration............................................................91
Blood Pressure.................................................................................................................92
Taking and Recording Blood Pressure.......................................................................93
Measuring and Reporting Vital Signs........................................................................94
Taking and Recording Pulse
The Pulse Rate = the number of heartbeats measured in 1 minute.
Generally pulse is taken for 30 seconds and multiplied by 2.
The normal adult pulse rate is between 60 and 100 beats per minute.
Any pulse below 60 or above 100 should be reported to the nurse or a responsible
person promptly.
The apical pulse is taken with a stethoscope for 1 minute. Generally apical pulse is
taken when there are irregularities.
The rhythm of the pulse should be regular. Irregular pulse should be reported.
A pulse may be reported as strong or weak depending on the force of the beat felt
when taking the pulse.
Taking and Recording Respirations
Each respiration involves one inhalation and one exhalation. The chest rises during
inhalation and falls during exhalation.
In normal/healthy respiration both sides of the chest rise and fall equally.
The healthy adult has 12 to 20 respirations per minute.
Count respiration for 30 seconds and multiply by 2, unless irregular. When

respiration is irregular, measure for full minute, and report irregularity.
It is best to measure respirations when the person does not know you are doing it,
in order to measure a natural and accurate rate.
Blood Pressure
Blood pressure is the amount of force exerted against the walls of an artery
by the blood.
Systolic pressure: (recorded as the top number) Measures the amount of force
needed to pump blood out of the heart into the arterial circulation.
Diastolic Pressure: (recorded as bottom number) Measures the pressure in the

arteries when the heart is at rest.
Average Blood Pressure 120/80

High Blood Pressure Hypertension
Low Blood Pressure Hypotension
Stethoscope Sphygmomanometer
There are two additional types of blood pressure equipment, a column of mercury
in a calibrated tube and electronic, which shows a digital reading.
Taking and Recording Blood Pressure
Equipment:
1. Sphygmomanometer (blood pressure cuff) - select appropriate size cuff.
2. Stethoscope
Safety:
1. Too much inflation can alter one’s blood pressure
2. Ask the nurse of any specific considerations needed before taking a blood pressure
Blood Pressure Steps:

1. Deflate the bladder of the cuff and place it around the upper arm, one inch above
the fold of the elbow, so it fits snug but not too tight.
2. Feel for the brachial artery.
3. Put the head of the stethoscope just under the edge of the cuff, a little above the
crease of the person’s elbow. Hold it there firmly with the thumb, or with a few
fingers. Put the ear pieces of the stethoscope in your ears.
4. Inflate the cuff with brisk squeezes of the bulb. Watch the pressure gage as you
do it. For most you shouldn’t go over 160 (the markings indicate “pressure” in Hg or
mercury.)
5. If at 160 Hg you hear the pulse/beat, inflate another 20Hg of mercury. Slightly
open the valve on the air pump (this takes practice). It’s important that you don’t
let the air out too suddenly (approximately 2-3 Hg per second).
6. Pay attention *Very Carefully* to what you hear through the stethoscope as the
needle on the pressure gauge falls. You will be listening to the pulse beat. The
first time you hear the sound, note what the reading was on the pressure gauge.
This value/number represents the systolic blood pressure.
7. The sounds should continue and become louder in intensity, then softer. Note the
pressure reading when you hear the sound for the last time. This value/number
represents the diastolic blood pressure.
8. Remember even number are needed for an accurate blood pressure and don’t forget
to write them down. A normal blood pressure at this time is 120/80
9. When inflated, the cuff is tight on the arm, this is uncomfortable and can be
painful. Do not leave cuff inflated for more than a minute; if unable to get a good
reading deflate and try again. Only try twice on one arm.
Measuring and Reporting Vital Signs
Vital signs reflect the functions of the body processes essential to life. They can
show how even minor changes in a person’s condition and they may signal life-
threatening events.
The Four Measurements of Vital Signs of Body Functions are:
 Temperature
 Pulse
 Respiration
 Blood Pressure
Vital signs are part of the nursing assessment process. They are taken at the time
of admission and measured regularly as part of the ongoing monitoring of a person’s
condition. Each facility/agency has its own policy and protocols related to vital
signs. Generally vital signs are taken while the person is at rest in a lying or sitting
position.
When completed, vital signs are reported on a graphic or flow sheet. Abnormal vital
signs must be reported to the nurse or responsible person promptly.
Temperature
Site Normal Range
Rectal 98.6 to 100.6 F -- 37.0 to 38.1 C
Oral 97.6 to 99.6 F -- 36.5 to 37.5 C
Tympanic Membrane 98.6 F -- 37 c
Axillary 96.6 to 98.6 F -- 35.9 to 37.0 C
Glass thermometers are now illegal and will need to be properly disposed of. You
can dispose of them at local pharmacies or call your town offices.
Module 10
Digestion and Nutrition
The Digestive System...................................................................................................98

Dysphasia..........................................................................................................................99
Nutrition.........................................................................................................................100
Factors Affecting Eating and Nutrition.................................................................101
Food Groups...................................................................................................................102
How The Body Uses Vitamins And Minerals..........................................................103
Understanding Nutrition Labels...............................................................................104
Understanding and Managing Diabetes...................................................................105
Special Diets..................................................................................................................107
Preventing Constipation in the Older Adult
Constipation is a common problem for older people. Expect

constipation to occur when a pain medication is prescribed, or
when mobility is decreased due to illness, injury or significant
change in routine.
Constipation is often relieved by adequate hydration, (at least

one quart of water a day) increased mobility (Walking is excellent)
and fiber supplementation (wheat or oat bran, fruits, vegetables
or nuts) Nuts can be ground in a coffee grinder to make digestion
easier.
Many older people don't drink enough because they don't want to
have an increased, need to urinate, especially at night. Encourage
intake early in the day.
When fiber intake is increased excessive gas may initially present,

but generally resolves as the body becomes accustomed to the
change. It is recommended to increase fiber slowly,
approximately 5 g
A bran mixture that significantly reduces laxative use for older

people includes:
3 cups unsweetened applesauce
2 cups course wheat bran
1 ½ cups unsweetened prune juice or 1 cup stewed prunes
Administer 4 tablespoons a day
(Two before breakfast and two before super)
Monitoring bowel elimination is a very important aspect of elder

care. Using a tracking sheet is very helpful.

The Digestive System
The digestive system is the group of organs that work together to gain fuel from
the food we eat and discard the unwanted waste. This system breaks down food
into simple substances your body’s cells can use. It then absorbs these substances
into the bloodstream and any leftover waste is eliminated. This path is called the
alimentary canal. The alimentary canal is folded back and forth, like a fan, in your
body so that it fits.
1.) Teeth tear and grind food and moistened by saliva (1 minute)
2.) Esophagus carries food to stomach (4-8 seconds)
3.) Stomach mixes food with acid to further break it down (2-4 hours)
4.) Pancreas makes food small enough to mix with blood stream
5.) Liver cleanses food and mixes it with blood
6.) Broken down food is sent into bloodstream and the rest of the body
7.) Small intestine further break down food (3-5 hours)
8.) Large intestine water and minerals are added (10 hours to several days)
9.) Bladder and rectum food is passed as waste
10.) Gallbladder stores bile produced by liver and sends it to small intestine
Dysphasia
Difficulty swallowing. This condition is most commonly

Dysphasia caused by stroke. Often the Doctor will order that
liquid be thickened or food consistency be changed to
meet the person’s swallowing needs. The condition is
generally managed by a speech therapist/pathologist.
Exercise may be ordered to strengthen the muscles
involved in swallowing.
The person has difficulty getting enough food and fluids

Slow Swallow to maintain adequate nutrition and fluid balance.
Food may accumulate in the back of mouth, between the

Pocketing gums and teeth
Breathing fluids or food/object into lungs. This may

Aspiration cause pneumonia
The person is at risk for food or fluid entering the

Unsafe Swallow airway
The Doctor has ordered that the person take nothing by

NPO mouth. In some cases a feeding tube may be used to
provide nourishment
When eating, the individual with dysphasia must always be in a sitting (Fowler’s)
position and must remain focused on chewing and swallowing. Talking should take
place between mouthfuls and only after swallowing. It is important that food is
chewed well before swallowing and that the person eats slowly and mindfully. The
person should remain in the Fowler’s position for at least 30 minutes after eating.
Signs and Symptoms

Changes in eating habits – Coughing – Water, Gurgley Voice – Drooling - Fever
Food Residue in Back of Mouth - Feeling a “lump in throat”
Nutrition
The process involved in the ingestion, digestion, absorption, and use of foods and
fluids in the body.
Nutrients: The elements in food that the body uses as fuel: Carbohydrates – Fats
–Minerals – Protein – Vitamins. Carbohydrates, fats and protein give the body
energy. The amount of energy provided by a nutrient is measured in calories. A
calorie is the amount of energy produced when the body burns food.
 Carbohydrate – 1 gram = 4 calories

 Fat - 1 gram = 9 calories
 Protein - 1 gram = 4 calories
Vitamins- There are 2 kinds of vitamins, fat soluble and water soluble. Fat soluble
vitamins can be stored in the body. Water soluble vitamins are not stored in the
body; they must be ingested daily. Vitamins are essential to health. They are used
for many body processes and functions. Fat soluble vitamins are A, D, E, and K.
Water soluble vitamins are C and B complex which includes: Thiamine – Riboflavin
– Niacin – Biotin - Folic Acid - Pantothenic Acid
Minerals are needed for strong bones and teeth, for nerves and muscle function,
fluid balance and many other body processes. There are nine minerals the body
requires: Calcium – Chromium – Copper – Magnesium – Manganese – Phosphorus -
Potassium – Selenium - Zinc
It is necessary to know the content of foods in order to plan a healthy diet. Most
foods have labels that list the ingredients and nutrition facts such as, calories, fat
and the percent of daily value (DV) of the food item. The daily value is set by the
US Food and Drug Administration’s recommendations as to how much of that food
item a day a person needs to have. The DV is generally based on a 2000 calorie a
day diet. It is important to note the serving size, which is also listed on the label.
Factors Affecting Eating and Nutrition
 Age
 Culture and Religion
 Finances
 Physical and Mental Help
 Appetite
 Personal Choice
 Physical Condition
What You Need to Know to Prepare Food at Home
 Need to understand the food pyramid
 Need to understand basic nutrition
 Need to understand food labels
 Need to understand people’s personal choice
 Need to understand any religious constraints
 Need to know if there are any dietary restrictions or special diet(s) ordered
by doctor
 Need to understand any dietary habits or religious rituals
Go over to the grocery list with the person you are shopping for before going to
the store. It is important to know brand preferences and amounts needed.
When planning menus, check to make sure that you have all of the needed
ingredients.
SAVE ALL RECEIPTS FOR THE PERSON OR FAMILY MEMBER

