Define the following term: Subacute care care given in a hospital or in a long-term care facility for people who have had an acute injury or illness or problem resulting from a disease.

1. Understand the types of residents who are in a subacute setting The following residents may be found in subacute units: Residents who need more treatment, monitoring and services than other residents Residents having recent surgery and chronic illnesses, such as AIDS Residents requiring complex wound care, dialysis or a mechanical ventilator

Define the following term: Anesthesia the use of medication to block pain during surgery and other medical procedures.

2. Discuss reasons for and types of surgery Note the following reasons for surgery: Relieve symptoms of a disease Repair or remove problem tissues or structures Improve appearance or correct function of damaged tissues Diagnose disease Cure disease

2. Discuss reasons for and types of surgery The following are three categories of surgery and examples of each: Elective surgery (e.g. facelift) Urgent surgery (e.g. coronary artery bypass surgery) Emergency surgery (e.g. repairing damage from a gunshot wound) There are three levels of anesthesia: local, regional, and general.

Define the following term: Preoperative before surgery.

3. Discuss preoperative care Remember the following information about preoperative care: Includes both physical and psychological preparation Doctor will explain the procedure. Patient can ask questions, give opinions, and must give consent for surgery. Patient often experiences anxiety, fear, worry, sadness and other emotions. NA can listen to residents’ concerns, report concerns/questions to nurse.

Transparency 22-1: Guidelines for Preoperative Care Follow NPO (nothing by mouth) order by removing water pitcher, glass, and any food or fluids from the immediate area. Explain to the resident why you are doing this. Assist resident to urinate before surgery. Enema or suppository may be ordered to clear the bowels. Assist as trained, ordered, and allowed. Provide privacy. Assist with bathing as needed. Make sure call light is within reach every time you leave the room.

Transparency 22-1: Guidelines for Preoperative Care (cont’d.) Measure and record vital signs as ordered. Remove and store dentures, glasses, contact lenses, hearing aids, jewelry, hairpieces, hairpins and any other personal items. (For local or regional anesthetic, hearing aids and dentures may be needed for better communication.) Assist resident to change into gown if required. Transfer to gurney/stretcher if necessary. Make sure identification bracelet is accurate prior to transport.

Define the following term: Postoperative after surgery.

4. Describe postoperative care Remember the following about postoperative care: Goal is to prevent infections, promote healing, return person to state of health. Immediate concerns: Problems with breathing Mental status Pain Wound healing Complications can include urinary retention or infections, constipation, BP variances, and blood clots. Careful monitoring is critical.

4. Describe postoperative care The following equipment may be needed for postoperative care: Bed protector Towels and washcloths Vital signs equipment Emesis basin Pillow and other positioning devices Warming blankets IV pole Oxygen and suction equipment

Transparency 22-2: Guidelines for Postoperative Care Move furniture as needed to allow room for the stretcher. Assist with transferring resident back into bed (see Chapter 10). Return personal items to resident. Measure and record vital signs as directed. Reposition resident every hour to two hours, or as ordered. Elevate extremities as ordered. Assist with deep breathing and coughing exercises. Apply anti-embolic hose if ordered. Assist with leg exercises. Apply binders as ordered. Encourage proper nutrition and fluid intake. Assist with elimination. Help with bathing and grooming. Assist with ambulation as needed/ordered. Be encouraging and positive.

4. Describe postoperative care Observe and report these signs and symptoms of complications when providing postoperative care: Changes in vital signs Difficulty breathing Mental changes (e.g. confusion, disorientation) Changes in consciousness Pale or bluish skin Cold or clammy skin

4. Describe postoperative care Signs and symptoms of postoperative complications (cont’d.): Increased drainage Swelling at IV site IV not dripping Nausea or vomiting Numbness or tingling Resident complaints of pain

Define the following term: Pulse oximeter a device that measures a person’s blood oxygen level and pulse rate.

5. List care guidelines for pulse oximetry Remember these points about the pulse oximeter: Warns if blood oxygen level is less than optimal Normal blood oxygen is between 95% and 100%, but it can differ. Report any increase/decrease in oxygen levels to nurse.

