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Alzheimer's Disease: Connecting with the Care

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

Upon completion of this course, the participant will be able to:

Describe Alzheimer’s Disease (AD)
State the stages and symptoms of AD
Outline the progression of needs for AD residents
Discuss communication techniques used with the resident with AD
List safety issues related to residents with AD
Identify four approaches to managing behavioral issues in the resident with AD

The objectives for this program will revolve around your role in care and communication. A description of the disease process, stages, and symptoms of those stages will provide a foundation of knowledge for tackling the challenges faced when caring for this type of resident. We will review the progression of needs as reflected by the progression of the disease itself and discuss communication techniques that can be used. Safety issues are an important focus as is the effective approaches that can be utilized in managing the behavioral issues that can affect care.

Software Requirements:

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Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater

*Adobe Acrobat Reader
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Instructor: Lori L. Ley, RNC, MSN

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

Alzheimer's Disease:
Connecting with the Care

to see the .pdf format of this course click here.

Alzheimer's Disease (AD) is a progressive, degenerative disease of the brain. Although most people believe that memory loss is a normal part of aging, there is no scientific evidence to support this belief. Today, approximately 7 out of 10 people with Alzheimer’s Disease (AD) live at home and 75% of them receive their care from family and friends. The CNA spends the most time with the resident in long term care settings. This makes you one of the most important caregivers and connections to the team approach for effective care and safety for these residents. It is important to have an understanding of AD to provide the necessary care and support required for residents and their families.

Who has Alzheimer’s Disease?

~ 4.5 million Americans (doubled since 1980)

Projected by 2050 = 11.3 to 16 million
Half of all long term care residents have Alzheimer’s or a related cognitive disorder
1 in 10 – family member
1 in 3 – know someone

An estimated 4.5 million Americans currently have Alzheimer’s (pronounced AHLZ-high-merz) disease. This number has more than doubled since 1980. The number of Americans with AD will continue to grow as it is projected that by 2050 it could range from 11.3 to 16 million.1 This number could be reduced by 50% after 50 years if a treatment could delay the onset by a mere 5 years.2 Nearly half of all nursing home or LTC residents have Alzheimer’s disease or a related disorder.3

In a Gallup poll commissioned by the Alzheimer’s Association in 1992, 1 in 10 Americans said that they had a family member with Alzheimer’s and 1 in 3 knew someone with the disease.4 Those numbers will continue to go up as the population as a whole continues to age.

GLOSSARY OF TERMS

Alzheimer's Disease (AD) - is a progressive, degenerative disease that attacks the brain and results in impaired memory, thinking and behavior. It is recognized as the most common cause of dementia.
Activities of Daily Living (ADL) - are the usual and customary activities done each day such as bathing, eating, exercising, dressing, etc.
Dementia - is not a disease in itself but a group of symptoms that characterize certain diseases and conditions that cause a decline in thinking skills. The major symptom is a decline in ADL.
Senility - was once a term used to describe people 65 years or older with dementia. Today it is recognized that senility is not part of the normal aging process.
Chronic organic brain syndrome - is a label given to patients with a collection of symptoms such as memory loss, disorientation, confusion, personality changes, and the inability to carry out ADLs. Today, the preferred term for these symptoms is dementia.
Delusion - is persistent, incorrect beliefs that remain so in spite of all rational evidence to the contrary.
Hallucinations - are sensory feelings experienced by the patient and not other people in the same environment.

What is Alzheimer’s Disease?

Progressive brain disorder
No cure
Most common form of dementia

AD is a progressive brain disorder that gradually destroys the person’s memory, their ability to reason, learn or make judgments. It eventually will impact their ability to communicate with others and perform activities of daily living. The disease process may also effect behavior and personality changes are common.

There currently is no cure for the disease but research is focused on looking for treatments that can delay the progression. Research has shown that effective care and support can improve the quality of life for the resident over the course of the disease from diagnosis to end of life.5

AD patients may live several or many years after the onset of the disease.

Ten warning signs

Memory loss
Difficulty performing tasks
Language problems
Disorientation to time and place
Poor or decreased judgment
Problems with abstract thinking
Misplacing items
Mood and behavior changes
Personality changes
Loss of initiative

As we grow older, some change in memory is normal but the changes that occur with Alzheimer’s are more extreme than a simple lapse in remembering something. Again, communication, reasoning, problem solving etc. are all impacted and will impact social and family relationships. The Alzheimer's Association has developed a list of 10 warning signs that can help in the recognition of disease. 6

1. Memory loss is revealed as forgetting recently learned information is the most common early sign of dementia.
2. Forgetting how to do everyday tasks such as preparing a meal, doing the laundry etc.
3. Language problems such as forgetting simple words or substituting unusual words making speech and conversation difficult to understand.
4. Disorientation to time place and means that the Alzheimer’s person can become lost in what was once a very familiar place. They may forget where they are and how they got there.
5. Display poor or decreased judgment as they may wear clothes inappropriate for weather, mismatched, etc. They could make poor decisions related to finances or investments and give away all their money etc.
6. Abstract thinking may be affected as they may be unable to perform simple mental tasks such as forgetting how to add and subtract money for making change.
7. Misplacement of items or placing things in strange places for example, putting a sandwich in a closet would be out of the norm.
8. Mood and behavior change, usually drastic swings in moods, going from happy to angry in very rapid succession.
9. Personality changes might occur, usually the opposite of normal. If someone is normally quiet and then suddenly becomes outgoing this could signify a change.
10. Loss of initiative is when someone no longer wants to do anything or participate in any activities.

All of the above do not have to occur to lead to diagnosis.

Diagnosis and causes of AD

No test for the disease
History and assessment
“Diagnosis of exclusion”
Unknown cause
Risk factors

There is no test to identify Alzheimer's Disease (AD). Diagnosis is made by a complete physical examination, neurological, psychiatric, and patient history evaluations. Alzheimer's is often called a "diagnosis of exclusion". This means that other conditions which result in symptoms similar to Alzheimer's are first tested for and then excluded.
A list of some the conditions with symptoms that mimic AD include depression, reactions to drugs and alcohol, metabolic changes, severe nutritional deficiencies, brain tumors, and head injuries. Many of these conditions can be reversible while AD is not.

After other causes of symptoms similar to AD are eliminated, a diagnosis of AD is made. The only positive medical confirmation of AD can be made by microscopic examination of the brain tissue, usually done during an autopsy after death.

The cause of AD is not known. Researchers continue to investigate a variety of suspected causes including genetic factors, biochemical disturbances, the immune processes, trauma and environmental toxins are also being studied for possible connection with the causes of AD.

The greatest risk factor is of course age (some have shown symptoms as early as their 40s). Most with the disease are 65 years old or greater. The risk of getting the disease doubles for every 5 years after 65. After age 85, the risk nears 50%. 7

Treatment options

Medications
Support and care

Medications may help some aspects of behavior, and several new drugs are being tried. Three drugs are currently approved by the Food and Drug Administration (FDA). These drugs are Tacrine, Donepezil and Rivastigmine. Again, these drugs do not cure the disease, but do help relieve the symptoms in some people. Long term studies have not been completed but some are promising as some of these medications may help delay the progression. Again, effective support systems and care can help to improve quality of life for those with AD.

Damage in stages

Nerves for learning and memory

Nerves controlling thinking, judgment, behavior

Nerves controlling movement and coordination

Many different “staging” terms have been used by experts to describe the progressive nature of this disease. This progression is tied to the nerve damage as it occurs initially in the learning and memory cells, moving then to nerves that control all areas of thinking, judgment and behavior. Eventually the cells that control movement and coordination are affected.

Stages and symptoms of AD

Stage 1 – No impairment
Stage 2 – Very mild decline
Stage 3 – Mild decline (early stage)
Stage 4 – Moderate decline (mild or early stage)
Stage 5 – Mod. severe decline (mod or mid-stage)
Stage 6 – Severe decline (mod. Severe or mid-stage)
Stage 7 – Very severe decline (severe or late stage)

These staging terms are used as a reference when trying to determine how the disease might unfold so that future plans can be developed. Unfortunately, the terms are not distinct and can very from one person to another. Everyone doesn’t experience every stage at the same times. People with Alzheimer’s usually live an average of 8 years after diagnosis but survival could range anywhere from 3 to 20 years.

The 7 stage system was developed by a Dr. Barry Reisberg, Clinical Director of the New York University School of Medicine’s Silberstein Aging and Dementia Research Center. Here is a review of those stages as they coincide with other staging terms used in the community.

Stage 1 – No impairment – may not be detectable at this point
Stage 2 – Very mild decline – the person might sense that they keep forgetting little words and phrases here an there but many still do not detect an issue
Stage 3 – Mild decline (early stage) – family and friends may now start noticing some problems with memory or the person’s ability to concentrate
Stage 4 – Moderate decline (mild or early stage) – certain recent events may now be forgotten, personal history becomes fuzzy and the first signs of withdrawal may begin to occur
Stage 5 – Mod. severe decline (mod or mid-stage) – Big gaps in memory now occur, a decline in performing ADLs may now become evident, time and place can be forgotten
Stage 6 – Severe decline (mod. Severe or mid-stage) – Personality changes are now seen, sleep/wake disturbances occur, incontinence increases during this stage
Stage 7 – Very severe decline (severe or late stage) – the ability to respond to surroundings and people is lost, speech may become garbled and unrecognizable. This is the final stage of the disease.

Stages of care advance with stages of disease

Safe and caring environment
Assistance with ADLs
Total care

Treatment for Alzheimer's is mainly one of providing a safe, calm environment as well as working with various behavioral symptoms. While Alzheimer's disease affects individual persons differently, it is possible to draw a general picture of what to expect.

In the earliest phase, the person may complain of memory loss, forgetting names, and misplacing items. These symptoms are often dismissed as the results of temporary stress, especially since the person usually still functions well at work and socially.

As the mental abilities decline, daily activities become impaired. Problems arise if the person has to travel to a new place. Managing one's finances becomes a problem. Other symptoms may include: poor concentration, decrease in attention to daily tasks, anxiety, and hostility.