Food Group Good Source Of
Bread, Cereal, Rice and Pasta Group Complex Carbohydrates, Fiber, Riboflavin,
Niacin, Thiamin, Folate and Iron
Vegetable Group Complex Carbohydrates, Fiber, Vitamins A, B-6

and C, Folate, Potassium, Iron, Magnesium
Fruit Group Carbohydrate, Fiber, Potassium, Folate,

Vitamins A and C
Meat, Poultry, Fish, Dry Beans, Eggs Protein, Iron, Phosphorus, Potassium, B
and Nuts Group Vitamins (Meat, Poultry, Fish, Eggs may contain
saturated fat and cholesterol)
Milk, Yogurt, and Cheese Group Protein, Carbohydrate, Calcium, Vitamins A, B-

12 and D, Riboflavin, Phosphorus
(Most contain fat, saturated fat and
cholesterol)
How The Body Uses Vitamins And Minerals
Vitamins and minerals are needed for many body functions and processes. There
are two types of vitamins: fat-soluble and water-soluble. Fat-soluble vitamins can
be stored in the body. Water-soluble vitamins are not stored in the body and must
be ingested daily.
Fat Soluble Vitamins
Vitamin A – Retinal – maintains healthy skin, hair and mucous membranes, aids in cell
development and vision, especially night vision.
Vitamin D – regulates the absorption and use of calcium and phosphorus, which aids in
bone and muscle function. We can get Vitamin D from the sun.
Vitamin E – anti-oxidant, which helps to maintain healthy cells and to prevent

cardiovascular disease and cancer.
Vitamin K – promotes blood clotting.
Water Soluble Vitamins

Vitamin B – actually, 8 vitamins including thiamine, riboflavin, niacin, biotin, folic acid and
pantothenic acid. These vitamins are important for metabolism, healthy cell growth –
including red blood cells – and they support nervous system function.
Vitamin C – promotes iron absorption and the immune system.
Minerals
Calcium – important to formation of bones and teeth. Supports muscle and nerve function
and aids in blood clotting.
Chromium – works in conjunction with insulin to maintain normal blood sugar metabolism.
Copper – works with enzymes that maintain bone, blood vessel and lung cells.
Magnesium – helps maintain stable levels of calcium and phosphorus.
Manganese – involved with protein metabolism.
Phosphorus – works with calcium to promote proper bone and tooth mineralization.
Potassium – required for normal nerve transmission, muscle contraction and to maintain
blood pressure within normal range.
Selenium – preserves tissue elasticity, slows down the aging and hardening of tissue.
Zinc – helps with digestion, wound healing and reproductive health.
Understanding Nutrition Labels
Serving Size
Compare your serving to the one on the label. If you eat double
the serving listed, you will need to double the nutritional values
Calories and Calories from Fat
Calories are a measure of how much energy a serving of this food
provides. Try to limit your calories from fat. Choose foods that
have less than one third of the calories from fat.
Total Fat: 45-55g. per day or less

Saturated Fat: as little as possible
Saturated fat increases LDL (“bad”) cholesterol and increases
your risk of heart disease.
Trans Fat: Less than 2-3g Per day
Too much Trans Fat has been linked to heart disease and
diabetes. Trans fat is also listed on the ingredients list on food
labels as ‘hydrogenated’ or ‘partially hydrogenated’ oil
Cholesterol: 300 mg. per day or less

Cholesterol is only found in animal foods like meat, fish, cheese,
and butter. Too much cholesterol is not healthy for your heart.
Sodium: 2400hm. per day or less

Too much salt can lead to high blood pressure in some people.
Examples of high sodium food include pre-packaged, convenience,
and fast foods.
Total Carbohydrates: 45-0g. per meal (women), 60-75g. per

meal (men), 15-30g. per snack
Carbohydrates (starch and sugar), are found in breads, potatoes,
rice, cereals, fruits and juices, milk, sweets, and sweetened
drinks. Carbohydrates are our most important source of energy,
but too many carbohydrates raise the blood sugar too high.
Fiber: 25-35g. per day

Choose whole grain breads and cereals and at least 5 servings of
fruit and vegetables per day. If the word ‘whole’ is first in the
ingredient list, the food is a whole grain product and high in fiber.
When you are counting carbohydrates, dietary fiber grams (g) can
be subtracted from the Total Carbohydrate g.
Sugar:
It’s okay to have a little sugar once in a while, but it can make
those total carb grams add up quickly! Other names for sugar
include: corn syrup, high fructose corn syrup, fruit juice
concentrate, maltose, dextrose, sucrose, honey, and maple syrup.
Protein: 6-8 ounces of meat, fish, poultry, or pork daily

NA/HHA
Most adults Training
get more protein Manual
than they– need.
GCC Some
/ Tripp Memorial
meat is high inFoundation – Page 109: Module 1
fat. Use skim or low-fat milk, yogurt, and cheese. Choose lean
meats. Try to get some of your protein from high fiber plants like
beans and vegetables.
Understanding and Managing Diabetes
Diabetes is a disorder of the Endocrine system. Diabetes occurs when the

pancreas does not produce enough insulin to turn glucose/sugar into energy, or the
body does not use insulin in the right way (abnormal metabolism). Sugar/glucose
builds up in the blood and cells do not have enough sugar/glucose for energy and
they cannot perform their functions. Almost 20% of people over the age of 65
have diabetes.
There are three types of diabetes:
 Type 1- Occurs in children and young adults. The pancreas produces little or
not enough insulin. Generally onset is rapid and the condition is treated with
insulin injections 2 to 3 times daily.
 Type 2- Occurs in adults most commonly over 40. With this type the
pancreas produces insulin, but the body cannot use it well. High blood
pressure and obesity are risk factors. Onset is slow and the condition can
often be treated with diet, oral medication or, in severe cases, insulin
injections.
 Gestational Diabetes- Occurs during pregnancy and generally goes away
after pregnancy.
Symptoms of diabetes include: Increase in thirst and urination, blurred vision,

weight loss, frequent infections, slow wound healing, tingling or numbness in feet,
and fatigue.
All types of diabetes require monitoring of blood sugar/glucose levels. The normal
range is 70-110.
There are two types of acute complications:
Hypoglycemia, when levels fall too low, caused by too much insulin or diabetic drugs
in the blood, or by eating too little food.
Signs and symptoms include: Shakiness, low blood pressure, sweating,
confusion, rapid pulse, headache, cold/clammy skin, dizziness, seizure and
unconsciousness. This is a potentially fatal condition.
Treatment: If alert and able, ingest orange juice, sugar in water, or other
high carbohydrate item such as glucose paste.
Hyperglycemia, when levels are too high, caused by not enough insulin in blood,
eating too much, too little exercise, stress.
Signs and symptoms include: weakness, drowsiness, excessive thirst, sweet
breath odor, dry skin, frequent urination, nausea or vomiting, flushed face,
leg cramps.
Treatment: Fluid replacement.
The long- term effects of high blood sugar include vascular and nerve damage.
Unmanaged diabetes can cause permanent cell damage resulting in amputations,
heart attack, or stroke.
Meal Planning
Most important is the total carbohydrate count. As a general rule:
 Protein should account for 10 to 20 percent of calories.

 Fat no more than 30 of calories.
 Carbohydrates should make up the rest.
 Carbohydrates are more slowly digested and provide the body with other
needed nutrients.
Consistency is key: it is important to consider the person’s food preferences,

likes, dislikes, eating habits, meal times, culture and life-style. It may be
necessary to limit the amount of food or prepare it in a different way.
Calories needed (determined by doctor): The same amount of carbohydrates,

protein and fats eaten each day.
Meal times and snacks are eaten at regular times. The person eats at the same
time each day to maintain a stable blood sugar.
If food is left on the plate at the meal, a between meal snack is needed.
If person is taking insulin, it is very important that they eat all meals and
snacks to prevent the blood sugar from dropping dangerously low.
Special Diets
Doctors order special diets for many reasons. Often there are specific guidelines
or limits; for example, number of calories or grams of protein, fat, or
carbohydrates.
Regular diets or House diet - means that there are no dietary restrictions.
Types of Special Diets:
Clear Liquid: Water, tea or coffee (without cream or milk); jello; clear broths;
clear fruit juices; and popsicles.
Full Liquid: Foods liquid at room temperature or melt at body temperature. Foods
on clear-liquids; plus custard, eggnog, strained soups, strained fruits and vegetable
juices; milk and milk shakes; strained cooked cereals; plain ice cream and sherbet;
pudding and yogurt.
Mechanical Soft: All liquids; eggs (not fried); broiled or roasted meat, fish or
poultry that is chopped or ground; mild cheese; strained fruit juices; refined
breads and crackers; cooked cereal; cooked or pureed vegetables; cooked or
canned fruit without skin or seeds; pudding; plain cakes and soft cookies without
fruit or nuts.
Bland: Foods that are mechanically and chemically nonirritating and low in
roughage; foods served at moderate temperatures; no strong spices or condiments;
lean meats; white bread; creamed and refined cereals; cream or cottage cheese;
gelatin; plain puddings, cakes, and seeds; strained fruit juices; potatoes (not fried);
pasta and rice; strained or soft cooked vegetables; creamed soups; no fried food.
High Calorie: Calorie intake is increased to about 3000 to 4000; includes 3 full
meals and between meal snacks. Dietary increases with all foods, large portions of
a regular diet, 3 between meal snacks.
Calorie controlled: Provides adequate nutrients while controlling calories to

promote weight loss and reduction of body fat. Food low in fats and carbohydrates;
lean meats; avoid butter; cream; rice; gravies; salad oils, noodles, cakes, pastries,
carbonated and alcoholic beverages; candy; potato chips; and similar foods.
High Iron: Foods that are high in iron: liver and other organ meats; lean meats;
egg yolks; shellfish; dried fruits; dried beans; green leafy vegetables; lima beans;
peanut butter; enriched breads and cereals.
Fat Controlled (Low cholesterol): Foods low in fat and foods prepared without
adding fat; egg whites, skim milk or buttermilk; cottage cheese (no other cheeses
allowed); gelatin; soups made with skim milk; margarine; rice; pasta; breads and
cereals; vegetables; potatoes; olive and canola oil.
High Protein: Meat, milk, eggs, cheese, fish poultry; breads and cereals;
vegetables; potatoes
Low Sodium/No added salt: High sodium foods are omitted.
Module 11
Integumentary System
The Integumentary System = Skin.................................................................................111