Transparency 22-3: Guidelines for Pulse Oximeter Report to the nurse immediately if alarm sounds. Tell the nurse if pulse oximeter falls off or resident requests you remove it. Check the skin around device often. Report any of the following: Swelling Bluish, or cyanotic, skin Shiny, tight skin Skin that is cold to the touch Sores, redness or irritation Numbness or tingling Pain or discomfort Check vital signs as ordered and report changes to the nurse.

Define the following term: Telemetry the application of a cardiac monitoring device that sends information about the heart’s rhythm and rate to a monitoring station.

6. Describe telemetry and list care guidelines REMEMBER: Telemetry data is monitored and assessed at all times by specially trained staff.

Transparency 22-4: Guidelines for Telemetry Report to nurse if the pads become wet or soiled, or if they are loose or fall off. Report if alarm sounds. Check the skin around the pads often and report the following: Swelling Sores, redness, irritation Fluid or blood draining from skin Broken skin Report resident complaints of chest pain or discomfort, difficulty breathing Check vital signs as ordered, reporting changes to nurse.

Define the following terms: Artificial airway any plastic, metal, or rubber device inserted into the respiratory tract to maintain or promote breathing. Intubation the passage of a plastic tube through the mouth, nose, or opening in the neck and into the trachea. Tracheostomy a surgically-created opening through the neck into the trachea.

7. Explain artificial airways and list care guidelines REMEMBER: Artificial airways are necessary when the natural airway is obstructed to to illness, injury, secretions, or aspiration.

Transparency 22-5: Guidelines for Artificial Airways Observe resident closely. Tell nurse if tubing falls out. Check vital signs as ordered. Report changes to the nurse. Perform oral care often, as directed. Watch for biting and tugging on tube. Tell the nurse if resident is doing this. Use other methods of communication if person cannot speak. Be supportive and reassuring.

8. Discuss care for a resident with a tracheostomy Tracheostomies may be necessary due to Tumors/cancer Infection Severe neck or mouth injuries Facial surgery and facial burns Long-term unconsciousness or coma Airway obstruction Paralysis of muscles relating to breathing Aspiration related to muscle or sensory problems in throat Severe allergic reaction Gunshot wound

8. Discuss care for a resident with a tracheostomy Review the following points about tracheostomies: Be supportive and responsive. Resident may be unable to speak. Use other methods of communication. Answer call lights promptly. NA responsibilities will mostly include observing and reporting.

8. Discuss care for a resident with a tracheostomy Observe and report the following: Shortness of breath Trouble breathing Gurgling sounds Signs of skin breakdown Type and amount of discharge coughed up through tracheostomy Any increase in discharge Thick, yellow, green, or bloody discharge, or discharge with an odor Mouth sores or discomfort

8. Discuss care for a resident with a tracheostomy REMEMBER: It is very important to prevent infection when caring for residents with tracheostomies. Wash hands often, wear gloves when indicated, and keep equipment clean.

Define the following terms: Mechanical ventilation the use of a machine to assist with or replace breathing (inflate and deflate the lungs) when a person is unable to do this on his own. Sedative an agent or drug that helps calm and soothe a person and may cause sleep.

9. List care Guidelines for residents requiring mechanical ventilation Remember these points about mechanical ventilators: May be required due to cardiac or respiratory arrest, lung injuries or diseases, or head and spinal cord injuries. Resident will not be able to speak, which can greatly increase anxiety. Being on a ventilator has been compared to breathing through a straw. Be supportive. Enter the room so the resident can see you often. Use other methods of communication. Act and speak as if resident can understand everything even if he or she is unconscious or heavily sedated.

Transparency 22-6: Guidelines for Mechanical Ventilation Wash hands often. Tell nurse right away if alarm sounds. Report disconnected or loose tubing right away. Answer call lights promptly. Follow care plan for repositioning instructions. Give careful skin care, and report any of the following: Swelling Sores, redness, irritation Fluid or blood draining from skin Broken skin Report if resident is pulling on or biting tube. Report resident anxiety, fear, distress. Be patient during communication. Check on resident often so resident can see you. Be supportive.

10. Describe suctioning and list signs of respiratory distress Remember these points about suctioning: Necessary when a person has collected secretions in upper respiratory system. Suction comes from a pump and bottle or canister collects suctioned material.