Depression increases as the patient becomes aware of advancing impairments; yet denial of the problems usually continue.

In the more advanced stages, the person is unable to cope without assistance with activities of daily living. Often, the patient may not recognize family members or recall current life events. At this point personality changes are common. For example, the person may accuse the spouse of being an impostor or they may talk to imaginary people.

In the later stages, the person becomes completely incapacitated and disoriented. Total care is required. Verbal skills may be lost. Physical movement is often limited to simple movements, such as minimal walking with assistance.

As you can see, as the disease progresses, needs change and the degree of help with activities of daily living requires constant reevaluation. A simple list of symptoms may help you understand the progression of Alzheimer's disease.

This would be:
Forgetfulness Ú confusion Ú decline in ADL Ú total deterioration (loss of recognition of self, body parts, family)
or:
Memory loss (most common symptom) Ú intellectual deficits (inattention, inability to make decisions) Ú personality deficits (inappropriate behavior) Ú stress tolerance deficits (confusion, night-time awakening, anxiety)

Tips for caregivers

Keep it simple
Don’t argue
Show respect
Provide personal safety
Remember the 5 “Rs”
- Reassess
- Reconsider
- Re-channel
- Redirect or distract
- Reassure

As a caregiver, no two days will be the same as you work with your resident; constant readjustment to daily activities is required. A few basic guidelines will help if you remember the following:

Keep things simple: Do not overwhelm the resident with strange situations, noises, or several questions at one time.
Don't argue: Give choices, not orders. Example, ask "Do you want to eat lunch now, or go for a walk?". Giving choices helps deflect an emotional response.
Show respect: Treat the resident as a person, even if you must guide the resident in a situation.
Provide personal safety: Disorientation leaves a person vulnerable to accidents. Remove clutter and try not to change the basic, familiar arrangement of furniture or daily routines. Check and see if your state's Department of Motor Vehicles issues a non-driver identification card.

As we describe and discuss behavioral management, Mace, in her book on AD, summarized the five “R”s in the following manner:8

FIVE "R's" OF ALZHEIMER'S DISEASE BEHAVIORAL MANAGEMENT

REASSESS - is when a new behavior occurs. The healthcare team & you may find a medical problem, or it may be a worsening of the condition.
RECONSIDER - some behaviors. Is the behavior dangerous to the patient & others? Or, should caregivers change their own attitudes so that the behavior can continue in a controlled environment?
RE-CHANNEL - the behavior, rather than stop it. Find a way for the behavior to continue in a less disruptive way. Example: allow residents to rummage in their drawers, find space which is safe for their uninterrupted walking, look for simple tasks they can do; such as, sorting clothes, folding towels, etc.
REDIRECT OR DISTRACT - resident from the situation before an angry outburst occurs.
REASSURE the residents. Stay with them, reassure them that they are safe, utilize touch & calming activities; then the AD residents can pick up on your emotions.

Personal Care

Bathing and grooming

Simplify the bathing and dressing routine. Do not announce that the resident "needs" a bath; factually state it's "time" for a bath. "Time" has a gentler, simpler implication than a "need" for a bath.

Try to bath the resident at the same time each day in the same way. Step-by-step explanations, versus asking them to make decisions, usually promotes a more comforting environment.

Check and determine if the environment is safe for the resident. Grab bars, a shower chair, and a non-skid mat are good fall preventive measures. Bathroom falls are very common. Stay in attendance at all times.

Allow the resident to bath themselves as much as possible even if you must guide the activity and assist at times. Bathing also provides an opportunity for you to check for skin irritations or sores.

The resident's clothes should be laid out in the order in which they are put on. Anything that will slip on, versus complicated buttons, will be easier for the patient. Again, simplify the situation.

Out of season clothes and dirty clothes should be out of sight, so as to minimize confusion and choices. Praise may encourage them to be more participative, enjoy, and be proud of the ability to participate.

Other grooming tasks such as hair and nail care should be done on a regular basis. Toenails may require medical care, especially trimming the toenails.

Oral hygiene should be accomplished in a simple, factual method. Again, encourage independence and offer praise appropriately. For women, makeup and jewelry may be enjoyed by the resident.

Personal Care

Toileting

Your resident may forget where the bathroom is, may not realize the body signals for the need to void or how to express the need to go to the bathroom. A sign on the bathroom door noting "Bathroom" may be helpful. As a safety measure, remove door locks.

You may need to learn their toileting patterns or to establish a care routine. Handle accidents in a matter of fact manner and do not scold.

If the resident is incontinent, incontinence panties or diapers may be needed. Keep track of the number of times they void and defecate, to help assure adequate output.

Personal Care

Nutrition

Adequate food and nutritional intake poses a problem to the AD resident and is often related to memory loss (forgetting to eat) and decreased intake.

Regular scheduled meals are important in maintaining a structured environment. Consider the resident’s independence and success at eating, as well as nutrition.

A balanced diet consisting of small meals and nutritious snacks in between is encouraged. Small quantities and a pre-set plate helps avoid decisions and may encourage the resident to eat everything.

Anything you can do to encourage independence and easier handling of food is helpful. Finger type foods are a good choice. Also, prior to offering the plate of food or a meal tray to the resident cut up the meat, open containers, and so forth.

Fiber and fluids are an essential part of the diet to promote regularity and prevent dehydration. The resident may not recognize thirst and may have to be reminded to drink.

Adaptive equipment to encourage independent eating by the resident may be used. Plates with rims, a covered cup to avoid spells, spoons versus forks and knives, and flexible drinking straws are some alternatives.

If you must feed the resident, do so in a manner which helps maintain their dignity. Sit at their level and pace the feeding so there is time to chew and swallow.

Personal Care

Activities

Adequate exercise and activity help maintain the resident's mobility and prevent complications, such as pressure ulcers and pneumonia. Exercise also helps maintain a normal day and night routine.

Repetitive tasks and motions relieve the resident of making a decision about what to do next; this also decreases the stress level.

Walking, dancing, simple gardening, and routine household chores can give the resident something meaningful and satisfying to do.

The resident will be more relaxed, feel success at self-expression and gain a feeling of self-worth when accomplishing simple tasks.

Music is a very good activity. A sing along of favorite songs is usually enjoyed. The resident may be able to play a piano or operate a tape player.

Some hobbies and simple crafts, painting, and games may interest them, depending on their usual activities and degree of illness.

Television programs can entertain and relax residents. Avoid violence; instead try old movies or nature programs as they may be more appropriate choices.

Exercise is important to maintain muscle tone and motor skills. Stretching or a mild exercise videotape may be used. Consult with the nurse to learn if there are limitations to the types of exercise.

Personal Care

Safety

Safety issues have been addressed throughout this course. Simplified routines, a familiar environment, labeling, and signs on bathroom doors are all examples of safety. Remove hazards such as throw rugs and clutter to prevent accidents and falls.

Adequate lighting is helpful. Use night lights in all rooms after dark. Night lights also help with ongoing reorientation to the environment.

Avoid using restraints, if possible (these may be prohibited in your facility). Restraints increase the resident's agitation and paranoia and may contribute to injury. Use alternative devices, such as a bell or alarm which sounds when the resident gets out of bed. There are many types of safety alert systems.

Other issues

Wandering

Caregivers should remember that the resident's behavioral problems are the result of a disease. Many of these problems are more annoying and frustrating than dangerous. The resident has no control and these behavior problems must be managed as best as possible as there are no cures.

WANDERING
There are different kinds and reasons for wandering. The AD resident may wander due to confusion that results in getting lost or it may be due to agitation or other reasons. If a cause can be identified, try to work with resolving the problem. If they do get lost, determine right or left handedness. When a wanderer does leave, it is generally in the direction of hand dominance.9 Generally though, it is easier to manage wandering than to resolve the wandering.

Moderate physical exercise during the day may help induce sleep, versus wandering, at night. Other measures you can take include:

Take away the patient's shoes.
Safety latch door knobs.
Never leave the AD resident alone in a vehicle or even unattended on a porch. It can take only seconds or minutes for the AD resident to wander into harm's way.
Observe when wandering occurs. You may see a pattern, such as at sundown, or rush-hour traffic noises, etc. If so, try to involve the AD resident in some type of activity or conversation until that time has passed.
AD residents should wear a Medic-Alert bracelet or some type of identification at all times.

Other issues

Delusions and Hallucinations

DELUSIONS AND HALLUCINATIONS
Both of these are commonly seen in AD residents. Delusions are persistent, incorrect beliefs that remain so in spite of all rational evidence to the contrary. An example of a delusion is a resident who thinks she is your aunt, but she is not. Hallucinations are sensory feelings experienced by the resident but not you. They may hear noises or sounds.

Both of these problems can cause panic reactions in the resident and require prompt interventions by the CNA. Sometimes medication can help control these symptoms, but the symptoms can often be managed. Some strategies include:

Distraction may redirect the resident’s activities and attention.
Do not try to reason or prove the behavior is incorrect. This may lead to extreme agitated behavior. Be noncommittal if the resident insists on discussing specific delusions or hallucinations.
If the resident is frightened, acknowledge the fear and provide reassurance that you are there. Use gentle, affectionate talk and contact to comfort. If the resident is agitated, be careful that the physical contact is not misunderstood as an attempt to restrain.
If the resident is not upset by the mistaken belief or perception, it may be wise to let it persist, if it is harmless. For example, if the resident thinks she is a young mother rocking her baby (a doll) to sleep. Let this go, as it may be a harmless, yet comforting, delusion to the resident.

Other issues

Other inappropriate behavior
Demands
Persistent following
Repeated questions
Pillaging/hoarding/rummaging
Improper dressing/undressing

In general, you should try to distract or divert the resident to another activity or acceptable behavior. Do not criticize! If change is achieved, offer them praise and positive reinforcement for the new activity.

COMPLAINTS/INSULTS/FOUL LANGUAGE
The AD resident is forgetful and may use any of these behaviors because of fear or concerns. Perhaps foul language is the only phrase they can remember and speak. Ignore this behavior; do not react. Look for other ways to communicate with them and meet other needs.