Maintaining Skin Integrity...............................................................................................112
Risk Factors for Skin Breakdown...................................................................................113
The Integumentary System - Skin
The skin is the body’s largest organ. It has two major layers -- the epidermis and
the dermis -- and includes the nails and hair.
The Epidermis: is the outer layer of skin. It has pores, very few nerve endings,
and no blood vessels and contains the pigment, which gives the skin color. The cells
of the epidermis are constantly dying, flaking off and being replaced by new cells.
The Dermis: is the inner layer. It is made of connective tissue, blood vessels,
nerves, sweat and oil glands and hair roots.
The integumentary system has many functions:

 It is the body’s first defense against germs, by keeping bacteria and other
substances out.
 It holds and releases water through the pores, which helps to regulate body
temperature. Nerve endings in the skin sense both pleasant and unpleasant
sensation, such as touch, pressure, pain, heat and cold.
 It cushions, protects and insulates the body.
 The hair acts as a filtering screen to keep unwanted particles from entering
the body. Eyebrows prevent sweat from falling into eyes. Hair also provides
insulation.
A quarter size piece of skin contains: 1 yard of blood vessels, 4 yards of
nerves, 25 nerve endings, 100 sweat glands and more than 300 cells.
Maintaining Skin Integrity
Normal age-related skin changes -- such as, loss of fatty tissue, decreased
secretion of oil glands resulting in dry skin, thinning of skin and decreased
sensitivity due to fewer nerve endings -- cause elders to be at a higher risk for
skin break down. Preventing skin breakdown is much easier than trying to heal it.
Good nursing care is essential to the prevention of skin breakdown. The most
common causes are:
Pressure Ulcers: also known as Bedsores, Decubitus Ulcers, and Pressure Sores.
They are caused by unrelieved pressure over a bony prominence, preventing blood
flow to the skin and underlying tissue. In most cases, pressure ulcers can be
prevented by regularly repositioning (every two hours is the standard). There are
4 stages of pressure ulcers, beginning with a reddened area over a bony
prominence that does not go away within a few minutes after pressure is relieved,
and advancing to serious wounds that can be very painful and are excellent portals
of entry for infection.
Friction is caused by two surfaces rubbing together resulting in heat and injury to
the skin. This can happen if dragging the person’s skin on the sheets below when
repositioning. Proper repositioning technique is very important to prevent
friction and/or shearing.
Shearing is caused by separation of tissue below surface. Several layers of skin

move in different directions causing capillaries to bleed and a deep wound may
result. Proper repositioning technique is very important to prevent friction
and/or shearing.
Skin to Skin Contact, especially under breast and under folds of fat on people who
are overweight can cause skin irritation and create a perfect environment for
infection. It is very important to clean and dry these areas very well.
Ulcers may also be caused by poor circulation. Decreased blood flow to an area can
cause tissue death. This type of ulcer is most common to the lower extremities.
Frequent and careful observation and timely reporting of skin changes is very
important for people with impaired circulation.
Risk Factors for Skin Breakdown
It is essential to have knowledge of a person’s condition and ability to function. A

person with any of the following conditions is at greater risk for skin breakdown:
Bed bound or limited mobility - Unable to reposition independently - Poor
nutritional or fluid intake - Impaired circulation – Diabetes - Cognitively
impaired - Dry or sensitive skin - Overweight with skin folds – Under weight.
Stages of Pressure Ulcers
Stage 1. Persistent red, pale, or dark skin (generally over a bony prominence). The
color does not return to normal after pressure is relieved.
Stage 2. The skin cracks, blisters, or peels. There may be a shallow crater,
indicating that skin breakdown has reached the inner tissue.
Stage 3. The skin is gone. Underlying tissues are exposed. The exposed tissue is
damaged. There may be drainage from the area.
Stage 4. A deep crater that extends to expose the muscle and/or bone. Drainage
or crust formations usually present. There is a high risk of infection.
Techniques for Preventing Skin Breakdown
* Frequent observation of skin, especially at pressure points, under breasts and

skin folds.
* Immediately report any changes in skin condition to the nurse.
* Keep skin clean, wash, rinse and dry the person’s skin thoroughly (pat dry, do not
rub). Apply moisturizers and/or powder per nurse’s instructions.
* Reposition the person every two hours.
* Get help when moving a person in bed, make sure to lift rather than slide the
person.
* Encourage the person to drink an adequate amount of fluid daily.
* Encourage high protein intake, including beverages and snacks.
* Use assistive devices, such as sheepskin, egg crate mattresses, cushions, heel
and/ or elbow protectors to reduce pressure and friction.
* Keep the bed linens clean and as wrinkle free as possible.
* Keep the person out of bed as much as possible. Assist with exercises to
promote circulation.
Module 12
Musculoskeletal System
The Musculoskeletal System...........................................................................................116

Disorders of Musculoskeletal System..........................................................................117
Musculoskeletal System - Diagram................................................................................118
Bones of the Body...............................................................................................................119
Types of Joints...................................................................................................................120
Range of Motion..................................................................................................................121
The Musculoskeletal System
The musculoskeletal system is the framework for the body. It provides protection, allows
our bodies to move and gives us our shape. The system has three components:
1) Bones, which are hard and rigid. Inside the hollow center of bones is a substance called
bone marrow, which is where blood cells are made. There are four types of bones:
 Long bones bear the body’s weight. Leg bones are long bones.
 Short bones allow ease in movement, such as wrist, ankles and fingers.
 Flat bones protect the organs. Examples are ribs, pelvic bones, the skull, and
shoulder blades.
 Irregular bones are the vertebrae in the spinal column.
2) Joints are the point where two or more bones meet. They allow movement. Joints are
held together by cartilage and lubricated by synovial fluid. Bones are held together at the
joint by strong bands of muscle called ligaments.
3) Muscles, which have three functions. They help the body to move, to maintain posture
and produce body heat. Strong connective tissues called tendons connect muscles to
bones, which help with movement. When muscles contract (shorten) they burn food for
energy and heat is produced. Shivering, which is a form of rapid general muscle
contraction, is how the body produces heat when exposed to cold. There are two types of
muscles:
 Voluntary muscles can be consciously controlled. They do not move unless you will
them to move.
 Involuntary muscles work automatically. You cannot control them. The heart is an
involuntary muscle.
The CNA role in musculoskeletal health:
Encourage balanced diet and vitamin/mineral supplements as ordered by Physician.
Encourage activity which is weight bearing to strengthen/tone muscles and support bone
density. Assist with braces, canes, walkers, wheelchair use. Observe and report red areas
that may be caused by these devices.
Ambulate consumer as instructed on care plan. Use gait belt for safety. Assist with ROM
exercises.
Care provider can prevent injury to themselves by keeping muscles toned, eating balanced
diet, getting plenty of rest, staying well hydrated (drinking plenty of water), and balancing
stresses.
Disorders of Musculoskeletal System
Atrophy is the most common disorder of the musculoskeletal system. It is the decrease
in size or wasting away of muscle tissue due to inactivity. Some atrophy is normal to the
aging process. Severe atrophy can seriously limit range of motion and mobility. It is
commonly a result of extended inactivity or bed rest after an illness or medical episode.
In many cases muscle tissue can be regained with exercise.
Contracture is the lack of joint mobility due to severe shortening of a muscle. The
contracted muscle is fixed in position, deformed and cannot stretch.
Arthritis is inflammation of one or more joints or part of the spinal column. This occurs
with aging, excessive weight, and joint injuries. Joint stiffness occurs with lack of motion.
Pain occurs with weight bearing or joint motion. Cold weather and dampness seem to
increase symptoms. Severe pain affects rest and mobility. The two most common types
are:
 Osteoarthritis (Degenerative Joint Disease)(DJD) is the most common type of

arthritis. It is caused from general wear and tear and generally occurs late in life.
Treatment involves pain management, which includes medication, heat and/or cold
application, exercise and rest. Weight loss is stressed for individuals who are
overweight.
 Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune disease most
common in women. It can occur at any age, but generally onset is between 40 and
60 years old. With RA both sides of the body are affected; for example, it will
affect both wrists or both knees. The wrist and finger are the most commonly
affected. In addition to pain and stiffness, joint swelling occurs; also bone erosion
and joint deformity. In addition to pain management, treatment goals are to slow
down or stop joint damage, or possibly joint replacement.
Osteoporosis is when the bones become brittle, fragile and break easily. Elderly women
are at risk due to the lack of estrogen after menopause. Inactivity is also a risk factor.
Back pain, loss of height and stooped shoulders are common signs. Fractures can occur
very easily; turning in bed, twisting, even coughing or getting up from a chair can cause a
fracture. Preventing falls is very important for someone with osteoporosis.
Fracture is a broken bone. There are several types of fractures:
 Closed Fracture (Simple Fracture) - The bone is broken, but the skin is intact.
 Open fracture (Compound Fracture) - The bone has come through the skin.
For healing, bones are brought back into alignment. Sometimes, nails, rods, pins, plates or
screws are used to keep the bones in place. Movement is prevented with a cast or
traction.
Hip fractures are common in the elderly, generally from falls. After surgery rehabilitation
is needed, and can take several weeks in a facility.
Musculoskeletal System - Diagram
Bones of the Body
Types of Joints
Range of Motion
Range of motion (ROM) = the amount of movement possible in a joint, or how far a
person can move a joint comfortably.
R.O.M. exercises can be:

 Active: Which means done by the person
 Active assisted- by the person with assistance
 Passive: Done for the person by another
Abduction
Abduction is movement away
from the midline, or to abduct.
Adduction
Adduction is movement toward
the midline, or to add.
Flexion
Flexion is to bend at a joint, or
to reduce the angle.
Extension
Extension is to straighten at a
joint, or to increase the angle,
for example, from 90 degrees to
180 degrees.
Medial Rotation
Medial rotation is to turn inward.
Lateral Rotation
Lateral rotation is to turn
outward.
Module 13
Body Mechanics and

Assisting With Transfers
Rules of Lifting Mechanics..............................................................................................123
Assisting With Transfers................................................................................................125
Proper Use of Gait.............................................................................................................126
Rules of Lifting Mechanics
 Maintain a relaxed posture
 Keep feet apart for a good base

of support
 Keep knees slightly bent
 Tighten stomach muscles
 Hold items close to body
 Don’t over reach
 Don’t twist
 Use legs and arms to lift – not

back
 Vary task to reduce repetition
 Take a break and relax
Squat Lift
Tripod Lift
Rules of Lifting Mechanics (cont.)
Straight Leg Lift Bend at the

