Lecture # 404:
Essential Nursing Skills (Cont'd.)

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Being ill makes a person lose his sense of self and body image. For a mother, a terminal or chronic disease takes away those things that define who she is: a wife, mother, cook, and looking as best she can. Anything that makes a person feel like he used to feel before he got sick makes them feel better. It make be simply changing pajamas for street clothes, shaving, or getting hair styled.

Dressing a person as neatly as possible helps those around him to feel better as well. A disheveled appearance may make family and friends avoid visiting a person. You can propose helping a person look better by using such questions as: "Do you want me to help you shave today?" or "Would you feel better if I washed your hair and dried it?"

Meditate Word By Word On These Verses:
Luke 4:16-19.

Washing hair in bed is a problem, but can be done. Perhaps the person can simply extend his head over the edge of the bed for washing. A basin underneath can catch the water. If that is not feasible, use a towel rolled up to form a horseshoe ridge. Cover the towel and the bed inside the horseshoe with a large plastic sheet. Direct the sheet into a bucket at the side of the bed so the water flows into the bucket.

Other suggestions for hair care include:

• Encouraging a person to brush hair himself. This gives them physical exertion that stimulates circulation and uses muscles of the hands and arms.
• Using a scarf or other hat to cover hair if the person does not feel like working to make himself look better.
• Thinking practical and avoid aerosol hair sprays that may impair breathing, especially if the person has problems with lung disease.
• Asking a beautician to come to the home to cut or style hair.

Question 1: What do sick people think about having their hair washed?

Nail and cuticle care is important to reduce scratching. Cuticles need to be soaked and cut carefully. Long, ragged toenails are unsightly and turn thick and brittle. They snag on the bedclothes and socks. In cases of extreme neglect, the nails be so long they curl under can break the skin, which may cause infection.

The best time to cut nails is after bathing and drying feet. Trim the nails straight across. Use an emery board for filing away the corners.

Question 2: When is the best time to do nail care? Why?

Dressing
On a practical level, it is best if a person is confined to bed not wear any clothes. However, most people are not comfortable without clothing and modesty is an issue. People feel most comfortable covered.

Forget about nightgowns that go over the head and long pants. Have you ever tried tugging long pants on and off a man while he is lying down? It is a long and difficult process. Long nightgowns entangle a woman. What if the woman urinates or defecates on herself? The gown may need to be cut off since we don't want the soiled gown near her face. Usually, there are not hospital gowns in the home, but you can cut a nightgown down the back and attach ties so that the back is closed.

Question 3: How can you make clothing more practical for a disabled person's use?
(Only one of the following answers is correct.)
For a man, use long pants with a zipper and belt.
For women, use a nightgown that pulls over the head.
For men and women, use a gown with 3 or 4 ties in the back.

The most practical garment for most patients is the standard hospital gown that falls knee length on the average person and ties in the back. They are designed to leave the backside exposed - for good reason! Here are some suggestions for clothes selection for someone who is ill with a chronic condition:

1. Clothes should be easy to remove in the event of a toilet emergency. Examples are pants or skirts with elastic waistbands.
2. Clothes should be easy to put on - wrap-around in style or tie up the back.
3. Fabrics that are lightweight are easiest to wear.
4. Don't use fabrics that are abrasive to the skin.
5. Tight, restrictive clothing can constrict the chest or abdomen. Try not to use belts, brassieres, or girdles. If the person feels undressed without these items, suggest suspenders or a camisole.
6. Socks or stockings with elastic bands can restrict blood flow to the legs.

Question 4: What is the best garment for the person who is confined to bed?

Here are some ideas for dressing:

1. Have the person sit on the edge of the bed.
2. Help him with his undershirt and shirt so he does not chill. Run your hands up the sleeves and take his hands and pull them through each sleeve.
3. If the person is paralyzed on one side, pull the paralyzed arm through the sleeve first.
4. If a pullover-style shirt, gather up the excess material and pull the garment over his head.
5. Slip on socks and stockings.
6. Place underwear inside the pants and pull them all on together.
7. Put on the person's shoes.
8. Ask the person to stand - wrapping his arms around your neck if necessary for support - while you pull up the pants at the same time.