DEMANDS
Demanding behavior may reflect feelings of loneliness, loss or fear, or the resident's inability to judge time. You cannot change the behavior, and usually, you cannot meet the demands. Try alternative diversion activities.

PERSISTENT FOLLOWING
Your AD resident may want you within sight all the time and shadow you everywhere. You represent security. Try diverting them to another activity. Comment "You do this now while I….”

REPEATED QUESTIONS
This is very common in the AD person. AD residents lose the ability to judge time and also the question may not reflect what they really want. Try to guess at the worry behind the question and reassure them.

PILLAGING/HOARDING/RUMMAGING
AD residents are suspicious. This increased feeling of suspiciousness leads to hiding valued items. Hoarding and pillaging reflects their confusion, anxiety, and forgetfulness.
Try an alternate way for them to fiddle with a box or drawer of items. It may satisfy their needs.

Learn favorite hiding places and look there first for any missing items. Try diversional activities.

IMPROPER DRESS/UNDRESSING
Modesty is forgotten by the AD resident. Check to be certain the clothes they are wearing are comfortable. Undressing may be a signal for a need to use the bathroom. Ultimately, if no apparent reasons can be found, simply redress them in a calm, matter-of-fact manner. Never scold the resident. Inappropriate dress such as winter clothes in the summer and so forth is best handled by storing all clothes except a limited selection of appropriate clothes.

Communication with the Alzheimer’s Resident

Alzheimer's Disease and other dementias affect the resident's ability to use words. Remember that as spoken and written communication becomes increasingly difficult, a smile and gentle touch will continue to show the resident your caring and understanding.

A list of hints on how to communicate with the AD resident can be helpful, especially if you keep it with you and review it frequently.

Be calm and supportive. Approach the resident from the front. Establish eye contact before addressing them. Maintain eye contact while talking and listening.
Avoid environmental distractions, such as noise and busy surroundings.
Use different tools to communicate. Signs and labels may be useful reminders of what things are and how they are used. Clocks, calendars, and family pictures may help the resident remain aware of the time and place.
Speak slowly and distinctly in a calm pitched voice. Tone of voice is as important as words you say because the resident can sense your emotions.
Use short, simple, familiar words and sentences.
Be redundant; repeat important points several times. Use the same phrasing and words used before.
Remember that repetitive questions are part of the AD resident’s behaviors. While exhausting for you, respond with the same answers, in a calm voice. This can be reassuring to the patient, and build the resident's trust in you.
Keep topics focused on what is important at that particular time.
When giving instructions, break tasks into simple steps and give one step at a time. Explain your actions as you do them. For example tell the resident "We are going to get dressed now. Here is your shirt."
Use names - the resident's or that of the person you are speaking about - instead of pronouns, such as "he" or "she".
Avoid open-ended questions, such as "What do you want to do?" Instead, ask questions that include limited choices, such as "Would you like to bathe or take a walk?"
Speak in positive terms. Try to limit the numbers of "don'ts" and avoid harsh or direct orders as much as possible.
Give the resident time to respond. Rushing only increases agitation and confusion. If the resident does not respond in 1 to 2 minutes, calmly repeat what you said.
If the resident looks as though he/she is not paying attention, try to communicate again in a few minutes.
Do not "talk down" to the resident. Avoid expressions that can be taken too literally, such as "hop into bed".
Ignore harmless hallucinations or delusions. Confrontation may make the situation worse. If possible, redirect the resident to another activity.

Non-verbal communications are very useful. AD residents are especially sensitive to body language and voice tone. AD residents often mimic your mood and respond to the tone of communication.

Reassuring mannerisms help to assure good communications.
The resident may be able to see and imitate your moves more easily than process words or instructions.
During periods of suspicion or distrust expressed by the AD resident, be aware that they may react forcefully against any physical contact.
Be sensitive to the resident's non-verbal and body language. Look for facial expressions that may reveal feelings - averted eyes, tightened lips. Fidgeting and fear, nervous type movements are also seen.

Catastrophic Reactions

A cardinal rule is to avoid catastrophic reactions when caring for an AD resident.

A "catastrophic reaction" is any situation that results in the AD resident reverting to impulsive, childlike behavior. The reaction may be seen as mood changes, restlessness, extreme suspiciousness, crying, anger, and combativeness.

A cardinal rule is to avoid catastrophic reactions when caring for an AD resident.

Several strategies can avoid this reaction, such as:

If you realize a certain activity precipitates a catastrophic reaction, try to change or avoid it.
Never force a resident to participate in anything.
Avoid activities or events where there is a lot of noise and confusion.
In the event that a reaction does occur, you should:
Stay calm.
Announce your moves in advance and move slowly.
Do not attempt to restrain the resident.
Sometimes soothing touch helps calm them.
Allow the resident to forget the event; after they calm down, move on to something else.

Care and Documentation

For legal purposes, to prove you gave care; and for reimbursement, you must document. Your facility may have forms such as checklists for you to note whatever care or assistance you provide. Remember that Medicare residents, and generally for other insurers, there must be behaviors demonstrated that impede safe, effective resident care.

Summary

Keep it simple
Show respect
Provide personal safety
Remember the 5 “Rs”
- Reassess
- Reconsider
- Re-channel
- Redirect or distract
- Reassure

By now you may feel care for a resident with Alzheimer's Disease is primarily custodial care. In many ways, it is. The number of elderly residents entering long term care continues to increase. As the baby boomer generation continues to age, the incidence of the disease will climb. Your skills as a CNA to both the family and the resident are important to the safety and care of these persons.

Remember the simple way is usually the best for this resident population. Always show them respect and provider for their safety. The 5 “Rs” will help you organize your thoughts, use them as a guide for care of the AD resident.

REFERENCES

Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer disease in the U.S. population: Prevalence estimates using the 2000 census. Archives of Neurology 2003;60:1119 – 1122.
Brookmeyer R, Gray S, Kawas C. Projections of Alzheimer’s disease in the United States and the public health impact of delaying disease onset. American Journal of Public Health 1998;88:1337 – 1342.
National Nursing Home Survey. National Center for Health Statistics, 1985; p. 49.
1992 Gallup survey of 1,015 individuals. For more information, please contact our Green-Field Library.
Alzheimer’s Association. What is Alzheimer’s disease? Available at: http://www.alz.org/AboutAD/WhatIsAD.asp Accessed: December 29, 2006.
Alzheimer’s Association. What is Alzheimer’s disease? Available at: http://www.alz.org/AboutAD/Warning.asp Accessed: December 29, 2006.
Alzheimer’s Association. What is Alzheimer’s disease? Available at: http://www.alz.org/AboutAD/causes.asp Accessed: December 29, 2006.
Mace N, Rabins P. The 36-Hour Day: A Family guide for Persons with Alzheimer's's Disease, Related Dementing Illness and Memory Loss in Later Life. Baltimore, MD: The John Hopkins University Press, 1981.
Alzheimer’s Association International. Alzheimer’s Disease: Alternative Treatments, Dispelling Myths, Safe Return, Preventing & Preparing for Wandering Behaviors (in Physician and Health Care Professional section). Available at: http://www.alz.org Accessed; December 29, 2006.

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Body Mechanics: Preventing Self Injury With Proper Use of Your Body

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

This program presents body mechanics and work related injuries with emphasis on back injuries. Upon completion of this educational presentation, participants will be able to discuss the basic principles of body mechanics, describe the relationship between back injury and body mechanics, state the incidence of work related back injuries, identify common errors in lifting and state ways to prevent back injury through specific techniques.

After completing this program, participants will be able to:

1. Discuss the basic principles of body mechanics
2. Describe the relationship between back injury and body mechanics
3. State the incidence of work related back injuries
4. Identify actions that contribute to back injury
5. State ways to prevent back injury

Software Requirements:

PC
Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater

*Adobe Acrobat Reader
Click here to download

MAC
Internet Explorer is not supported on the Mac
Mac OS 10.

Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

Body Mechanics: Preventing Self Injury With Proper Use of Your Body

This presentation is about body mechanics or preventing self injury (especially back injury) with proper use of the body

BODY MECHANICS

Body mechanics refers to the use of our body at rest and in motion.
GOOD body mechanics refers to keeping our body in correct alignment and using it correctly to prevent injuring ourselves.

Body mechanics, as stated above, refers to the proper use of our body whether at rest or in motion. The proper use of body mechanics is termed “good body mechanics” and prevents injuries to our body especially to the back. Maintaining good posture is the key to good body mechanics. If we keep our spine in correct alignment, and we use our larger, stronger muscles to lift and move objects, we will prevent injury that results from poor body mechanics.1

The Human Body as a Machine

Larger muscles in the body
Joint movements
Spine alignment

Machines work effectively when all the moving parts function as they are supposed to. The human body is composed of different parts that must work together to produce effective movement. The muscles in the body vary in size and strength depending on their primary function. In other words, the muscles of the legs are much stronger than the muscles of the eye. The leg muscles are much stronger than the back muscles so they should be used when moving or lifting objects. The combination of the muscles, bones, and joints produces the ability to move and to lift just the way levers, pulleys and ball and sockets do in machines. In using proper body mechanics, maintaining a proper center of gravity prevents us from losing our balance. Additionally, the spine is kept in correct alignment when a center of gravity is maintained.2

The Back as a Lever

Your back (lever)
- Your center of gravity (fulcrum)
- Object to be moved (resistance)
- Strength of back (force)

The reason your back is at high risk of injury is that most of us will bend at the waist to pick something up. When we do this, our body works the same as a lever and puts strain on our backs. A lever has three parts—the fulcrum or balancing point (as in a seesaw) between the force that is trying to move the object and the resistance which is the object itself. When you bend over to lift an object, your back acts as a lever by providing the force necessary to move the object and your body’s center of gravity becomes the fulcrum. Although the task of lifting can be accomplished, unnecessary strain is placed on the back.