HIPS, not the back (Power
Lift)
Golfer’s Lift
Lifting the incorrect way

puts unnecessary,
excessive stress and strain
on your back. Use your
legs, not your back!
Keep the weight you’re lifting

close to your body.
Assisting With Transfers
Transfer = assisting a person to move from one surface to another; for example, a
bed to chair transfer.
Body mechanics = the position of the person performing the transfer. To help a
patient transfer safely, you must understand body mechanics. This is the way you
move your trunk, legs, and arms for the best leverage with the least stress and
fatigue.
Rules for Transferring a Patient
 Communicate -- tell the person what you are going to do. Speak slowly and clearly
 Transfer on the count of 3 -- count out loud, with person if they can
 Lock the wheelchair at an angle
 Move the person’s hips to the front edge of the chair/bed
 Instruct/assist person to lean shoulders forward
 Place the person’s knees between your knees, or place your feet in front of their
feet
 Hold on to the gait belt
 Have patient rock back and forth before transfer
Special Considerations
 Transfer toward the patient’s strong side

 If the patient is heavy, get help or use a sliding board
 If patient is anxious, reassure and be sure that they feel safe
Rules That Protect You When Transferring a Patient
 Keep your back straight

 Tighten your stomach muscles
 Bend your knees
 Keeping a good base of support
 Keep your feet apart
 Turn, don’t twist your back during the transfer
 When appropriate, use a gait belt
 Hold patient close to you
 Don’t reach a long distance
 Never let the patient hold you around your neck during the transfer
Proper Use of Gait
Module 14
Nervous System and

Nervous Disorders
The Nervous System.........................................................................................................128
Understanding Cognitive Functioning............................................................................129
Common Disorders of the Nervous System................................................................130
Signs and Symptoms of Stress......................................................................................132
Fight or Flight.....................................................................................................................134
Beck Depression Inventory.............................................................................................137
Alcohol and Medication Issues Among Older Adults...............................................139
The Nervous System
The nervous system controls all body functions. It has two main divisions:
 The Central Nervous System: Consisting of the brain and spinal cord.
 The Peripheral Nervous System: Consisting of the nerves throughout the

body.
The Central Nervous System: The brain weighs about 3 pounds, is 90% water and
has 4 main parts:
1. The Cerebrum: The largest part of the brain, controls the highest functions
such as conscious thought, memory, speech and voluntary muscle movement.
It processes sensory information from the outside world through vision,
hearing, smell and sensation. Our personal individuality is developed through
this part of the brain. The cerebrum has two hemispheres. The right
hemisphere controls movement on the left side of the body while the left
hemisphere controls movement on the right.
2. The cerebellum- Controls balance and coordination. It sends instructions

through the spinal cord to the muscles, promoting smooth movement and
mobility.
3. The Spinal Cord is another part of the central nervous system. It lies
within the spinal column and is approximately 18 inches long. It contains
pathways which conduct messages to and from the brain.
4. The Brain Stem- connects the spinal cord with the rest of the brain. It
controls the functions that happen automatically such as heart rate and
breathing. It also controls sleeping and dreaming
The Peripheral Nervous System: is a network of nerves that carry impulses back
and forth from the body to the brain. Some peripheral nerves form the autonomic
nervous system, which controls involuntary muscle/body functions. This system
contains the sympathetic nervous system, which increases the function needed for
exercise, and the parasympathetic nervous system, which slow functions to allow
for relaxations. They balance each other out.
Understanding Cognitive Functioning
Cognition is the process by which we learn, store, and use information.
Cognitive Functions Include:
1. Intelligence- The ability to deal with symbols, abstract ideas and to comprehend
new information.
2. Learning- The means by which new information is stored in the brain
3. Memory- The process of recalling (recognizing) information stored in the brain.
Cognitive development continues throughout life. The process of fulfilling basic human
needs at every stage of life influences the development and function of cognitive faculties.
Other factors include:
 Stress- A Condition or feeling experienced when a person perceives that external

and or internal demands may exceed the resources the person is able to mobilize.
 Maturity- A state of being encompassing a person’s experience, ability for self
reflection, mastery over the emotions, interaction with the environment and a use
of reasoning.
 Creativity- The ability of a person to apply unique and practical solutions to new
situations, to come up with original ideas and to communicate these in an effective
ways.
All cognitive processes take place in the brain. The brain is part of the body’s central
nervous system.
Frontal Lobe: Intellectual function, smell, and speech.

Motor area of the Frontal Lobe: Initiation of skilled and postural movement.
Parietal lobe: Awareness and distinction of taste and touch, pressure, temperature,
muscle and sense of body position.
Occipital Lobe: Vision
Temporal Lobe: Hearing, language, smell, and emotional behavior.
Corpus Callosum: A bundle of nerve fibers connecting the left and right cerebral
hemisphere.
Cerebellum: Equilibrium, muscle tone and postural control, coordination of voluntary
movement.
Common Disorders of the Nervous System
Stroke/CVA (Cerebrovascular Accident): The third leading cause of death in this country
and the leading cause of disability. A stroke affects the blood supply to the brain. The
two main causes are:
 A ruptured blood vessel in the brain, resulting in bleeding swelling, pressure and
ultimately damage in the brain.
 A blood clot that blocks the flow of the blood to the brain.
Functions controlled by the affected part of the brain, such as speech, swallowing and
muscle control, may be temporarily or permanently impaired or lost. Strokes occur in the
right or left hemisphere of the brain and affect function or cause paralysis on the
opposite side of the body; this is known as hemiplegia.
Warning Signs of Stroke
 Sudden numbness or weakness of the face, arm, or leg, especially on one side of the
body
 Sudden confusion, trouble speaking, or understanding.
 Sudden trouble seeing in one or both eyes.
 Sudden trouble walking, dizziness or loss of balance or coordination
 Sudden severe headache with no known cause
TIA= Transient Ischemic Attack- A short episode of muscle weakness, confusion, memory
loss, slurred speech or other, stroke like symptoms from which the person recovers in a
few minutes. A TIA may be an early warning of an impending stroke. Risk factors for
stroke include: age, male gender, hypertension/high blood pressure, family history,
cardiovascular disease, diabetes, high cholesterol, obesity, alcoholism, and inactivity.
People who have suffered a stroke often experience frustration, emotional instability, and
impulsive behavior. These behaviors are commonly related to the difficulty with
communication, called Aphasia. There are two types of aphasia; one or both can be present.
Expressive Aphasia = Difficulty sending messages. Speech may be slurred or the person
may not be able to form words at all. They may think one thing but say another. They may
shout or cry without reason, or they may not be able to speak, write or signal at all due to
paralysis. Receptive Aphasia = Difficulty receiving messages. The person has trouble
understanding what is said; a person may not recognize familiar objects, people or words
(written or spoken). Recovery from stroke depends on the type and extent of damage to
the brain and the ability of the person to participate in rehabilitation.
Parkinson’s Disease- A progressive degeneration of specific parts of the brain. There is
no known cause for this disease. Symptoms include: lack of facial expression, muscle
stiffness, rigidity, tremors, shuffling gait, shaking, or repetitive movements, especially of
the hands, (pill rolling = rubbing of the thumb and index finger), a slumping posture, or
forward tilt
of the trunk. Symptoms worsen as the disease progresses and may include problems with
speech, swallowing, elimination, memory and sleep. As with all disorders of the nervous
system, emotional/behavioral symptoms, such as frustration, anger, depression, or anxiety
may occur. While symptoms of this disease can be treated there is no cure. People over
50 are at risk.
Multiple Sclerosis (MS): is a chronic disease resulting in the destruction of the myelin
(the coating of the nerves in the spinal cord and brain), causing a disruption in the nerves
impulses/messages to and from the brain. Functions controlled by the damaged area of
the brain or spinal cord is impaired or lost. There are several types of MS. Some types
involve acute attacks or flare ups, following remissions when the symptoms lessen or
disappear. In other cases the losses are permanent and progressive. The disease may
progress rapidly or in a slow, gradual decline. Symptoms may include: poor coordination,
tremors, numbness, tingling or loss of feelings, vision problems, speech problems, or
problems with elimination, impaired concentration, memory, judgment and behavioral
instability. Respiratory muscle weakness is also common in people with M.S. The disease
generally begins between the ages of 20 and 40, but can be hard to diagnose because the
symptoms often come and go. There is no cure.
Head and Spinal Cord Injuries: Temporary or permanent damage to the brain and spinal
cord, generally caused by falls, car accidents or sports injuries. The damage can range
from temporary loss of consciousness, confusion and impaired nerve or muscle function to
permanent brain damage or paralysis depending on the location and extent of the injury.
Cervical injuries high up on the spinal column cause damage from the neck down.
Quadriplegia = paralysis from the neck down. Lumbar or thoracic level (lower down the
spinal column) injuries cause paraplegia = paralysis from the waist down. As with all
nervous system disorders emotional instability and behavioral symptoms are common.
Seizures are sudden and sometimes violent contractions of muscle groups caused by
electrical misfiring in the brain. There are a number of types of seizures. Safety is the
first concern of the care provider. Remove furniture or other objects that may cause
injury to your resident. Turn the person on their side to prevent aspiration, time the
length of the seizure and describe what you are seeing so you can report this to the nurse
or charge person. Reassure the resident. The person may be incontinent or be very drowsy
after the event.
Signs and Symptoms of Stress
Stress = the body’s response to demands. Distress = when the demands are perceived by
the person to exceed personal resources. What is stressful for one person might not be
stressful for another. People respond to stress differently. Some people blush or eat
more, while others grow pale or eat less. Prolonged stress is not good for physical or
mental health. Identifying personal signs and sources of stress can help in the
management of stress. The following are some common signs and symptoms of stress:
 Frequent headaches, jaw clenching or pain

 Gritting, grinding teeth
 Stuttering or stammering
 Tremors, trembling lips, hands
 Neck ache, back pain, muscle spasms

 Light headedness, faintness, dizziness
 Ringing, buzzing, or “popping sounds”

 Frequent blushing, sweating
 Cold or sweaty hands, feet

 Dry mouth, problems swallowing
 Frequent colds, infections, herpes sores

 Rashes, itching, hives, “goose bumps”
 Unexplained or frequent “allergy” attacks

 Heartburn, stomach pain, nausea
 Excess belching, flatulence

 Constipation, diarrhea
 Difficulty breathing, sighing

 Sudden attacks of panic
 Chest pain, palpitations

 Frequent urination
 Poor sexual desire or performance
 Excess anxiety, worry, guilt, nervousness
 Increased anger, frustration, hostility