10. Describe suctioning and list signs of respiratory distress Signs of respiratory distress include the following: Gurgling Difficulty breathing Elevated respiratory rate Pale or bluish skin Nostrils flaring Chest retracting (sinking in below the neck with each breath) Sweating Wheezing

Transparency 22-7: Guidelines for Suctioning Report signs of respiratory distress immediately. Monitor vital signs closely, especially respiratory rate. Follow standard precautions. Assist nurse as needed. You may be asked to have a towel or washcloth ready for resident after suctioning. Perform oral care as ordered. Report resident complaints of pain or difficulty breathing.

Define the following term: Chest tubes hollow drainage tubes that are inserted into the chest to drain air, blood, or fluid that has collected inside the pleural cavity or space.

11. Describe chest tubes and explain related care Remember these points about chest tubes: Can be inserted at bedside or during surgery Drain air, blood, or fluid Allow a full expansion of the lungs Conditions requiring chest tubes include pneumothorax, hemothorax, empyema, surgery, and injuries. Chest tube is connected to bottle of sterile water. System must be airtight when attached to suction.

Transparency 22-8: Guidelines for Chest Tubes Be aware of where chest tubes are. Check vital signs as directed and report changes. Report signs of respiratory distress and pain. Keep drainage system below level of chest. Keep drainage containers upright and level. Make sure tubing is not kinked. Report disconnected tubing. Do not remove equipment in the area.

Transparency 22-8: Guidelines for Chest Tubes (cont’d.) Observe chest drainage for amount and color. Report if there is increase or decrease in bubbling. Report clots in tubing. Be gentle and careful with repositioning. Report odor. Provide rest periods. Measure I&O carefully. Encourage deep breathing exercises.

11. Describe chest tubes and explain related care REMEMBER: Other residents who require more direct care and observation include those with IVs and those with tube feedings.

Chapter Exam 1. What is one example of emergency surgery? (A) Having a facelift (B) Coronary artery bypass surgery (C) Surgery to remove a ruptured appendix (D) Surgery to remove the wisdom teeth 2. Which of the following is a task to perform for both preoperative and postoperative care of a resident? (A) Assisting the resident to change into a gown (B) Measuring and recording vital signs (C) Applying anti-embolic hose (D) Removing dentures, glasses, contact lenses, and any other personal items

Chapter Exam (cont’d.) 3. Which of the following statements is true of residents in a subacute setting? (A) They need a higher level of care than other residents. (B) They need less care and observation than other residents. (C) The cost for their care is higher than a hospital’s costs. (D) The nursing assistant has less responsibility for residents in subacute care. 4. A pulse oximeter measures (A) Blood pressure and heart rate (B) Blood pressure and pulse rate (C) Blood oxygen level and pulse rate (D) Blood oxygen level and temperature

Chapter Exam (cont’d.) 5. Which of the following statements is true of assisting a resident with a telemetry pack? (A) Do not get the unit, pads, or electrodes wet. (B) Vital signs do not need to be monitored. (C) There is no need to report if the alarm sounds. (D) The unit, pads, and electrodes should not get wet. 6. The method used to insert an artificial airway is called (A) Telemetry (B) Intubation (C) Ventilation (D) Dyspnea

Chapter Exam (cont’d.) 7. Alternate communication methods for a resident with an artificial airway include (A) Playing charades (B) Shouting at the resident (C) Asking the resident’s family what they think he wants (D) Using communication boards 8. What might a nursing assistant do for a resident with a tracheostomy? (A) Keep the stoma clean. (B) Perform suctioning. (C) Remove the tube for cleaning. (D) Insert the tube.

Chapter Exam (cont’d.) 9. Which of the following statements is true of a resident on a ventilator? (A) The resident will be especially relaxed. (B) Clipboards, pads, and communication boards can help with communication. (C) Being on a ventilator is not much different from regular breathing. (D) The resident will be able to speak. 10. Signs of respiratory distress include (A) Excessive sleep (B) Fever (C) Lack of interest in surroundings (D) Elevated respiratory rate

Chapter Exam (cont’d.) 11. Which of the following statements is true of chest tubes? (A) The drainage system must be kept above the level of the resident’s chest. (B) The chest drainage must be observed for amount and color. (C) The tubing should be kinked. (D) Chest tubes will only be in the front of the body. 12. When might suctioning be needed by a resident in subacute care? (A) After a heart attack (B) When a wound is healing too slowly (C) When secretions have collected in the upper respiratory system (D) When blood oxygen level is too low