CENTER of GRAVITY

Center of gravity for the body
- Location
- Balance and alignment
- Base of support

To maintain balance and proper spinal alignment, the point of the body’s mass must be centered. Although each of us has a different body mass, the center of gravity for the human body is the pelvis. An imaginary line drawn through the body from head to toe to identify the center of gravity would equally divide the pelvis. To maintain balance and proper body alignment, the base of support (our feet) must be wide enough apart to keep the center of gravity in the middle. As a result, the legs and feet are placed closer or farther apart depending on whether we are standing or stooping.2

Alignment of the Body

Posture
- Definition
- Effects of proper posture
  - Bones
  - Joints
  - Muscles
  - Ligaments
  - Spine
  - Overall

Posture can be defined as “the position in which you hold your body upright against gravity while standing, sitting or lying down.”1 When proper posture is used, bones and joints are kept aligned and abnormal stress on the surfaces prevents wearing on the bones. Muscles are used efficiently because the work load is evenly distributed preventing strain on individual muscles. The ligaments especially in the spine are not over stretched. The spine itself is not twisted or pulled or required to do more work than it should. Overall, good posture prevents pain from muscle strain and overuse. It also impacts your appearance and presentation to others.1

Proper Body Alignment

Sitting, standing or lying
Moving objects
Usage of muscles
Effect on back muscles

Maintaining proper body alignment means that the body mass is centered on the body’s line of gravity, the base of support for the body is correct so muscles are not strained, and the spine is straight. When walking, the head is held erect, the shoulders are held back, and the spine is straight. Correct posture is generally easy to maintain while sitting, standing, or lying. One must practice good posture to prevent chronic muscle fatigue and back strain when moving about. When moving objects, it is easy to use poor posture and injure the back muscles. Always use the stronger muscles of the arms and legs by keeping the spine straight. Curving or rounding the back will result in use of the muscles of the back doing the work rather than the leg and arm muscles. Injury can easily result.2

Back Injuries

Incidence in general workforce
National Statistics
Significance related to nursing

Statistics from the U.S. Bureau of Labor Statistics show that “more than one million workers suffer back injuries each year.”3 The National Institute of Occupational Safety and Health (NIOSH) states that twenty-four percent of all workplace injuries and illnesses involve the back. The number one type of work related injury is back injury. Back injuries among healthcare workers occur at a very high rate at about 5% higher than any other type of worker. Furthermore, “according to national statistics, six of the top ten professions at greatest risk for back injury are nurses’ sides, licensed practical nurses, registered nurses, health aides, radiology technicians, and physical therapists.”4 Nursing personnel in nursing homes were at a 5% higher risk than the nurses in hospitals. From these statistics, you as a CNA are in the highest risk category for back injuries among nursing personnel. Therefore, it is of the utmost importance that you learn and practice good body mechanics.3,4,5

Spinal Anatomy

Bones
Discs
Ligaments
Tendons
Spinal column
Nerves

To understand why injuries occur to the back, a little spinal anatomy must be discussed. The spine is composed of small bones stacked on top of one another. Between every two bones is a cushion of tissue called a disc. Tying all the bones and discs loosely together are ligaments creating small openings between the bones on the both sides of the spine. The back muscles are attached to the spine by tendons. Through the center of the spine, there is an open column and through the column a bundle of nerves runs from the brain to the end of the spine. This is called the spinal cord. At the small openings between the spinal bones, nerves branch out from the spinal cord to the other parts of the body.6

TYPES of Back Injuries

Acute
Chronic

The majority of back injuries are not related to a single event. Over time, the work of the back causes stress that can weaken or strain the structures of the back. Injuries to the back fall into two general categories: acute or chronic. Since the majority of the weight of a person’s body is supported by the lower back, injuries to the lower back often occur. These injuries usually involve the muscles of the back and cause acute or sudden injuries and sharp pain. Such injuries are treated with medications, ice and heat, and often back exercises to strengthen the back. Injuries that occur to the spine involve the discs and nerves and require various treatments including possibly surgery. Spinal injuries can also be acute. Either type of injury can become chronic or continue over a long period of time. Without the support of the spine, the body can not perform routine functions such as sitting, standing or walking. Back injuries can change your lifestyle including your occupation. 6

Actions that Contribute to Causing Back Injury

Lifting
Twisting the spine
Reaching
Carrying objects
Awkward positions
Lengthy stationary positions
Slipping

As previously stated, most back injuries are not related to a single event but result from damage that occurs over time. Repeating specific movements and actions that cause poor spinal alignment and straining or pulling on the muscles, ligaments and tendons wears down the back structures and eventually, a seemingly insignificant action can result in injury. The movements that have been identified as affecting the back are lifting of heavy objects by oneself which often causes improper body mechanics and puts too much work load on the spine. Twisting the spine, reaching to lift an object, and carrying objects are all actions that cause stress to the spine. Anytime that you are in a position that feels awkward, you are stressing your back. Other activities that wear on the back are sitting or standing for long periods of time. Of course any time you slip or trip, the stress placed on the back can result in injury.7

Other Contributing Factors

General health
Obesity
Overdoing

We have already discussed that poor body alignment, poor posture, and specific stressors can result in back injury. Additionally, a person’s overall health will impact the possibility of injuring one’s back. Obviously, the healthier life style you have, the more likely you are to have stronger muscles and bones. Being overweight contributes to back injury by adding stress to the back especially the lower back since the back supports the weight of the body. As with many other injuries, simply overdoing activities that result in fatigued muscles can cause injury.6

Techniques for Prevention

Maintain your center of support
Get help
Lower the head of the bed
Keep your spine straight

The nursing activities that place you most at risk of having a back injury are moving, transferring, or lifting patients and changing bed linens. There are techniques based on the principles of body mechanics that should be followed to prevent injury. To prevent back injury, always place the height of the bed at the position you need to maintain your center of support or your body’s center of gravity. Move your feet apart to widen your base of support. Take a good look at the task you face and decide if you need help due to the patient’s weight, size or their inability to help themselves. If your facility has a lifting devices, learn how to use them properly. These devices include various levels of assistance from a Hoyer lift to sliding boards and draw sheets. Some facilities provide employees with back belts. Again, use it properly and remember that the back belt will not prevent injuries if you use unsafe practices. Lower the head of the bed rather than having to work harder to move the patient. Remember to keep your spine or back straight not curved.2,5

Techniques continued

Push, Pull, or Roll Objects
Pull patients towards you
Use stronger muscle
Avoid specific actions like twisting

You should always push, pull, or roll an object rather than try to lift it. Pull instead of pushing whenever possible. Patients are no exception. When making a bed with the patient in it, pull the patient towards you to the edge of the bed and remove the sheet on the unoccupied side of the bed. After placing the sheet on the empty side of the mattress, roll the patient onto the new sheet and finish putting the sheet on the mattress. Use your leg and arm muscles when assisting the patient out of bed or onto the bedside commode. Remember not to perform the actions that place your back at risk like twisting, overreaching, getting into an awkward position, and lifting. When it is necessary to lift an object follow the guidelines on the next slide.2,5

Lifting Techniques

AVOID Lifting whenever you can
DON’T use your back as a lever
Bend your knees
Place your feet apart
Squat
Get a good grip
Lift gradually

Sometimes it is not possible to avoid lifting an object. When you are in a situation that you have to lift an object, don’t use your back as a lever by bending over. Bend your knees with your feet apart to provide a good base of support—probably at shoulder width. Squat down and get a firm grip on the object to be lifted. Gradually lift the object using the muscles of your legs, keeping your abdominal muscles tight.8

Assisting with transfers

Bed to stretcher
Bed to chair or toilet
Chair or toilet to standing
Chair to bed or other chair

Transferring a patient from one level to another requires use of good body mechanics to prevent various back injuries. If the patient can not assist with supporting his/her own weight, use a mechanical transfer device if possible. Be sure that you have been trained in the proper use of the device prior to using it. For a bed to stretcher transfer, follow the guidelines on the two previous slides. To accomplish other types of transfers such as those listed on the slide, do not bend at your waist. You will need to stoop, squat, and possibly, kneel. To prevent injury to yourself, always first make a determination as to whether you need another person to help. When it is necessary to lift an object, you must place your body as close as possible to the object and use the instructions on the next slide on how to squat, stoop, and kneel properly.

Steps to Follow

Face patient or object
Base of support
Tightening muscles
Leg muscles
Straight spine
Position of buttocks
Lower your body

Whenever you are going to stoop, squat, or kneel you need to use certain techniques. These apply whether you are assisting a person or moving an object. Always face the person or object to be moved. Make sure that your feet are far enough apart to provide a wide base of support for your body to maintain its center of gravity correctly. Use your stomach and abdominal muscles to protect your back by tightening them. Your leg muscles are strong and they are going to do most of the work. To use the leg muscles correctly, you keep your spine straight by sticking your buttocks backward much as the position in which you would “moon” someone. By doing so, you put the weight on your legs and keep your back straight. Slowly lower yourself to the necessary level to place the person or object where needed.

If you need to stay in a squatting position, you should kneel down on the floor.1

SUMMARY

Body mechanics refers to proper positioning of the body to prevent injury whether at rest or during movement.
The principles of body mechanics are to use the stronger muscles, keep the back straight, and maintain the body’s center of gravity which is in the middle of the pelvis.
The back supports the weight of the body and injury is usually caused by repetitive actions that cause wear on the spine and stress or strain on the back muscles.
CNAs in extended care facilities are one of the highest risk occupations for back injury which is the leading cause of work related injuries among all workers.
Prevention of back injuries includes never bending at the waist, twisting, or trying to move too heavy a load.
Techniques for CNAs to prevent back injuries include: work at the proper level; push, pull or roll rather than lift; look at the patient; use a wide base of support; squat, stoop, or kneel

Let’s summarize some of the important points we have discussed:

Body mechanics refers to proper positioning of the body to prevent injury whether at rest or during movement.
The principles of body mechanics are to use the stronger muscles, keep the back straight, and maintain the body’s center of gravity which is in the middle of the pelvis.
The back supports the weight of the body and injury is usually caused by repetitive actions that cause wear on the spine and stress or strain on the back muscles.
CNAs in extended care facilities are one of the highest risk occupations for back injury which is the leading cause of work related injuries among all workers.
Prevention of back injuries includes never bending at the waist, twisting, or trying to move too heavy a load.
Techniques for CNAs to prevent back injuries include: work at the proper level; push, pull or roll rather than lift; look at the patient; use a wide base of support; squat, stoop, or kneel

REFERENCES
The Cleveland Clinic Foundation. Peoples Health and Fitness Posture for a Healthy Back. Available at: http://resistancetraining.wordpress.com/tag/anatomy-physiology Accessed January 4, 2007.
Ignatavicius DD. Physical mobility. In: Harkreader, H.,ed. Fundamenatls of Nursing. Philadelphia, PA: Saunders: 2000: 973-974.
Oklahoma State University. Online Safety Modules. Back safety. Available at: http://www.pp.okstate.edu/ehs Accessed January 4, 2007.
Premier. Back Injury Prevention. Available at: http://www.primierinc.com/quality-safety/tools-services/safety/topics/back_injury Accessed January 4, 2007.
SpineUniverse. Back Care for Nurses. Available at: http://www.spineuniverse.com/displayarticle.php/article1509.html Accessed January 4,2007.
Oklahoma State University. Online Safety Modules. Back safety. Anatomy of the Back: Why Do Injuries Occur? Available at: http://www.pp.okstate.edu/ehs Accessed January 4, 2007.
Oklahoma State University. Online Safety Modules. Back safety. Common Causes of Back Injuries. Available at: http://www.pp.okstate.edu/ehs Accessed January 4, 2007
Oklahoma State University. Online Safety Modules. Back safety. How To Prevent Back Injuries. Available at: http://www.pp.okstate.edu/ehs Accessed January 4, 2007.