 Depression, frequent or wild mood swings
 Increased or decreased appetite

 Insomnia, nightmares disturbing dreams
 Difficulty concentrating, racing thoughts

 Trouble learning new information
 Forgetfulness, disorganization, confusion

 Difficulty in making decisions
 Feeling overloaded or overwhelmed

 Frequent crying spells or suicidal thoughts
 Feelings of loneliness or worthlessness

 Little interest in appearance, punctuality
 Nervous habits, fidgeting, feet tapping

 Frustration, irritability, edginess
 Overreaction to petty annoyances

 Increased number of minor accidents
 Obsessive or compulsive behavior

 Reduced work efficiency or productivity
 Lies or excuses to cover up poor work

 Rapid or mumbled speech
 Excessive defensiveness or suspiciousness

 Problems in communication, and sharing
 Social withdrawal and isolation

 Constant tiredness, weakness, fatigue
 Frequent use of over-the-counter drugs

 Weight gain or loss without diet
 Increased smoking, alcohol or drug use
Excessive gambling or impulse buying
Fight or Flight
The General Adaptation Syndrome (GAS), also known as the “Fight or Flight”
response, is our biological coping mechanism. When confronted by a threat or
stressor, the body responds by preparing to fight or flee from danger.
Stressor = an activity, event or stimulus that causes stress. The body

automatically responds to all threats, or stressors the same way. The brain sends
a message to the pituitary gland to release hormones. This triggers the adrenal
glands to pour out adrenaline. Adrenaline increases the heartbeat and rate of
respiration, raises the blood sugar level, increases perspiration, and dilates the
pupils. Digestion slows to allow oxygen to be more readily available to the muscles,
muscles contract to increase strength and blood-flow to the extremities is
decreased to slow bleeding if injured.
This response helped ancient humans to survive, but today it is often counter
-productive. The spurt of adrenaline, bracing muscles, quickening pulse and
shutting down of digestion we experience may leave us feeling anxious and unable
to relax. We may feel exhausted and foggy. Chronic unrelieved or unexpressed
tension can build up and can lead to a variety of long-term health issues such as
high blood pressure, heart disease and diabetes.
The symptoms of unrelieved tension are many and they differ for different people.
Commonly we feel exhausted after a bout of G.A.S. Some other common symptoms
include: headaches, body aches, loss or increase of appetite, irritability, confusion,
inability to focus, hyperfocus with inability to think of anything else, general
feeling of anxiety, muscle weakness and digestive distress.
We treat the symptoms with pain relievers, anti-anxiety, anti-depression and other
drugs. We self medicate with comfort food, alcohol, caffeine and diversional
activities. These methods help us to achieve temporary relief, but often cause
other problems.
We can learn to minimize the effects of G.A.S. and help our body systems to
return to normal more quickly by controlling our reactions and our thoughts.
We can also intentionally relax. It is not possible to be both tense and relaxed at
the same time. When we can pay attention to what we are thinking and feeling, we
can maintain better control of our reactions and prevent a bout or G.A.S.
Physical exercise also helps us to express and release tension. Good nutritional
intake is essential to counter the effect stress has on the cells and organs of the
body.
DEMENTIA
An Umbrella
That Covers Multiple Symptoms
Memory Loss of memory is the most common symptom of

-
dementia.
Short Term loss is more common in the early stages.
Concentration Decreased ability to focus attention and stay

-
on task.
Orientation The awareness of who, where and when is

-
affected. This may be referred to as oriented x 3 Person,

Place and Time.
Language Problems finding, using and understanding words.

-
Judgment - Decreased ability to make decisions, to

understand consequences of actions.
Visuospatial The ability to make sense of what is seen. And

-
how objects relate to one another.
Sequencing Being able to do things in a logical order.

-
Mental Health
Mental health involves the mind and thought processes: According to most
definitions, a mentally healthy person is someone who copes with and adjusts
to everyday stresses in a socially acceptable way. Mentally healthy people
also can control or adapt their behavior as needed to cope with increased
stress.
Mental Illness is defined as a disturbance in the ability to cope or adjust to

stress, resulting in impaired function, judgment and/or abnormal behavior.
Mental illnesses, just like physical illness, can be mild or severe, short term,
acute or chronic. There are many different kinds of mental illness that fall
in to three categories:
Mental Disorders - Emotional Illness - Psychiatric Disorders
Causes of mental illness include:
 Inability to cope or adjust to stress. Example- Depression

 Chemical imbalance - Example - Bipolar Disorder
 Genetics - Example - Schizophrenia
 Substance abuse or side effects - Example - Intoxication
 Social or cultural factors - Example - Eating disorder
The signs and symptoms of mental illness vary depending on the type and
severity of the illness and may be physical as well as behavioral. The
following is a list of common disorders/symptoms and definitions.
Anxiety - Vague, uneasy feeling of distress.

Depression - Persistent feelings of sadness.
Compulsion - Repeated act.
Delirium - Acute confusion.
Delusion - False believe.
Disorientation - Confusion related to person, place, or time.
Hallucination - Seeing, hearing feeling something that is no real.
Panic - Intense, sudden feeling of fear.
Paranoia - Suspicious beliefs.
Phobia - Fear of object or situation.
Psychosis - Inability to view the real or unreal correctly.
Obsession - Recurrent, unwanted thoughts.
Beck Depression Inventory

Choose one statement from among the group of four statements in each question
the best describes how you have been feeling during the past few days. Circle the
number beside your choice.
1. 0 – I do not feel sad 2. 0 – I don’t feel I am any worse than anybody
1 – I feel sad else
2 – I am sad all the time and I can’t 1 – I am critical of myself for my weaknesses
snap out of it or mistakes
3 – I am so sad and unhappy I can’t 2 – I blame myself all the time for my faults
stand it 3 – I would kill myself if I had the chance
3. 0 – I am not particularly discouraged 4. 0 – I don’t have any thoughts of killing
about the future myself
1 – I feel discouraged about the 1 – I have thoughts of killing myself, but I
future would not carry them out
2 – I feel I have nothing to look 2 – I would like to kill myself
forward to 3 – I would kill myself if I had the chance
3 – I feel that the future is hopeless
and that things cannot improve
5. 0 – I do not feel like a failure 6 0 – I don’t cry any more than usual
1 – I feel I have failed more than the 1 – I cry more now than I used to
average person 2 – I cry all the time now
2 – As I look back on my life, all I 3 – I used to be able to cry, but now I can’t
can see is a lot of failure cry even though I want to
3 – I feel I am a complete failure as
a person
7. 0 – I get as much satisfaction out of 8 0 – I am no more irritated by things than I
things as I used to ever am
1 – I don’t enjoy things the way I 1 – I am slightly more irritated now than
used to usual
2 – I don’t get any real satisfaction 2 – I am quite annoyed or irritated a god
out of things anymore deal of the time
3 – I am dissatisfied or bored with 3 – I feel irritated all the time now
everything
9. 0 – I don’t feel particularly guilty 10 0 – I have not lost interest in other people
1 – I feel guilty a good part of the 1 – I am less interested in other people than
time I used to be
2 – I feel quite guilty most of the 2 – I have lost most of my interest on other
time people
3 – I feel guilty all of the time 3 – I have lost all of my interest in other
people
11. 0 – I don’t feel I am being punished 12 0 – I make decisions about as well as I ever
1 – I feel I may be punished could
2 – I expect to be punished 1 – I put off making decisions more than I
3 – I feel I am being punished used to
2 – I have greater difficulty in making
decisions than before
3 – I can’t make decisions at all anymore
13. 0 – I don’t feel disappointed in 14 0 – I don’t feel that I look any worse than I
myself used to
1 – I am disappointed in myself 1 – I am worried that I am looking old or
2 – I am disgusted with myself unattractive
3 – I hate myself 2 – I feel that there are permanent changes
in my appearance that make me look
unattractive
3 – I believe I look ugly
15 0 – I can work about as well as 16 0 – I haven’t lost much weight, if any lately
before 1 – I have lost more than five pounds
1 – It takes an extra effort to get 2 – I have lost more than ten pounds
started at doing something 3 – I have lost more than fifteen pounds
2 – I have to push myself very hard (score 0 if you have been purposely trying to
to do anything lose weight)
3 – I can’t do any work at all
17 0 – I can sleep as well as usual 18 0 – I am no more worried about my health
1 – I don’t sleep as well as I used to than usual
2 – I wake up 1-2 hours earlier than 1 – I am worried about physical problems
usual and find it hard to get back to such as aches and pains, or upset stomach, or
sleep constipation
3 – I wake up several hours earlier 2 – I am very worried about physical
than I used to and cannot get back problems, and it’s hard to think of much else
to sleep 3 – I am so worried about my physical
problems that I cannot think about anything
else
21 0 – I don’t get more tired than usual 22 0 – I have not noticed any recent change in
1 – I get tired more easily than I my interest in sex
used to 1 – I am less interested in sex than I used to
2 – I get tired from doing almost be
anything 2 – I am much less interested in sex now
3 – I am too tired to do anything 3 – I have lost interest in sex completely
Scoring: 1-10: These ups and downs are normal; 11-16: Mild mood disturbance; 17-
20: Borderline clinical depression; 21-30: Moderate depression; 31-40: Severe
depression; Over 40: Extreme depression
Alcohol and Medication Issues Among Older Adults

As a home care aide, you help keep your clients healthy. You are the eyes and ears
of the home care team and may be the first to notice if a client has a health
problem. Some older clients may have problems with medications or alcohol. You can
help by sharing your concerns about these and other health problems with your
supervisor. You can make the difference.
WHAT YOU NEED TO KNOW
Signs of a Problem Medications
Some signs of a medication or alcohol  Older adults can feel the effects
problem, which may also be signs of of medications more than younger
other health conditions, include: adults do.
 Missing pills, confusion about  Some prescription drugs, over-
medication the-counter drugs, and
 Empty alcohol containers or a supplements --, like vitamins and
large supply of alcohol herbs -- can interact with one
 Drinking more than recommended another.
by one’s health care providers  Some older adults take their
 Blackouts, problems with memory, medication in the wrong way,
speech, or vision which can be harmful. They may
 Getting hurt, including falls take too many, too few, or forget
 Sleep problems to take them at all.
 Feeling depressed, anxious,
confused, or moody Alcohol
 Not caring for oneself
 Being mean to loved  Older adults can feel the effects
one/caregivers of alcohol more than younger
 Spending a lot of time alone adults do.
 Other signs like weight loss, upset  Alcohol can interact with some
stomach, or shaking prescription and over-the-counter
drugs and supplements
If a client shows these signs or other  Alcohol can cause health
major changes all of a sudden, speak problems, falls, and sleeping
with your supervisor. You can help your troubles in older adults. It can
clients get the support they may need also make their health problems
for any of their health problems. worse.
WHAT YOU CAN DO TO HELP
You Make the Difference