When a person has difficulty using his hands, consider the following:

1. Replace buttons with velcro straps.
2. Put cloth or leather pulltabs on zippers so they are easy to grip.
3. Use oversized pullover shirts, sweaters, or sweatshirts.
4. Consider tennis shoes with elastic laces or velcro straps.

Question 5: How do you put a shirt on a man who is paralyzed on his left side?
(Only one of the following answers is correct.)
Pull the arm opposite the paralyzed one through the sleeve first.
Pull the paralyzed arm through the sleeve first.
Pull both arms through both sleeves at the same time.

When a person has memory loss, confusion, or intellectual impairment, he may become frustrated trying to decide which clothes to wear or may no longer remember how to get dressed. "Once," recalls a woman, "after giving my father a bath, I handed him a pair of socks and told him to put them on while I straightened up the bathroom. When I came back, he was just staring at them. 'Daddy', I said, 'why didn't you put on your socks?' and he said, 'I don't know what to do with them!'" The ideas below are meant to help you dress the mentally impaired person easier. This may be an immensely frustrating task. The best advice is to set aside extra time and keep patient. Persons with dementia become easily upset and if you are hurrying, they just become more upset.

• If the cognitive impairment is relatively mild and the person can dress himself with verbal supervision, organize clothing in drawers or shelves and label the shelves.
• Too many choices of clothes can be overwhelming. Put away clothing that is seldom worn, no longer fits well, or is out of season. Clothing that has complicated fasteners should also be stored.
• Offer no more than two choices of clothing at a time. Hold up two blouses and ask, "Which would you like to wear today?" If this question is too complicated to answer, select the blouse yourself.
• Set out clothing in the order in which it is put on. Hand the person one piece of clothing at a time.
• If the person wears a diaper, loose fitting clothing is best. A sports suit is good because it has no zipper, only an elastic waistband, it is fairly easy to wash, and the fullness of the pants help to accomodate the bulky diaper.
• Tops need to have zippers, snaps, or buttons down the front. Having a shirt pulled over the head can sometimes be frightening for the person.
• If the person wants to wear the same clothing for 2-3 days at a time, don't argue. If the clothes are soiled, put them out of the person's sight so that he does not insist on wearing dirty clothes.
• Keep jewelry and other accessories to a minimum.
• Because Alzheimer's persons sometimes wander off, sew or write the name of the person on the labels of his clothing.

When giving instructions for dressing, use short sentences and give praise when a person is able to dress himself with little or no instruction. A cognitively impaired person needs praise, acceptance, and love.

Question 6: How do you help a cognitively impaired person to dress?

Turning, Maneuvering, and Lifting
The purpose of learning the proper ways to maneuver patients is to ensure the safety of the person you can about and yourself. The answer to saving your back and moving a bedridden person is a drawsheet. They are recommended for all circumstances and your back will be eternally grateful.

To make a drawsheet, fold a regular sheet in half or thirds, place it lengthwise across the bed and under from the person's shoulders to his hips. Now you can reposition a person without having to actually lift them. If you want to turn a person from his back to the right side, do this:
Stand at the person's left side, put his arm and leg across the other arm and leg and pull on the sheet to turn him gently to his side. The person should be in the middle of the bed.

If a person needs to be pulled up in bed, two people can grasp the drawsheet on either side and lift the person up while he holds his own head up.

A drawsheet can also keep urine and feces off the actual bed sheet. If your patient coughs and loses urine with the cough, you may simply turn him over and take out the dirty draw sheet and put another in its place.

Lifting a Person By Yourself
There are basic body mechanics for lifting. Sometimes if we try to help, we may fall ourselves or hurt our backs. There are four important rules for lifting another person or any heavy object:

1. Always keep your knees slightly bent so that the center of weight of your body is low. This position uses the large muscles in the thighs and hips so that as you maneuver when lifting, there is less stress to the back.
2. Always plant your feet squarely on the floor, about shoulder width apart.
3. Do not hold your breath. Plant your feet and pause. Before you move the person, take a deep breath, then squeeze your abdominal muscles tightly and exhale as you pull up the person toward your body.
4. Always tell the person you are lifting what you want him to do and when. Count to three and then move: this usually helps them get into a rhythm with your body so that you move as a unit.