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Effective Communication: Threading the Information to a Better Quality of Life

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

Effective communication is the key to “getting the message across”…the methods may be different but the effectiveness is measured by the message that is heard or perceived. It is a two way street and both participants play equal roles in responsibility for the information being transmitted and received.

Upon completion of this course, the participant will be able to:

Describe the CNA’s role in communicating with residents, patients, family members, and other staff.
You should also be able to discuss communication processes and methods used in staff and resident interactions.

Software Requirements:

PC
Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater

*Adobe Acrobat Reader
Click here to download

MAC
Internet Explorer is not supported on the Mac
Mac OS 10.2.8
Safari
Firefox

*Adobe Acrobat Reader
<a href="http://www.adobe.com/products/acrobat/readstep2.ht

Instructor: Lori L. Ley, RNC, MSN

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

Effective Communication:
Threading the Information to a Better Quality of Life

Process of Communication

There are 4 parts to the process of communication.1

The sender begins the communication while the receiver is the person that the message is sent to.

The feedback is the return of information, or responses, and determines whether the communication is successful or not. Without the feedback…the process is incomplete.

We have to be able to say what we mean clearly and without confusion so that the information supports the needs of the resident. The CNA usually begins the communication flow as they spend the most time with the resident…usually more than even the family. You are the eyes and ears of the entire care team.

Lines of Communication

The nursing assistant is responsible for communicating with residents, patients, family members and other staff members with of course each of them communicating with each other as well. Again, the burden lies with each person making sure that the messages are clear and easily understood by all involved. Sometimes this seemingly simple task can turn bad quickly.

Most facilities or agencies have a “chain of command” or “line of communication”. It is very important that you know what the facility/agency expects regarding your responsibility in reporting problems. After information is communicated to the nurse, they then decide who is given the information. It could be anyone from the doctor to the dietician, physical therapy, social worker, or even administration.

Poor or lacking communication is the leading cause of system breakdown in resident and patient care.2,3,4 As a primary source for error, you can see why this topic is so crucial to the quality of life for the residents…and the staff that care for them.

Types of Communication Among Staff

Verbal or oral – the spoken word
Non-verbal – the way your body sends messages (with or without verbal)
Written – writing or typing information that is available for review by others
Manuals – references and resources

When we think of communication in our daily lives, oral or verbal forms are probably the first we think of. It is the spoken word whether face to face, by audiotape, or by telephone. Sign language is considered verbal.

Non-verbal communication is the way your body sends messages whether you are speaking at the same time or not.

The written word is a method for recording information in a permanent form that can be reviewed many times. This may be done by hand or typed in to an electronic form.
Manuals or references are another form of communication. This type of communication usually contains information that is available to all staff that helps direct care, or the conduct of business in your organization. It can also contain important safety guidelines that will help protect you and the residents in your care.

Staff Verbal Communication

Shift reporting
CNA to nurse conversation
- Assignments
- Care given
- Observations
Telephone

When beginning our shifts or assignments, the report on changes in resident or patient conditions, new physician orders, or incidents that may have occurred will drive the work of the day and help in planning assignments. This is a good time to set priorities and ensure that issues that need immediate attention are addressed. It will also help you understand what things you may need to pay special attention or watch out for during the day. A good example would be getting the information in a shift report that one of the residents was having some aggressive or anger episodes. As the CNA, that information will alert you to the need to be extra careful in not irritating or raising the level of anxiety in that resident during care routines. Talk with the nurse regarding the best way to approach this type of situation. Always report off to the nurse before leaving your assigned areas for breaks or at shift end.

Asking questions and holding discussions related to care can help ensure that the communication is exchanged accurately and thoroughly.

Telephone conversations are another type of verbal exchange of information. This method of communication can add an extra layer of “miscommunication” for several reasons. Activity going on around the area that the phone is located can distract or reduce the listening capability of the person on the phone. How many times have things gotten a little louder than usual around the nursing station or charting area and the person on the phone says “shh”? Another example may be someone on a mobile or cell phone while driving in rush hour traffic. How effective do you think this person can be in listening or responding?

Again, asking questions or restating what was heard can help ensure that the information (feedback) was relayed accurately. Writing down when and what was communicated to whom can support further exchanges of information.

Staff Non-verbal Communication

Gestures
Body language
Posture
Facial expression
Eye Contact

An entire lecture devoted just to non-verbal communication could not do the subject justice. The topic is very broad but for the sake of time, we will only scratch the surface.
Non-verbal communication is the process of sending and receiving wordless messages. They are usually communicated by gestures, body language, posture, facial expressions, or eye contact. Any and all of these factors can add a certain level of miscommunication to exchanges of information. How many times have you been involved in a conversation and you just get the feeling the other person really isn’t listening to you? It’s not because they say they aren’t listening but you perceive they are “tuned out” by the messages you receive from their non-verbal communication.

In your communication, try to stay focused and listen. Watch for others’ hidden messages and again, ensure the other person heard your message or that you heard theirs by asking questions or restating the conversation. If the feedback doesn’t fit, the message was lost and the communication must be attempted again.

Staff Written Documentation

Assignment sheets
Charting in Medical Record
MDS
Cue Cards

There are many care situations in which the CNA may be required to document. The places and methods used for documenting will vary by the facility you work at but the medical record (or chart) is to be used by all members of the disciplinary team. Most CNAs may be asked certain questions that will help support the nurse’s documentation.

The CNA should be acquainted with the MDS (Minimum Data Set) which is a reporting tool used to determine the resident’s need for care and the amount that the facility gets paid for providing that care. Some facilities have “cue cards” used by the CNA to assist them in determining specifics of care and assistance that residents may have needed during the care routines. These cards can be important bridges to ensuring that the information that needs to be documented on the MDS is done so completely and accurately. Up to date and accurate MDS information is essential in assigning the appropriate amounts of staff to care for the residents in the facility.

Nurses need to know every little thing, both physical and behavioral, about the resident in order that they can document the needs on the MDS. The fact that it takes someone to feed the resident for even one meal is important for determining the right choices when documenting on the MDS checklist.

Manuals and resources

Safety &/or Disaster manual
Policy & Procedure manual
Material Safety Data Sheets (MSDS)
Other references

Above lists several types of manuals or references that should be available for review at your facility. These communication threads will help to ensure both resident and staff safety. Following the policies and procedures is fundamental in functioning safely and securely in the LTC or ALF setting.

Other references are also helpful when trying to communicate a resident problem or abnormal behavior. Reference books can help by providing information that may not normally be remembered on a daily basis. Product equipment or supply instructions can be handy when a new product is introduced for care. Reading these instructions will help you gain confidence in your skill of performing the task while also ensuring that all safety measures are taken to be sure the resident is not injured or fears that you do not know what you are doing.

Reporting Requirements and Chain of Command

Safety issues
A change in resident physical, emotional or behavioral condition
Signs of neglect, injury, or abuse

There are many things that should always be reported but most importantly are those that are safety hazards or those that have already resulted in resident injury. No matter the chain of communication, the resident always comes first and ensuring their safety is your primary goal.

A change in resident condition is also a reportable event. Even the most minor observations can turn into major health issues. Give the nurse the opportunity to decide whether it needs to be communicated further or not. Don’t take it upon yourself to make that decision.

If you feel, after reporting an incident or a condition change, that the action taken was not equal to the need for it to be addressed further, discuss this with the nurse and explain why you think it should be acted upon. If they still do not follow-up on the issue, it is within your responsibility to verbalize to them that you are initiating the chain of command. The chain of command is a mechanism used to ensure that the right thing is done for the patient. If they still do not take action you should then seek help from the next person in the chain of communication. This is usually the supervisor over that nurse. Again, you are the eyes and ears of the team and you know these residents the best. Your observations are crucial to their health and well-being.

Resident Communication

Showing respect and care
Verbal & nonverbal
Barriers
- Cultural
- Disabilities
- Language
- Bias & prejudice

Another aspect of the CNA’s role is to communicate with the resident directly. Keep in mind that the most powerful message you send to the residents everyday is that you care about them. You do this numerous ways...both verbally and non-verbally. Remember that the way you enter the room, the body language that you use, and the tone of your voice may say more than the actual words that come out of your mouth. Make sure your nonverbal communication is also saying that you care.

Communication barriers will need to be overcome. Examples such as cultural or ethnic differences, physical and mental disabilities, language, biases and prejudices can all impact the messages being communicated. An example would be the resident that comes from a culture in which touch is considered disrespectful and intruding. How do you get the attention of a person that comes from this type of culture that is also visually impaired? This could be a challenge because you should never use touch if the resident is offended by the contact. Coming up with ways to deal with these types of issues and communicating the methods with the other staff will help bridge the differences and hopefully accomplish the goals.