To help your clients, it is important for
you to know the signs of a possible It has been shown that many older
medication or alcohol problem. adults who get help for their problems
 Learn the signs listed on the can improve their health and quality of
front of this sheet. life. You can assist your clients to get
 Watch for changes in how your this help. You can make all the
clients look, feel, and act. difference.
 Do not try and diagnose a
problem. Your very important role Resources
is to observe and report to your To learn more about alcohol,
supervisor. medications, and other adults, you can
contact:
Report the Problem
Tell your supervisor if you see any signs Massachusetts Substance Abuse
of a problem or changes in your clients Information & Education Helpline
that concern you. It is your job to (800) 327-5050
report anything that may harm your www.helpline-online.com
clients, even if they ask you not to.
Sharing what you see or hear with your Bureau of Substance Abuse Services
supervisor may help your clients get the Massachusetts Department of Public
support they need. Health
 Report anything that might put www.state.ma.us/dph/bsas/bsas.htm
you or your client in immediate
danger, like falls, as soon as you Massachusetts Health Promotion
can. Report less dangerous Clearinghouse
situations once you have left the (800) 952-6637
client’s home www.maclearinghouse.com
 When you contact your
supervisor, you will talk about National Clearinghouse for Alcohol &
what you have noticed and what Drug Information
concerns you, confidentiality (800) 729-6686
issues, and safety issues for you www.health.org
client and you (including whether
you feel unsafe at work or about Massachusetts Council for Home Care
reporting your client’s problem) Aide Services, Inc.
(617) 224-4141
Module 15
Dementia
Dementia...............................................................................................................................142
Stages of Alzheimer’s Disease.......................................................................................144
Caregiver’s Techniques for Communicating With the Memory Impaired...........147
The Principles of Validation............................................................................................148
Dementia
Dementia = Loss of social and cognitive function. Not all people with dementia
have Alzheimer’s Disease, but all people with Alzheimer’s Disease have dementia.
Alzheimer’s Disease is a chronic-progressive condition. Many older people have

short-term memory problems, or lapses of memory. This does not mean that they
have dementia or Alzheimer’s Disease. Dementia can be an important symptom of
many health problems. There are many other disorders, some very treatable, that
can cause dementia. These include:
o Strokes are not always a big medical crisis; some are mini-strokes (TIAs)
that happen recurrently and may not be identified by the person. A series of
these tiny infarcts can bring on symptoms that look like Alzheimer’s.
o Brain Injuries. Symptoms similar to Alzheimer’s are found in persons who

have repeated head injuries. A blow to the head can cause a blood clot under
the skin which puts pressure on the brain. With an elderly person the injury
can be a very simple one; it does not have to be a severe blow.
o Alcoholism. Some elderly people have a history of frequent use of alcohol.

This problem can be treated and the result is a reverse of the symptoms.
o Endocrine disorders. For instance, a disturbance in the thyroid gland is very

easily treated and can reverse the symptoms of dementia. There are other
endocrine system imbalances that effect cognition and reasoning.
o Syphilis. This is a sexually transmitted disease that can affect the brain
and cause behavioral problems. It, too, is treatable when diagnosed early.
o Brain tumors. Surgery can remove a tumor that has caused changes in
behavior and personality.
o Malnutrition. Elderly people don’t always eat enough of the right foods and
are consequently they may develop vitamin and nutritional deficiencies. We
see poor nutrition in older people who are having financial problems or who
are taking medications that depress appetite. Some people may not have
anyone who can help them with food shopping or preparing appropriate meals.
Addressing the nutritional needs of the elderly person can reverse the signs
of cognitive impairment.
o Medications. Medications can affect the behavior of all of us. When we

suspect that someone is having memory loss or other problems, we must
identify what medications the patient has been taking. Multiple medications
are often taken by elderly people and not always on time or in the right
dosage.
o Depression. Depression is seen in elderly people, sometimes to such an

extent that Alzheimer’s is suspected. Changes in personality, sleeping
patterns, behavior, and sociability are not only symptoms associated with
depression, but also a major problem for the elderly population. This is
particularly true when family members no longer live near the person and are
not available for assistance or support. Depression is treatable.
o Respiratory. Respiratory problems can cause anxiety and disorientation that

mimic the anxiety found in Alzheimer’s.
o Infections. Infections such as urinary tract infection or pneumonia can

manifest in signs of noticeable confusion or hyperactivity or even
hallucinations or delusions. Infections are easily treatable.
o Metabolic disturbances. Metabolic disturbances are easily treated when

identified. These disturbances are seen in adults suspected of having
Alzheimer’s because of altered attention span, depression, and physical
tremors.
(One third to one half of people referred to gerontologists and Alzheimer’s

specialists have some other illness or problem)
Stages of Alzheimer’s Disease
Alzheimer’s Disease is a chronic-progressive condition. People with A.D. live an
average of 8 years after diagnosis, but may have been coping with signs and
symptoms for several years prior to diagnosis. The following is a guideline for the
progression of A.D. However, it is important to note that no two people with A.D.
progress in the same exact way. Not everyone will experience every symptom. For
some the progression is slow, for others more rapid.
The Early Stage
The person may have some or all of the problems listed below. Initially the
problems may not be very evident to others. The person will often deny -- or cover
up -- the problems in order to pass as “normal.”
 Awareness that she/he is forgetting more often, having memory lapses

 Problems with sequencing; may forget how to begin or complete tasks
 May be unable to think back chronologically
 Forgetting familiar words and names
 May check and recheck their watch/calendar
 Household tasks may be left undone
 May become more withdrawn in social situations
 Becomes socially isolated, and may seem self-absorbed
 Experiences anxiety
 Loses things and may become paranoid that things are moved or stolen
 Declining ability to plan and organize day to day activities
 Decreased memory of recent activities and current events
 Decreased attention to hygiene and grooming
 Dresses inappropriately, sometimes in layers
 Interruptions in sleep patterns
 Repetitive behavior begins (asking questions over and over again)
 Has problem remembering to eat, or may eat too much
 Inability to reason appropriately
Role of Caregiver in Early Stage
 Validate feelings - try to address the feelings behind the questions

 Re-assure that support is available
 Provide positive messaging
 Pay attention to ADL needs, Provide cues, reminders, notes, check ins
 Gently suggest rather than instruct
 Be responsive rather than directive
 Encourage routine
 Reorient as tolerated
It is all about maintaining the person’s dignity.
Persons in the early stage of A.D. need someone to perform tasks with them rather
than for them. Supporting the independence of the person is extremely important
at this stage, because it helps to preserve their sense of self-worth. Let the
person have as much choice as they can tolerate. Be flexible about schedules and
agenda.
Be sensitive to the fears and worries of the person in regard to the future.
Middle Stage - This is generally the longest stage
 Stage one problems are more evident

 Shorter attention span
 Less able to learn new information; long term memory is still possible
 Less able to recognize familiar faces
 Ability to speak in words that can be understood is gradually disappearing
 Loses the ability to write, may be able to write only their name
 Losing ability to read
 Cannot remember names of family and friends
 Eventually will not recognize family and friends
 May identify self as younger, may not recognize self in mirror
 Restlessness, wandering
 Sundowning = Increased agitation at sunset
 Motor problems might occur, such as jerking and twitching movements
 Mood instability - may laugh or cry inappropriately, or switch between the
two
 Hallucinations are possible
 May express insecurity or discomfort by asking to go home or for mother
 Eating may become a problem, may grab food from others food
 May lose interest in eating
 May have visual problems, depth perception is impaired
 Unable to understand and answer questions
 Unable to manage ADLs independently
 Becomes incontinent
 Unable to express needs
 May lose sense of socially acceptable behavior
Role of Caregiver in Middle Stage
 Don’t correct - redirect

 Limit decisions, keep choices simple
 Give information only as tolerated – Monitor for frustration (yours and
theirs)
 Take it one step at a time - Transitions become difficult
 Do keep good notes about client. Look for a pattern
 Avoid phrases like “I told you this before”
 Always speak calmly and maintain positive demeanor
 Validate: go where they are
 Caregiver will need to assist with bathing and dressing at this time
 If “sundowning” occurs use high voltage bulbs towards the end of the day
 Client may be suspicious of what you are doing
 Little fiblets may be necessary
Final Stage -Usually lasts 1 – 3 years
 Gradual loss of all bodily functions

 Weight loss
 Loss of interest in food, must be fed
 Can no longer communicate verbally
 Incontinent
 Potential seizures
 Requires total care
 Atrophy and contractures occur
 Spends much time sleeping
 High risk for secondary infections (UTI, pneumonia)
Role of Caregiver in Final Stage
 Provide for all ADLs.