Question 7: What body muscles do you use for lifting a person up?

Transferring From a Bed to a Chair or Wheelchair

1. Place the wheelchair or chair near you and the bed.
2. Help the person sit upright on the side of the bed. Have him lie in his side, facing you, with knees bent.
3. Swing his legs over the side of the bed.
4. With one hand gently supporting the upper back, gently pull him upright. Or have him help you by using the arm that is on the bed to brace himself up.
5. Never pull are person by the arms, this weakens the shoulder joints and does not lift the person where lifting can help him move. Let the person sit for a few minutes to stabilize his blood pressure.
6. When lifting, rely on your leg muscles, which are far stronger than the back muscles. Stand directly in front of the person, then move in closer to him. Put your knees against his and put your arms around the patient at the waist. Have the patient hold onto your shoulders or grip his hands behind your neck.
7. On counting to three, pull the person to an upright position straightening your legs as you rise. Now rest and stabilize yourselves. Continue to brace the knees. Tell the person that he needs to stand and to lock his knees into a standing position.
8. When you are ready to turn, tell him that the two of you will turn together. As you turn, always face the person, never twist your body. Be sure that the chair is well placed and when the back of his knees touch the chair, gently lower him into it.

Question 8: A person needs to sit at the edge of the bed for a few minutes before he tries to stand because:
(Only one of the following answers is correct.)
he may be weak and needs to stabilize his blood pressure.
his mind needs to stabilize.
he might fall and can fall back into the bed.

Tips for Preventing Falls
Many of us will be caring for elderly women with degenerative bone disease or cancer patients who may have tumor growing in their bones. Prolonged use of cortisone can cause breakage of long bones of the leg during ordinary physical activity.

A bone fracture can be fatal for those with frail health. they must stay in bed for convalescence and this predisposes them to infection that may result in pneumonia or septecemia. Therefore, preventing falls should be one of our primary concerns. There are several things you can do:

• don't put wax on the floors
• take away small rugs from in front of the bed or chair
• rearrange the furniture so that a path to the bed is straight
• put padding on furniture with sharp edges
• make sure electical cords do not stretch across the floor
• make sure that the glare from the sun does not reflect to your patient's eyes, this can cause disorientation

Walking Safety
Tennis shoes have rubber soles and can stick to the floor, especially during a transfer. A solid shoe is best for the handicapped person because it supports his ankle and arch. Shoes should not have high heels. If new leather shoes are bought, lightly coat the person's foot with oil and have him wear the new pair around the house for 2-3 days without stockings. This conforms the shoes to the shape of the foot. You may have to walk along side the person with support of his waist as he walks. For persons with Parkinson's disease, a cane or walker can actually get in the way and cause an accident.

Preventing Falls from Bed
If a person is tries to get out of bed, this causes worry for the family. If a family has access to a baby monitor, it can be used to alert the family in another room, that the patient is trying to get out of bed. If a person is constantly trying to get out of bed, we often take the mattress off the bed and put it on the floor. It is better to have a person on or close to the floor rather than falling out of bed and breaking a hip.

Question 9: What is one way to stop a person from falling out of bed?

If a Person Falls
Try not to grab the person and try to stop the fall. You might injure your own back and tumble to the floor as well. If you can, break the impact of the fall by sliding the person down the length of your body and try to protect his head.

Check for bleeding, bruises, and broken bones. If you suspect a serious injury, get medical help. Do not attempt to move the person yourself, just make him comfortable on the floor with pillows and a blanket while waiting for help. If there is bleeding, put a clean cloth over the wound and apply pressure to stop the bleeding.

Watch your patient for signs of head injury if he hit the floor or other object while falling. Observe for listlessness, blurred vision, headache, nausea, and numbness of extremities. Observe the person for the next several hours. If he hit his head, you need to waken him to check his level of consciousness:

• can he talk?
• is he alert?
• does he know where he is (he may become angry with you when you ask this question)?
• are the pupils of his eyes equal?

If someone falls to the floor, you must get help to lift him up again. First bring him to a sitting position and have him sit upright for a few minutes to adjust to changes in blood pressure. Then lift under his arms and grab the waistband of his clothes and bring him to a standing position. Be sure to explain to him what you are doing and how you will do it so that he can cooperate with you.