Barriers

Many of these barriers occur as if a wall stands between one of the threads of the 4 parts of the communication process. An example might be the CNA trying to talk to a resident that has aphasia (the condition that occurs after a stroke or brain injury – making the resident unable to understand spoken or written language or express spoken or written language, or both). As you can see with the slide display, the walls prevent either the receiving or feedback or both. This can be frustrating for both the CNA and the resident. Please refer to the lists describing ways to assist you in promoting communication in residents with aphasia, as well as those with visual or hearing impairments.

Solving the cultural, language, bias, and prejudices will take more learning on your part. These barriers require deeper understanding and tolerance but most importantly, they require a mutual respect.1 This subject will be addressed further in some of the other programs that deal with diversity, rights, and communication.

Communication Strategies
Communication With the Hearing Impaired

Do not have anything in your mouth such as gum or candy.
Ensure the resident can see you by lightly touching them and indicating that you wish to speak to them and make sure there is good lighting in the room.
Ensure any hearing aids are in, on and functioning properly.
Make sure that you do not cover your mouth with your hands while speaking.
Face the patient and speak in a calm manner.
Make sure that your tone, even if louder, is not intimidating or evokes fear. Don’t shout or exaggerate words. If necessary, use descriptive terms such as “B as in boy” or “D as in Dog”. These will help get the message across.
Start by using key words or phrases so the resident gets some idea in general as to what you may be trying to convey.
Try to stay on one subject at a time and keep sentences short and simple.
You can also use body language or gestures to provide support to the spoken words.
If necessary, you may have to write some things down.
If you both know sign language, use that method.
Those that are hearing impaired may also be hard to understand too so listen carefully.

Communication With the Visually Impaired

As you approach, speak the resident’s name, state who you are and then lightly touch them on the hand or arm.
Ensure any visual aids such as glasses are in good condition and clean.
Stand directly in front of them as their side vision may be poor and make sure there is good lighting.
In a normal tone of voice, tell them why you are there and what you will be doing to them.
Be specific about what you are doing, in other words, after you tell them you are there to take their blood pressure, verbalize your action such as “I am putting the cuff on your right arm…”
Before you walk out of the room, tell them that you are leaving and ask if you can do or get them anything else.
If you see that a visually impaired person has on mismatched or soiled clothing, tell them tactfully.
Be sure to offer to read to them and if possible, see if some talking books can be used for the times when you can’t be there. Offer television or radio.
While in their room, do not change the location of items or furniture without making sure they are aware of the change.

Communication With the Aphasic Resident

Make eye contact while speaking the resident’s name slowly and clearly in a normal tone of voice. Do not shout at them. Open with a social greeting rather than immediately giving instructions.
It is best to use short and simple sentences, pausing between sentences to allow the resident to think about what is being said.
Check that the resident is understanding you before moving on.
Use your hands and facial expression to help in communicating the message.
Repeat the resident’s response to you so that they stay focused on the conversation.
If picture boards or other tools are available, use them to convey your messages.
If they get frustrated, try changing the subject a bit and then work your way back.

Building Your Communication Skills

Laying the groundwork
- Planning
- Establish contact
- Establish the environment
Organization
Maintain focus

Building your communication skills is essential for success in your role as the CNA as well as life in general.1 Building your communication skills is like paving a solid pathway into the future. With each progression in your skill a stone is laid that helps move you closer to your destination toward success. With planning, establishment of the right contact in the right environment or atmosphere will promote your ability to get the message across and set up the feedback to support that all communication is sent and received accurately.

By organizing tasks and your communication, you will find that miscommunications will be less likely and you will accomplish more in a shorter period of time.

Maintain and focus on one step at a time, don’t get rushed and try not to do too much, too fast. The resident will become confused and you will have to start all over again. This could result in frustration for both you and the resident…setting you up for future failure.

Communication Tips

Know the name of the person you will be communicating with and what your plan is before entering.
Always introduce yourself and if possible, ask to come in.
Ask permission to turn down any distracters such as TVs or radios.
Face the resident and make eye contact (unless this is culturally inappropriate).
Explain procedures in a manner in which the resident will understand.
Be sure your non-verbal communication is displaying a caring attitude.

Here are a few communication tips that can guide you successfully down that path.

Think about what you will say and organize your thoughts. Know the name of the person you will be communicating with and what your plan is before entering. Always introduce yourself. The resident may have some type of change in condition. Asking permission to enter establishes a sense of respect on your part and affords the resident a feeling of privacy and control. Ask permission to turn down any distracters such as TVs or radios then be sure to face the resident and make eye contact (unless this is culturally inappropriate). Be sure your non-verbal communication is displaying a caring attitude.

Communication Tips

Never talk down to the resident or display anger.
Avoid using words with several meanings and do not use slang, obscene words or gestures.
Listen completely!
Say what you mean and if necessary, use family or friends to help with translation if the message is not getting through.
Be slow, steady, clear, and concise. Don’t get louder and do not mumble or whisper.
Remember to smile and use your sense of humor appropriately.

Other tips include never talking down to the resident and of course, never display anger. Avoid using words with several meanings and do not use slang, obscene words or gestures. You should learn the meaning of new words that you hear the resident use and be sure that you listen and let them finish before piping in. Listen completely! Repeat back what you perceive they said and ask them to repeat your words to check the effectiveness of your communication to them. If you don’t understand, speak up and say so.

Say what you mean and if necessary, use family or friends to help with translation if the message is not getting through. Be slow, steady and clear with your words and talk in a normal tone. Don’t get louder if they don’t understand…this can be a tough habit to break. Do not mumble or whisper either. Remember to smile and use your sense of humor appropriately.

Just a couple more words…

Maintain confidentiality
Be honest
Avoid certain behaviors
- Judgments
- Advice
- False assurances
- Focusing on self or your own problems or concerns
- Discussing controversial subjects

Before we close, there are few final words that bear mentioning at this time. Please be sure that you keep the resident’s confidential information safe. This goes for anything written, said or heard. Only those with the “need to know” should be consulted and information discussed. By keeping the confidences you build trust in the resident and gain respect from the other staff. Never take notes home in your pocket that could contain resident information or data on them. Check these before leaving your shift or the building. Dispose of in appropriate containers that will be shredded.

Be honest with the resident and their family. If they ask you a question about something that you should not be sharing, don’t say “I don’t know”. Tell them that you can’t answer that question but you will have the appropriate person discuss it or answer it for them. If in conversation with the resident they ask a question that you don't know the answer, say so. If they ask you do something and you can’t do it right now but instead tell them you will do it later…make sure you can actually grant that do it at the time you stated.

There are other certain behaviors that you should avoid when communicating with your residents.

Avoid making judgments and avoid giving them advice. Please do not provide false assurances about their health, physical, or emotional condition. Avoid focusing on yourself and don’t share your problems or woes. Try to stay away from controversial subjects such as religion or politics. These could serve to create bad feelings and therefore undermine any future communications and care.

Summary

Communication is the key to “getting the message across”
There are 4 parts to the process of communication and all are equally important
It is very important that you know what the facility expects regarding your responsibility in reporting resident problems
Building your communication skills is essential for success in your role as the CNA as well as life in general

Remember…
Communication is the key to “getting the message across”.

There are 4 parts to the process of communication and all are equally important with each party being responsible for assuring the message is conveyed and comprehended correctly.

It is very important that you know what the facility expects regarding your responsibility in reporting resident problems. You will be held to that standard and the resident is highly dependant on you and the system to work every time.

Building your communication skills is essential for success in your role as the CNA as well as life in general.

Practice, practice, practice….it’s that important!

REFERENCES

Hegner BR, Acello B, Caldwell E. Nursing assistant: a nursing process approach. 9th ed. Canada: Delmar Learning;2004:732-737.
Institute of Medicine Division of Health Care Services Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
O’Leary D. Reducing Medical Errors: A Review of Innovative Strategies to Improve Patient Safety. Testimony before the House Committee on Energy and Commerce Subcommittee on Health. Oakbrook Terrace, IL: Joint Commission on the Accreditation of Healthcare Organizations; May 6, 2002. Available at: http://www.jcaho.org/news+room/on+capitol+hill/oleary_test.htm. Accessed December 2, 2006.
Joint Commission on Accreditation of healthcare Organizations. Sentinel event statistics. Oak Brook, IL: Author. 2005.

PLEASE PROCEED TO TEST AND EVALUATION

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Domestic Violence: The Dangerous Secrets

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

This course defines domestic violence as family violence and breaks down the categories of intimate partner violence, child abuse and neglect, and elder & dependent adult abuse, mistreatment and neglect. The dynamics of domestic violence are presented using Pence and Paymer’s power and control wheel as a guiding explanatory model.1

Common forms of domestic violence are described and categorized and their effects within the family are reviewed. The core content within this course addresses concerns that are common to all forms of domestic violence. This course also focuses on child abuse and neglect and also elder and dependent adult abuse, mistreatment and neglect; recognizing that some forms of abuse and mistreatment take place outside the traditional home setting. Health care professionals’ responsibilities and mandates regarding recognition, intervention, reporting, documentation and prevention of domestic violence are all addressed.

Our objectives for this course are to:

Define domestic violence, intimate partner violence, child abuse and neglect, and elder and dependent adult abuse, mistreatment and neglect,
Describe the characteristics of abuse, mistreatment, and neglect,
Explain the three phases of abuse,
Recognize screening procedures used for determining whether a resident has any history of being a victim or a perpetrator of domestic violence,
Describe the major health implications of domestic violence, child abuse, elder and dependent adult abuse, mistreatment, and neglect.
Identify where to locate community, regional and national resources available for those affected by abuse,
Describe how to report suspected domestic violence, elder and dependent adult abuse, mistreatment or neglect in the state in which the health care professional practices.

Software Requirements:

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Instructor: Lori L. Ley, RNC, MSN

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

Domestic Violence:
The Dangerous Secrets

Domestic Violence Myths…

Because, no matter the circumstances or victim, it’s always wrong.