 Monitor for any physical changes, including pain
 Advocate for the person’s needs
 Communicate verbally while providing care.
 Provide comfort
Caregiver’s Techniques for Communicating With the Memory
Impaired
The ability to communicate with a person with dementia changes with the
progression of the disease. In the mild/early stages names of objects, persons,
and places may be difficult for the individual to recall. Words such as “this,”
“that,” and “there” may replace the word the person is unable to find. When you
listen carefully, the context of the conversation often gives you clues to the
missing words. At this stage, closed questions, cues and reminders may help.
Communication becomes increasingly difficult as the disease progresses. Language

becomes confused and harder to understand. Persons with mid to later stage
dementia may have difficulty understanding what others tell them. Words lose
meaning; they may not be able to understand or answer questions or instructions.
They may ask the same question repeatedly. Pay attention to the emotion or need
behind the question. Trying to reason with the person is not helpful. Validation of
the feeling is generally more comforting.
The following are some techniques to foster positive communication and avoid
frustration:
o Eliminate distraction: confusion is likely to increase with extra noise and

activity.
o Pay attention, watch for signs of frustration. Behavior is communication. If
the person is getting frustrated or agitated, pull back.
o Do not correct, redirect.
o Establish eye contact at a face to face level.
o Identify yourself by name and call the person by their name.
o Use non-verbal communication skill: smile, nod, touch, to convey positive
regard.
o Speak in a gentle tone.
o Break down tasks: give brief one-step directions, as tolerated.
o Keep choices simple.
o Ask closed questions, requiring yes or no answers.
o Emphasize the positive and be reassuring. Validate feelings.
o Allow plenty of time for response; if needed, repeat the question again
exactly as it was phrased the first time. If there is still no response, do not
force the person to respond or comply: pull back and try again in a few
minutes.
The Principles of Validation
By Naomi Feil
All people are unique and must be treated as individuals
All people are valuable, no matter how disoriented they are
There is a reason behind the behavior of disoriented old-old people
Behavior in old-old age is not merely a function of anatomic changes in the brain,
but reflects a combination of physical, social, and psychological changes that take
place over the lifespan.
Old-old people cannot be forced to change their behavior. Behaviors can be

changed only if the person wants to change them.
Old-old people must be accepted non-judgmentally
Particular life tasks are associated with each stage of life. Failure to complete a
task at an appropriate stage of life may lead to psychological problems
When more recent memory fails, older adults try to restore the balance to their
life by retrieving earlier memories.
When eyesight fails, they use the mind’s eye to see. When hearing goes, they
listen to sounds from the past
Painful feelings that are expressed, acknowledged, and validated by a trusted

listener will diminish. Painful feelings that are ignored or suppressed will gain
strength.
Module 16
Urinary System
The Urinary System and Common Disorders..............................................................150

Appliances that Elders may need to Support Incontinence...................................152
Approximate CCs of Food and Drink Served..............................................................153
The Urinary System and Common Disorders
The Urinary system is the filtering system for the body. It helps to maintain fluid and
chemical balance. It consists of 2 kidneys, ureters, bladder, and the urethra. The kidneys
are located in the back of the upper abdomen on either side of the spine. Blood is filtered
through the kidneys. Waste, in the form of urine, passes through the ureters to the
bladder where it is stored, until it is expelled out the urethra.
A normal/healthy adult urinates between 4 to 7 times a day and produces approximately 3

pints or 1500 milliliters (ml)
For persons who require assistance with urination or bladder retraining program, the
standard is every 2 hours. Output depends on fluid intake and the strength of the bladder
muscles. Males with enlarged prostates may urinate more frequently.
The urethra is a portal of entry/exit for bacteria. Always wipe from front to back.
Normal urine should be pale yellow or amber. It is clear with no particles and has only a
faint odor. Urine stored in the bladder is sterile.
Many factors effect urinary production and elimination. Some substances, such as coffee
(any caffeinated beverage), alcohol will increase urine production. A doctor may prescribe
a diuretic=medication to increase urine production. This will cause a person to urinate
more frequently. Decreased circulation can cause reduced urinary output, which can result
in edema = swelling, Most commonly in the ankles and feet.
Common Problems of the Urinary System
Incontinence – the inability to hold urine. An incontinence product will be needed and
changed when it becomes soiled to prevent UTIs (Urinary Tract Infection). Caregivers
will need to provide peri care after every incontinent episode if the elder is unable to care
for themselves.
* Stress Incontinence - Urine is expelled when one coughs, sneezes, laughs, or in severe
cases, even moves.
* Urinary Urgency and Frequency when one feels the urge to urinate often.
* UTI’s/Urinary Tract Infection/Cystitis – Causes inflammation of the bladder and
ureters, generally caused by bacteria. More common in women than men because of the
size of the urethra. Individuals who have incontinence or are bedbound are at increased
risk for a UTI. Women should wipe themselves front to back after using the bathroom.
* Kidney stones/Renal Calculi - Small stones that are passed through the urethra.
Individuals that are on bed rest, have a poor fluid intake and are immobile can be at risk
for “stones.”
When caring for someone that has urinary incontinence, it’s important to prepare in
advance for issues that may arise. Here are some important tips that may help you:
* During outings bring a change of clothes, extra incontinence products, and hand
sanitizer.
* Protect furniture and mattress by covering with plastic; chuck pads are available in
pharmacies, water proof quilted pads are available in medical supply stores. (Only wash 1
quilted pad at a time.)
* Assess the need for urinary appliance or product.
* Remember dementia patients will need to reminded and assisted with hand washing
after toileting.
* Elders with poor circulation will retain fluid. They may have swollen ankles and may
be advised to elevate their feet above their waste for 20 to 30 minutes 2 or 3 times a
day; they may need to use the bathroom shortly after.
* A daily weight may be advised. Generally a 3 lb weight gain in one day should be
reported to the nurse or responsible person.
* Low salt diet may be recommended.
* Observe amount, color, odor and report changes to the nurse or responsible person.
* Provide peri care after every incontinent episode.
* Ensure soiled clothes are changed and washed promptly and appropriately
* Take temperature if any signs of an infection. Report elevated temperature to nurse
or responsible person.
Appliances that Elders may need to Support Incontinence
There are many types of appliances that will support client/residents with bladder
incontinence. Most can be bought in pharmacies and medical supply stores; some
will need to be ordered through the physician. Here is a list that may help:
* Bed pans/Fracture pans - Used for bed bound patients, will need to be covered and
cleaned after every use.
* Bed side commodes - Portable toilets, helpful during night, or if the bathroom is on a
different floor. Some like to keep cleaner in bottom of the commode to help eliminate
odors.
* Raised Toilet Seats - Helpful for patients with low toilets, or may have mobility
issues.
* Grab bars - Mounted on the wall beside the toilet may help with bathroom
independence.
* Urinals - Male and Female. Useful especially for night time. They should be cleaned
and disinfected regularly. When empting a urinal use Universal Precaution. When
emptying urine in toilet, put toilet lid down, and then flush. This will help eliminate bad
“pathogens” into the air.
* Incontinence Products - There are many types of briefs and pads to choose from.
Caregivers will need to ensure incontinence products are being used and changed often.
Measuring Intake and Output
The doctor may order that all fluids consumed and eliminated be measured. This is called
I and O. Documentation of I and O is required, usually on a tracking or log sheet, generally
at the end of shift.
Fluids measured in ounces (oz) must be converted to cubic centimeters (cc)

1 oz = 30 cc. For example: 8 oz glass of water = 240 cc, because 8 x 30 = 240.
For a person that is incontinent, exact measurement of output is not possible. In that
case, the amount of output is recorded by estimation of amount and number of incontinent
episodes. The weight of the brief is heavier when there is a large amount of urine and less
weight when there is only a small amount of urine. This could be recorded as follows:
“Incontinent of large amount of urine, or Incontinent of small amount of urine x 3”
Approximate CCs of Food and Drink Served
Main Dining Room Water 240

Juice Glass 180
Milk 180
Coffee Cup 150
Milk Pitcher or Cereal 240
Units 7 oz Coffee 210
7 oz Juice Glass 210
4 oz Orange Juice 120
6 oz Resource Juice 180
Small Milk Carton 120
Large Milk Carton 240
5 oz Med Cup 120
2 Handled Cup 180
Foods ½ C Pudding 120
½ C Jello 120
½ C Custard 120
½ C Ice Cream 120
6 oz Soup 180
6 oz Italian Ice 180
12 oz Styro Cup 360
Supplements 4 oz Health Shake 120
8 oz Resource Plus 240
Ensure 240
Ensure Pudding 150
CNA/HHA Catheter Care
Your observations are important when it comes to caring for an
elder with a catheter bag. Here are several observations and steps
required of CAN/HHA.
 (Rule of Thumb) patient has a catheter always record intake and

output. Even if your nurse hasn’t delegated it to you. Total up at
the end of your shift and give to your nurse.
 Make sure catheter tubing is not kinked or looped.
 Keep catheter drainage bag below patient’s waist at all times.
 Provide pericare 2x a day and after a bowel movement. Be sure to
ALWAYS wipe patient from front to back.
 You may need to assist patient with securing the catheter. Tape
may be irritating to the skin, ask your nurse for catheter tube
holder if needed.
Reprtable Situation When Caring for a Catheter
 Complains of pain (and or burning) and fullness in the abdomen.

 Urinary leakage from catheter.
 A small/scant amount of urine output.
 Blood or thick sediment in the urine bag.
 Crusting around the catheter site.
 Dark urine.
Urine May Contain Microbes and Blood. Remember to Follow

Standard Precautions for Bloodborne Pathogens
Module 17
Death and Dying
Advanced Directives.........................................................................................................156
Hospice and Palliative Care Programs...........................................................................157
Communicating with the Dying Client............................................................................158
Common Signs of Impending Death...............................................................................159
Signs and Symptoms of Pain............................................................................................161
Water Bugs & Dragonflies...............................................................................................162
Advanced Directives
An Advance Directive is a document stating a person’s wishes about

health care procedures to be used in the event that the person cannot
speak for her/himself.
It is wise for everyone to designate a Health Care Proxy: a friend or

family member that can make medical/health care decisions in the
event that the person cannot communicate her/his own wishes. This is
a form that can be obtained at any Doctor’s office. The person
assigned as Health Care Proxy should have a copy to present if needed.
Advanced Directives generally forbid certain life sustaining procedures

when there is no hope of recovery.
A Living Will is a document a person completes about measures that

support or prolong life, such as feeding tubes or ventilator use,
generally to direct not to start such measures or to remove them if
started.
DNR/Comfort Care Order means that a person will not be

resuscitated if their heart stops. A person must consult with her/his
Doctor to get this order written. The original Doctor’s order must be
available to EMS personnel in order for it to be honored. If they
cannot see the actual order they must begin resuscitation measures,
such as CPR. A common place to keep the DNR is on the refrigerator.
A DNR is also available in a wrist band that looks very much like a
hospital name band.
Hospice and Palliative Care Programs
Palliative care = care that improves the quality of life of patients and their
families facing life-threatening illness. The focus is on comfort rather than cure.
Special attention is given to recognizing, preventing and managing pain and to
psychological, emotional and spiritual support.
Hospice = a program of palliative care for persons with a terminal illness. Hospice
has a holistic philosophy of care. The focus is not just on the medical needs of the
person receiving care. Much attention is given to the emotional and spiritual needs
as well. Services and care plan often address the needs of the caregivers as well as
the person receiving care.
Hospice programs in the U.S. have been focused on caring for the terminally ill
since the early 1970s. Care may be provided in a person’s home or in a hospital,
nursing home or a free standing hospice facility.
Palliative/hospice care programs aim to serve patients throughout their illness. If

