Subjective data is based on an individual's interpretation of a situation. Pain level is a good example. Each person has a different pain threshold that cannot be accurately measured. Two people who have had the same surgery may report entirely different levels of pain on the Pain Scale. Subjective information is not judged, but recorded as the person states.
The circulatory system is made up of the heart, arteries, veins, and capillaries. They are connected to make a complete circuit in the body. The heart pumps oxygenated blood from the lungs, as well as nutrients, through the arteries to the capillaries. The capillaries then deliver carbon dioxide and waste to the veins. The veins take the waste products to the liver and kidneys for disposal, and the carbon dioxide goes to the lungs to be exhaled.
As death nears, a patient may seem to be sleeping or unconscious. They are often aware of the presence of others and are able to hear. Support the patient and speak in a kind manner. Use touch and keep them comfortable.
Hypertension is defined as a blood pressure over 140/90. Severe hypertension is above 180/120. Even if the client has a history of high blood pressure, always immediately report a sudden increase to the nurse. Untreated hypertension can lead to heart disease and stroke.
180 cc = 6 oz. When converting cubic centimeters (cc) to ounces (oz) remember that 30 cc= 1 ounce. Although an ounce is slightly more, the amounts are considered to be equal by doctors and pharmacists. Also, 1 cc = 1 ml.
The bladder is a muscle that changes with age. The muscle walls become stiffer, causing a decrease in the bladder capacity. There is also a loss of muscle strength, which can lead to leakage or inability to completely empty the bladder.
When skin becomes wet from incontinence, it becomes soft and more likely to be damaged. Friction between the skin and clothing or linens is increased, leading to skin tears and abrasions. The risk for infection is also greater when skin is not intact.
Before serving a meal tray, always check the client's ID band or tag and match it with the correct tray. Some clients have special diets, severe food allergies, or strict fluid restrictions. While it can be tempting to skip this step in a long-term care facility, the nurse aide is legally responsible for verifying the identity of each client before serving food or giving care.
Infiltration happens when the IV fluid leaks into the tissue because of a dislodged or misplaced IV catheter . The nurse assistant should monitor the IV site and report if it becomes swollen, cool to the touch, or painful. The skin near the IV site may look pale. Always be careful when moving or assisting a client with an IV to avoid pulling the line.
A slipknot is secure, but can be easily released in an emergency, using one hand. It is also called a half-bow or quick release knot.
The normal SpO2 range for a client with Chronic Obstructive Pulmonary Disease (COPD) is 88-92%. This is because oxygen reaches the lungs, but lung damage prevents oxygen from getting into the blood. Giving oxygen is carefully regulated for clients with COPD, with limits according to how the oxygen is delivered. Immediately report a low saturation to the nurse. Do not make any changes on your own.
Before providing any care, the nurse aide must follow all the standard steps in preparation. ALL of the steps must be taken before proceeding, not just one. Gather everything needed, so that you don't have to leave the client's room once you begin. Handwashing is always done before and after each client interaction. Knocking before entering the client's room, introducing yourself, identifying the client, and explaining what you will be doing are also part of standard practice.
Report sudden changes in vital signs to the nurse. A higher pulse rate can indicate infection, dehydration, stress, anxiety, or a heart condition. It's wise to wait 10-15 minutes and recheck the pulse.
When an IV is running well, the tubing should be clear and the IV site clean and dry. If blood is noted in the tubing, notify the nurse. It is beyond the scope of practice for a nurse aide to do anything with an IV.
It is important to remember that only a doctor can order a treatment, test, or medication for a client. This includes simple treatments, such as hot and cold compresses. A nurse aide can be fired or lose certification for initiating treatments.
With severe or uncontrolled bleeding, the loss of blood means that less oxygen is available for the body. As a result, the heart beats faster to try and compensate. Well-trained athletes have a normal heart rate of 40-60 bpm, because their hearts are strong and fit.
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