Abuse is NOT a function of age, race, religion, education, economic class or cultural background
Abuse does not stop and may actually begin or intensify when a woman is pregnant
Domestic violence is not a private affair, it is a crime
Nobody deserves to be beaten or abused

Though domestic violence is primarily violence against women and children, it is always wrong no matter the circumstances or victim. There are a few myths that require clarification and/or obliteration…

• One is that abuse is NOT a function of age, race, religion, education, economic class or cultural background.
• Abuse does not stop and may actually begin or intensify when a woman is pregnant.
• Domestic violence is not a private affair, it is a crime.
• And again most importantly, nobody deserves to be beaten or abused.

The question commonly asked is, “why is there so much violence in our society?” Some suggest that increasingly graphic media content and violent video gaming has desensitized many of us - and this explains why violence is a growing presence in everyday life. In direct contrast, many others say that the media is only reflecting the reality of what society increasingly tolerates.2 Societal norms continue to reflect its tolerance of violence, but there are many factors influencing what people view as “normal”.

Defining Domestic Violence:

“Domestic violence constitutes the willful intimidation, assault, battery, sexual assault or other abusive behavior perpetrated by one family member, household member, or intimate partner against another”.3

“Domestic violence” as being any assault, aggravated battery, sexual assault, sexual battery, stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.4

According to the National Center for Victim Assistance,3 “domestic violence constitutes the willful intimidation, assault, battery, sexual assault or other abusive behavior perpetrated by one family member, household member, or intimate partner against another”.

In most states, like Florida, the statutes define “domestic violence” as being any assault, aggravated battery, sexual assault, sexual battery, stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.4 They further define “household member” as spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family or who have resided together in the past as if a family, and persons who are parents of a child in common regardless of whether they have been married. With the exception of persons who have a child in common, the family or household members must be currently residing or have in the past resided together in the same single dwelling unit.5

This broad definition attempts to capture all the variations of family oriented relationships, but it does not. Both common and legal definitions of terms continue to change - consider how the terms “household”, “home”, “family”, “spouse” and “marriage” have all changed over the last several decades. Adding to the confusion, a significant number of states have included dating relationships in their statutory definitions of domestic relationships. Domestic violence has come to be a generally inclusive term with a broad range of meanings. To accommodate all its varied meanings, domestic violence is more appropriately named “family violence”.

Connected & Overlapping Areas

There is an explanatory model describing how all forms of abuse, mistreatment and neglect are related. According to the model, they all represent aggressive and hostile behaviors that individuals use as primary defense mechanisms when they have limited coping skills and low self-esteem. Anyone having trouble with one relationship will soon have problems in other relationships. Over time, these individuals will develop a pattern of violence that becomes evident both inside and outside the home. For example, children who have been exposed to domestic violence often exhibit behavioral and mental health problems that continue throughout their lives. They tend to have problems at home, at school and at work; their problems are related to aggression, depression, lower levels of social competence and self-esteem, poor academic performance and poor problem-solving skills.5

A set of circles can help illustrate the proposed connectedness and overlapping of domains within the all-inclusive label of domestic violence. Consider the largest circle to represent domestic or family violence, and it usually occurs within the home. Any of the more specific forms of violence may also occur outside the family or home setting. Consider the largest circle to represent domestic or family violence occurring within a home setting. Domestic violence most often involves adult intimate partners (spouse abuse, partner abuse), followed by involvement with children (child abuse) and then older adults (elder abuse). Any of these forms of violence may also occur outside the family or home setting, but will continue to involve family or partner relationships. To accommodate these situations, the broader term “family violence” is more appropriately used.

Incidence

In the world – 1 in 3 has been beaten – most often by a family member6
Approximately 1.5 million women and over 800,000 men are victims of physical violence by an intimate person each year!

Domestic or family violence affects everyone, regardless of gender, race, education, profession, or socioeconomic status. Both abusers and victims come from diverse backgrounds. When considering incidence, data support that women are the most commonly abused persons. Around the world, at least one woman in every three has been beaten, coerced into sex, or otherwise abused in her lifetime. Most often the abuser is a member of her own family.6 In the United States, it is estimated that between 2 and 4 million women are assaulted by a domestic partner every year. It is further estimated that 12 million women (25% of the female population) will experience abuse during their lifetime.7

The U.S. Department of Justice reports that 1,510,455 women and 834,732 men are victims of physical violence by an intimate each year.8 It is important to note that men are also victims of domestic violence and can find themselves in a relationship where they too are battered. Abused and mistreated men represent a smaller percentage of all victims of domestic or family violence, but experts agree that abused men are also least likely to file a report.

Domestic violence is best understood within a cultural context, because violence against vulnerable people comes essentially from cultural patterns and certain traditional practices. Women, for example, are particularly vulnerable in many cultures because of long-standing oppression.9 Health care professionals must be prepared to work effectively with ethnic and cultural differences as they relate to domestic violence. Whenever possible, the abused victim should be interviewed by a health care worker who is very familiar with the cultural group represented. Immigrants and refugees are particularly at risk, because they fear a loss of immigration status and deportation if they report abuse. Health care professionals should know that non-citizens are entitled to obtain a protective court order, and can enter any shelter. Furthermore, naturalized citizens, legal permanent residents, or visa holders cannot be deported, unless they entered the U.S. on fraudulent documents, violated visa conditions, or were convicted of certain crimes.

Impact

Healthcare Implications
- Increased healthcare visits
- Everlasting effects on children
Economic Implications
- $5.8 billion/year

Domestic violence is a serious public health concern. Its overall impact is huge, and yet it often remains unrecognized by health care professionals. Unfortunately, when domestic violence isn’t recognized – it is allowed to continue.

Congress enacted the Violence Against Women Act (VAWA) in 1994 to expand efforts to raise awareness of domestic violence and increase the resources available to victims. VAWA was re-authorized in 2000. Reports of abuse, mistreatment and neglect are now mandated, and there is every hope that heightened awareness within the community will contribute to both prevention and intervention.

Children who have experienced abuse and neglect continue to suffer as they age. Abused and neglect children are at increased risk for experiencing adverse health effects and behaviors as adults. Typical behaviors include smoking, alcoholism, drug abuse, physical inactivity, severe obesity, depression, suicide, sexual promiscuity, and certain chronic diseases.10
In 2003, the Centers for Disease Control and Prevention (CDC) estimated that health-related costs of intimate partner violence against women exceed $5.8 billion each year in the United States. Because domestic violence is believed to be a preventable health problem, local, state and federal agencies are actively addressing the problem through awareness campaigns. Using public health principles to enhance primary prevention and build on community efforts, both lay public and health care professional education efforts are promoted in an attempt to reduce the violence.

Dynamics of Abuse, Neglect, and Mistreatment

Not just about the hitting
No one has or gives permission for domestic violence
Domestic violence affects many family and friends
Domestic violence is preventable

According to Newton (2001), domestic or family violence isn't just about hitting, or fighting, or an occasional mean argument. Instead, it is about a pattern of behaviors that reflect a chronic abuse of power. The abuser manipulates and controls the victim by a calculated pattern of behaviors in the form of threats, intimidation, and physical violence – and this is true among child victims as well as adult victims. Actual physical violence is often the result of months or years of intimidation and control. As one domestic violence slogan states, “the victim is always beaten down long before being beaten up”. This statement implies a pattern of behavior that continues over time, and experts agree that once a pattern of neglect, mistreatment and/or abuse is established, it will continue and it will escalate.

No one has or gives permission for domestic violence. Health care professionals who presume victim willingness are not recognizing the power of coercion and intimidation. A combination of personality characteristics and situational dynamics can work together to magnify a person’s vulnerability – so that under certain circumstances virtually anyone can be victimized. Another combination of personality characteristics and situational dynamics can encourage a person’s potential as an abuser. Once that pattern is established within a relationship, it becomes incredibly difficult to reverse it.

Domestic violence affects a wide scope of family and friends. Health care professionals who focus on a single individual are missing the dysfunctional dynamics that sustain all abusive relationships. The most tragic victims are young children who grow up with violence in the home. However, everyone who is even remotely involved becomes a victim – including the abuser.

Domestic violence is preventable. Through awareness and educational campaigns, various agencies and coalitions are hoping to encourage both victims and abusers to seek help. However, the damaging effects of an abusive relationship will only escalate when allowed to continue.

Power and Control Wheel

Coercion & threats
Intimidation
Emotional abuse
Isolation
Minimizing, denying, and blaming
Using children
Using male privilege
Economic abuse

Used with permission: Domestic Abuse Intervention Project, Duluth, MN.
www.duluth-model.org

Using the Power and Control Wheel, we can show the central intention or purpose of all abusive tactics is the desire to establish power and maintain control. Each spoke of the wheel represents commonly used tactics and strategies that are designed to achieve this purpose.

• Coercion & threats
• Intimidation
• Emotional abuse
• Isolation
• Minimizing, denying, and blaming
• Using children
• Using male privilege
• Economic abuse

The outer rim of the wheel, that which holds all the strategies together, is the real or imagined threat of physical abuse and violence. This model is helpful to health care professionals who are working with both abusers and victims; the model helps to explain what is going happening and why.

Phases of abuse

Tension building
Abusive incident
Calm and penance

The evolution of a situation that includes domestic or family violence is not reflective of the actual relationship; it is about a person's values, beliefs, and feelings concerning violent behavior. An abuser chooses to use violence as a method of behavior. Violence is not about a situation, stress, or a relationship; it is about behavior and control.