a hospice program wishes to have its services paid for under the Medicare Hospice
Benefit, the hospice program must meet federal regulations. Most hospice
programs and their patients and families rely on this payment option. The United
States Medicare Hospice Benefit limits care to patients who:
 Agree to therapy with a palliative intent
 Have less than 6 months to live if the disease runs its usual course, in the
judgment of the patient’s attending physician and the hospice medical
director
 Elect the Medicare Hospice Benefit for coverage of all services related to
their terminal illness
Communicating with the Dying Client
Talking with a dying person is less about building a relationship and more about
deepening our human connection. Validate the individual’s experience. Avoid
sharing your point of view or personal experience. Ask simple questions. Listen
with all of your senses. When working with a nonverbal client whose death is
pending, it is generally wise to make emotional contact before you make physical
contact. You can do this by stilling your mind, opening your inner senses and
directing your attention and focus to the person. Slowly enter the client’s energy
field. Silently ask permission to touch, and trust what you sense as a response.
Always allow silence, don’t push for communication -- this signals your acceptance
of the person just as they are and your willingness to be with them, to listen or to
simply sit in silent companionship. Ask the person if they want to talk. Ask them if
they would like to be alone, or if they want you to stay with them. Ask before you
touch. The dying person’s work includes de-indentifying with their life and their
body. Talk and touch can distract them. You may want to reassure them that it is
okay to let go, and that you will be the steward of their body while they make their
passage out of the physical world. Dying people often perform a life review. They
may want to tell stories or they may remark that they remember things that they
haven’t thought of for years. They may express regrets. Simply listen and validate.
Symbolic language – Talk of travel, a trip or a passage -- for example, waiting to

board a bus or plane, needing to pack a suitcase or purchase tickets for a trip,
needing to go home and closed or opened doors -- are commonly used by individuals
who are getting close to death. Caregivers should always reassure the person that
they can go when they need to and that they will help them to make a safe passage.
Visitations - Another common experience of dying people is visits and talks with
dead friends and family members. It is common for the dying person to see beings
or light in the room that cannot be seen by others. They may report that someone
who has passed is coming for them. They may say that they are waiting for them or
that they are going with them. These occurrences are often reported after
sleeping, but are perceived as real, rather than dreams. This can be a little
unsettling for a caregiver. Don’t worry, these beings are not there for you.
Generally the person is comforted by these visits. In the event that the person is
frightened or upset by these visitations, report this to the nurse or responsible
person.
Always observe for signs and symptoms of pain or discomfort.
Common Signs of Impending Death
As in every stage of life, no two people are exactly the same. Some persons will
exhibit all of the signs, while others will exhibit only some – or perhaps none -- of
them.
As a person enters the final stage of the dying process, there are certain signs
that are commonly present that you can see. These are signs that the body’s
systems are shutting down. Some people linger in the final stage for weeks, while
others pass very quickly. There are many factors involved, including the type and
length of the illness that led to this stage. The person’s spiritual beliefs and how
they’ve prepared for death emotionally will also influence their dying experience.
The following are signs and symptoms that commonly occur when death is near:
*A decreased interest in food. Food is the way the body nourishes, energizes and
maintains health. Body systems that are shutting down don’t need food any more.
There may be a gradual or sudden loss of interest in eating. Cravings may come and
go. When there are no swallowing or digestive issues, you can honor requests for
food, but it is not necessary to encourage food.
* Liquids may be desired as long as the person is conscious. As with food, it is

alright to give -- but not encourage -- fluids, as long as there are no prohibitive
health conditions. The symptoms of dehydration such as headache, cramping,
nausea, which generally occur in a healthy body, most commonly do not occur at this
stage. In fact dehydration is believed to have pain-relieving properties. As a
comfort measure ice chips may be helpful, or you can use swabs to moisten the
mouths, tongue and lips.
* The person sleeps a good deal of the time. They may wake confused and less able
to focus, respond and participate in the world around them. They may be less
interested in life. They may see and talk with loved ones who have died or other
beings you cannot see. They are often comforted by these interactions. Simply
validate their experience and reassure them that all is well.
* The person may seem restless due to lack of oxygen in the blood. They may pick
at bedclothes, move limbs aimlessly or seem to be reaching for something. Monitor
for signs and symptoms of pain, such as moaning, stiffening or grimacing. Pain
management is a very important part of the caregiver role at this stage.
* Generally urinary and fecal output will decrease with diminished intake. The
person may lose control of their bladder or bowels. Urine may become very dark in
color.
* Temperature goes up and down. The person may sweat, or be cold and clammy.
* Skin color changes occur as circulation decreases. Nail beds, hands and feet are
often pale or bluish. Very close to the end the underside of the body becomes
blotchy and purplish.
*Breathing becomes irregular, often stopping for ten or fifteen seconds before
resuming. Fluid pooling in the back of the throat can cause a rattling, congested
sound. Positioning on the side can help. Eyes be may open or semi open. The sense
of hearing remains intact until death.
Signs and Symptoms of Pain
Behaviors:
 Crying
 Gasping
 Grimacing
 Groaning
 Grunting
 Holding or rubbing the affected body part (splinting)
 Irritability
 Maintaining one position; refusing to move
 Moaning
 Quietness
 Restlessness
 Changes in speech: slow or rapid; loud or quiet
 Screaming
Body Responses:
 Increased pulse, respirations, and blood pressure
 Nausea
 Pale skin (pallor)
 Sweating
 Vomiting
Water Bugs & Dragonflies
By Doris Stickney
Down below the surface of a quiet pond lived a little colony of water bugs. They
were a happy colony, living far away from the sun. For many months they were very
busy, scurrying over the soft mud on the bottom of the pond. They did notice that
every once in a while one of their colony seemed to lose interest in going about with
friends. Climbing the stem of the pond lily, it gradually moved out of sight and was
seen no more.
“Look”, said one of the water bugs to another. “One of our colonies is climbing up
the lily stalk. Where do you suppose she is going?”
Up, up, up she went slowly. Even as they watched, the water bug disappeared from
sight. Her friends waited and waited but she didn’t return.
“That’s funny!” said one water bug to another. “Where do you suppose she went?”
wondered a third. No one had an answer. They were greatly puzzled.
Finally, one of the water bugs, a leader in the colony, gathered his friends
together. “I have an idea. The next one of us who climbs up the lily stalk must
promise to come back and tell us where he or she went and why.”
“We promise”, they said solemnly.
One spring day not long after, the very water bug who had suggested the plan
found himself climbing up the lily stalk. Up, up, up he went. Before he knew what
was happening he had broken through the surface of the water and fallen onto the
broad, green lily pad above. Weary from his journey, he slept. When he awoke, he
looked about with surprise. He couldn’t believe what he saw. A startling change had
come to his old body. His movements revealed four silver wings and a long tail. Even
as he struggled, he felt an impulse to move his wings. The warmth of the sun soon
dried the moisture from the new body. He moved his wings again and suddenly
found himself up above the water. He had become a dragonfly.
Swooping and dipping in great curves, he flew through the air. He felt exhilarated
in the new atmosphere. By and by, the new dragonfly lighted happily on a lily pad to
rest. Then it was that he chanced to look below to the bottom of the pond. Why,
he was right above his old friends, the water bugs! There they were, scurrying
about, just as he had been doing some time before.
Then the dragonfly remembered his promise: “The next one of us who climbs up
the lily stalk will come back and tell where he or she went and why.”
Without thinking, the dragonfly darted down. Suddenly he hit the surface of the
water and bounced away. Now that he was a dragonfly, he could no longer go into
the water. “I can’t return!” he said in dismay. “I tried, but I can’t keep my promise.
Even if I could go back, not one of the water bugs would know me in my new body. I
guess I’ll just have to wait until they become dragonflies too. Then they’ll
understand where I went.”
Then the dragonfly winged off happily into its wonderful new world of sun and air.

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Module 3: Documentation and Reporting...................................................................................................20

Module 4: Infection Control.........................................................................................................................27

Module 5: Safety and Emergencies............................................................................................................44

Module 6: Human Growth and Development..............................................................................................61

Module 7: Rights and Abuse Reporting.......................................................................................................71

Module 8: Cardio-Respiratory System.......................................................................................................82

Module 9: Taking and Recording Vital Signs.............................................................................................90

Module 10: Digestion and Nutrition............................................................................................................95

Module 11: Integumentary System............................................................................................................110

Module 12: Musculoskeletal System..........................................................................................................115

Module 13: Body Mechanics and Assisting With Transfers...............................................................122

Module 14: Nervous System and Disorders............................................................................................127

Module 15: Dementia......................................................................................................................................141

Module 16: Urinary System.........................................................................................................................149

Module 17: Death and Dying........................................................................................................................155

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 1

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 2: Module 1

The Main Ingredient..............................................................................................................3

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 3: Module 1

Water is needed for every bodily process

Water is vital to mental performance!

Our bodies are constantly using/losing water

Thirst lags behind our body’s water need.

Don’t wait to be thirsty –

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 4: Module 1

People Seek Assistance from Health Care Providers for:

The Places People Receive Health Care

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 5: Module 1

As a Nursing Assistant/Home Health Aide student you will learn many

Embedded in every task that a caregiver performs are 3 very

 SAFETY - This includes infection control, back safety,

 COMMUNICATION - Effective communication skills help to engage

 RIGHTS - Respect for the right of the person to be treated with

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 6: Module 1

 Complete a 75 hour training program

O.B.R.A. defines what a Nursing Assistant can do and what

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 7: Module 1

A Registered Nurse (RN) must have, at least, an Associate's degree, which

Licensed Practical Nurse (LPN) has from 10 to 15 months of training/education. An

The Five Rights of Delegation

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 8: Module 1

Role Limits of CNA and HHA

Ethics = principles and values governing conduct.

Guidelines for Ethical Behavior

 Be honest. If you make a mistake report it.

NA/HHA Training Manual – GCC / Tripp Memorial Foundation – Page 9: Module 1

 People who have paid in to social security for a certain period.

 Appeal denied services

 The reason for the treatment

Guidelines for Confidentiality

Congress passed HIPAA – Health Insurance Portability and Accountability Act - in

Due to the nature and content of this training, personal experience is

You have experienced loss of loved ones, challenges brought on by illness

I, ______________________________________, agree to keep

 Do not share your personal problems or your own life concerns.

As a caregiver it is my responsibility to establish healthy connections with the

I acknowledge and respect the whole person.

I am grateful to be of service and I believe that care giving is sacred work.

I consider it a privilege to be allowed in to a person’s vulnerability. As a caregiver I

 Maintain good hydration. Drink plenty of water.

 Get enough rest and nourishment.

 Perform only tasks that are within your job description.

Date of incident: _______ Time: AM/PM