Question 10: If a person falls you must:
(Only one of the following answers is correct.)
leave him on the floor and call the rescue squad.
check for signs of bruising and head injury.
offer him a drink of water.

Preventing Contracture and Foot Drop
We want the person we care for to be up and walking as much as possible. The human body has to move in order to function properly. When the body moves, circulation improves and helps prevent blood clots in the legs. the bladder and bowel have more normal function reducing the threat of urinary tract infection and constipation. A person breathes better, digests food better, and thinks more clearly when he is able to move around.

Mobility also safeguards against contracture or the atrophying of muscles and joints, if one is confined to bed for an extended period of time. Even if you stay in bed with flu symptoms for a week, if your joints are not exercised every day, stiffness results. True contracture, if untreated, can be permanently crippling. Hands can curl up like claws and shrinking muscles can pull persons into a fetal position. A contracture can be so tight that it feels like one is breaking bone if one trues to move it.

Question 11: Why does the body need to move?

Muscles and joints can remain pliable through simple exercises. If the patient is unable to do these exercises himself, we can help him by doing the joint exercises for him. Even if a person is unconscious, these passive range of motion exercises need to be done three to four times daily. Severe contractions make the task of giving care to a person more difficult. For example, if a person's arm has a contracture at the elbow and the arm is drawn up tightly on the chest, it is difficult to wash him and there may be sores on the skin where two skin surfaces touch one another.

To prevent contracture, range of motion exercises help joints to flex, rotate, and extend. To rotate is to turn; flex, to bend; extend, to straighten. Manuever limbs slowly, gently, rhythmically while assessing the patient's comfort and tolerance. Give your attention to fingers, wrists, neck, hips, knees, ankles and toes. Repeat each movement 6-8 times per joint. Each session should last about 10-12 minutes.

Question 12: Range of motion exercises:
(Only one of the following answers is correct.)
are good for the caregiver's health.
keep the muscles and the joints mobile.
can be done by the ill person himself.

Prevention of Foot Drop
Foot drop can be another serious concern. when you are lying down, the foot natuarally flexes down with the toes pointing downward. If you don't keep the foot from bending downward, the muscles will eventually get tight in that position.

If your patient will be in bed for long periods of time, it is good to buy them high-topped tennis shoes to prevent foot drop.

Managing Fever
Temperature, if needed can be taken once a day, about 16 P.M. An elevated temperature does not mean a fever. We routinely have elevated temperatures when exercising, sunning at the beach, and sometimes in response to emotional stress. If you suspect that your client has a fever, take his temperature every two hours or more frequently if his temperature increases. Elderly persons need monitoring carefully because the body-heat regulator in the brain loses sensitivity in old age.

Question 13: Elderly persons need monitoring of temperature more frequently because:
(Only one of the following answers is correct.)
they often don't drink enough fluids.
they have fevers induced by medications.
the temperature-regulating system in their brains may be impaired due to age.

Symptoms of fever:

• Skin feels warm and dry to touch;
• Flushed cheeks;
• Listlessness;
• Aching muscles and joints;
• Headache;
• Loss of appetite and thirst;
• Chills, sweating, shivering;
• Nausea, vomiting, diarrhea - all can be caused by rising temperature.

• rapid heartbeat;
• shortness of breath;
• confusion, delirium, seizures;
• a reaction called "drug fever".

• Cover him with only a sheet and make sure the room is free of drafts;
• Give him a cool sponge bath or place a cool cloth under the arms and in the groin area;
• Change the sweat-dampened sheets.

When a person complains of chills:

• Cover him with blankets;
• Chills precede a rise in temperature - after chills stop, take his temperature;
• Encourage him to drink fluids;
• Give the person foods that are high in carbohydrates and calories - potatoes, bread. butter, fruit.

At temperatures of 40C (103F) and above, the brain becomes overstimulated which causes confusion, delirium, and convulsions. The heart beats 8-10 beats faster per minute. For someone with cardiac or respiratory disease, this temperature could be fatal.

Question 14: When is a temperature potentially fatal to a person?