In her book on battered women, Dr. Walker identified three phases in the violence and abuse cycle illustrating how these phases connect in a cyclic manner. Although there will be individual variations, Walker suggests that many abusive relationships will repeat this cycle of abuse again and again. A thorough understanding of each of these phases is instructive for health care professionals who try to detect, treat, prevent and report instances of domestic or family violence.11

Tension Building Phase

Keeping the abuser at bay
Eventually failing
Victim blames self
Continues to build with each incident
Helplessness ensues
Can last for long time

Tension is a normal feeling and is a part of everyone's life and in all of life's relationships. During the tension-building phase in an abusive relationship, one individual works hard to keep the other individual calm so that no violent episode occurs. The individual works frantically, but eventually a verbal or other minor battery occurs. The victim is rarely angry at the most unreasonable occurrence during this phase. In fact, the victim usually takes the blame or accepts responsibility and attempts to calm the abuser. Each time a small abusive incident occurs, tension in the relationship increases. A nagging sense of helplessness begins to overwhelm the victim. Eventually the tension simmers to a boil, bringing on the next phase. Ordinarily, Walker suggests that this first phase can last for long periods of time.11

Abusive Incident Phase

Explosive violence
Rarely triggered by victim’s behavior
Can come out of nowhere
Fears reaching for help
Injuries
Denial by abuser

The tension-building phase ends in an explosion of violence without any apparent cause. The acute battering phase that follows, characterized by uncontrollable discharge of tension, is rarely triggered by the victim's behavior. Unlike the minor abusive incidents that occurred earlier, the incidents in this phase can be severe. Like a violent storm that strikes on a clear, sunny day, the physical attack or verbal assault seems to come out of nowhere. It could be a meal that is unsatisfactory or a refusal to have sex that sets off a partner. The victim is battered regardless of their response. Typically, the victim is unaware of the extent of injury or may fear reaching for help. The abuser may discount the battering and underestimate or deny that injuries have occurred. Normally, this phase lasts from 2 to 24 hours.

Initially, the victim is in a state of shock and disbelief. It is difficult for the victim to come to grips with what has happened. If the victim has been through the abusive cycle several times, a conflicted mixture of relief and rage will be experienced - relief that the inevitable assault is over, and rage over the abuser’s empty promises to stop. The victim may be faced with the need for medical treatment. The victim might report this episode to the authorities or inform family members of the abuse. Typically, however, the victim remains silent and doesn't expose the abuser. An increasing sense of helplessness develops, along with feelings of self-hatred for not doing something to prevent the abuse.

Calm and Penance Phase

Abuser appears grief stricken and guilty and tries to “make-up” for what was done
Make the victim feel guilty
Relief
Honeymoon phase
Healthcare providers as “enemy”
Or…silent treatment

This phase, also known as the loving, reconciliation phase. It can begin within a few hours to several days after an acutely abusive episode. During this period of time the abuser appears to be stricken with grief over such cruel and insensitive behavior. The abuser works very hard to make up for what has been done with apparent acts of kindness, promising never to abuse again. The abuser feels guilty and is excessively apologetic but works on making the victim feel responsible. These behaviors instill guilt and further "victimize" the abused.

The abuser and the victim typically show an enormous sense of relief that the incident is "over". The victim welcomes this phase of loving reconciliation and enjoys the special attention. This is a period of intense pleasure and reassurance for one another. It becomes a reward for the violence. Since there is a desperate wish to believe that the abuser is sincere, there is a tendency to overrate the genuineness of the apparent remorse. It is during this time that the victim may drop any criminal charges or shrink away from pursuing legal separation or divorce. The victim will frequently come up with "reasonable" explanations as to why the abuse happened. Health care professionals must recognize that during this phase, anyone who attempts to support the victim and urge the victim to leave this violent relationship may be seen as "the enemy" attempting to destroy a loving relationship.

This phase may last a day or a few months, and it tends to become less and less common. Eventually, however, the tensions will slowly begin to mount and the cycle will repeat.

Sometimes this phase is substituted with a sudden-return-to-normal phase. In this phase, there is often a significant period of silence. A victim may be hoping that the abuser will apologize. However, what usually happens is that the abuser eventually begins to act as if nothing ever happened. The abusive incident is not mentioned and no apology is offered. Life just somehow goes back to "normal." Yet because their problems are not exposed and worked through, the tension escalates again, leading to another abusive episode.

Vulnerability of the Elderly

Physically and emotionally frail
Often live alone with limited resources
Uncertain social support
No tension building phase if infrequent visits…just explosive abuse

Some of the descriptions regarding Walker’s phases of abuse can be applied to elder abuse. A primary difference for the elders is that many older adults will not experience any abuse or neglect until they become physically or mentally weakened because of their deteriorating health status. There is also no discernable tension-building phase for the elder and violent episodes may only occur during an infrequent visit by an adult child. Listed on the slide are other vulnerabilities of the elderly.

Why do they stay?

Homicide
Friends & Family
Financial
Dependence
Lack of self-esteem
Inconsistent feelings
Safety & Support
Making it work
One time incident
Children will be taken
Religious beliefs

According to the National Coalition Against Domestic Violence (NCADV), the question of why individuals stay in a violent relationship is often answered with a victim-blaming attitude; i.e. they like or need the abuse or else they would leave. The coalition goes to recognize that this pattern of thinking is wrongly based on stereotypical and prejudicial attitudes. In many abuse situations there is a real danger in leaving the abusive relationship and victims are absolutely correct to behave in whatever ways are needed to assure survival. The NCADV lists the additional complexities typically encountered when leaving an abusive relationship:12

• There is a strong and realistic fear that the abuser/batterer will become more violent and maybe even homicidal once attempts to leave are known;
• Friends and family may not support the individual leaving;
• There are profound difficulties of single parenting in reduced financial circumstances;
• Dependence and learned helplessness, most commonly seen among women;
• The victim may lack self-esteem, believing that they don’t deserve anything better;
• There is a mix of good times, love and hope along with the manipulation, intimidation and fear;
• The victim may not know about or have access to safety and support
• There is perceived love, and a strong desire to remain in an effort to make the relationship work;
• There is hope or belief that it will not happen again, or that the abuser may make that promise;
• Many are fearful that their children will be taken from them; and
• Religious beliefs may dictate staying in relationship.

The same experts who explore reasons for staying in an abusive relationship also offer insights on leaving an abusive relationship. Many of the tangible barriers can be overcome with help from friends, family, churches and shelters. It is the emotional aftermath of uncertainty, fear, confusion, and psychic pain that is most difficult to overcome. Mental health care professionals tell us that anyone can recover from the physical abuse, but no one ever fully recovers from the emotional abuse.

Health care professionals are in a prime position to detect, intervene, and prevent cases of abuse, mistreatment, and neglect. This can only occur when health care professionals have an increased awareness of the problems, and learn to incorporate these areas into their routine assessments.

Types of Abuse, Mistreatment, and Neglect

Physical
Sexual
Emotional or Psychological
Environmental

The continuum of violence extends from incidental and episodic “minor” mistreatment all the way up to and including murder. The degree of insult or injury may be perceived differently by the victim, the abuser, those within a community of friends and acquaintances, and those within the legal or law enforcement community. The physical, sexual, emotional, or environmental abusive situations are equally as important as the other. Any of these are considered “abuses” and deserve consideration when a person shares their burden.

Physical Violence and Abuse

Non-accidental
Committed by partner, family or household member
- Pushing
- Shoving
- Slapping
- Hitting
- Kicking
- Biting
- Weapons use

This is a non-accidental injury that is the result of acts of commission by a partner, family, or household member. Physical abuse involves behaviors such as pushing, shoving, slapping, hitting, kicking, biting, the use of weapons, or other acts that result in injury or death. It is the most common pattern in domestic violence cases, and is estimated to occur in 4 to 6 million intimate relationships each year in the U.S.13 In general, the degree of injury grows more severe as abuse continues in the relationship.

Among older adults, the physical abuse commonly reported includes beating, slapping, pinching, shoving and kicking. Unnecessary exposure to severe weather, depriving the individual from food and water, withholding needed medications or administration of excessive medication is also considered forms of physical abuse. Outright physical abuse often takes place within families in which there is a history of violence, including child abuse or spouse (intimate partner) abuse. Often there is a history of drug abuse, mental illness, or a combination of these. In some cases, episodes of physical abuse towards an older adult are explained as retaliation for earlier child abuse.

The inappropriate use of physical restraints is also considered a form of physical abuse. Health care staff is advised that civil and criminal charges may be filed when inappropriate restraint use is suspected.

Specific indicators of neglect include dehydration, malnourishment, poor hygiene, obvious evidence of inadequate care, and/or open pressure ulcers showing evidence of poor or nonexistent care. Among older adults, neglect is defined as the failure to provide an elder with necessities such as adequate food, shelter, medical treatment or personal care. Neglect often occurs in situations where the caregiver is unaware that basic needs are not being met, or sometimes when the caregiver is too stressed or exhausted to meet those needs. In some cases the caregiver has identified an elder’s needs but simply chooses not to take responsibility for using resources to meet those needs.

Health care professionals need to examine each patient carefully for suspected abuse, appreciating that the scalp may conceal signs of abuse.14 The presence of old and new bruises on the same part of the body are considered suspicious. The age of a bruise can often be determined by its color. Red or blue bruises are usually 1-5 days old. Green bruises are usually 5-7 days old. Yellow bruises are usually 7-10 days old, and brown bruises are usually 10-14 day old.

Sexual Violence and Abuse

Non-consenting adults or children
Single or multiple episodes
Many types of actions
Perpetrators varied
Vulnerable disabled

The terms sexual violence or sexual abuse are used to describe a variety of behaviors involving non-consenting adults and children. There may be singular or multiple episodes and a wide range of sexually explicit actions are included such as fondling, fellatio or cunnilingus, anal or vaginal penetration, and exploitation through photography or prostitution.

The legal term rape has traditionally referred to forced vaginal penetration of a woman by a male assailant. Many states have now abandoned this term in favor of the more gender-neutral term sexual assault. The legal definition of criminal sexual assault is any non-consenting sexual encounter in which an adult is either pressured, coerced (expressed or implied), or forced into sexual activity with the partner. The assault may involve genital, oral, or anal penetration by a part of the accuser’s body or by an object, using force, or without the victim’s consent. The assailant may or may not be known by the victim.

Among older adults, the sexual abuse typically involves forcible rape, forcing sadistic sexual acts and forcing unwanted sex. Reports of sexual abuse are more likely to involve those who reside in institutions, and typically do not include family members.

Individuals with developmental disabilities are also particularly susceptible to repeated sexual abuse, sexual assault, and rape.

Emotional and Psychological Abuse

Destruction of self-esteem
Post traumatic stress syndrome
Cycle of insecurity and fear
Commonly used in elders
Accusations and dementia

This is the psychological or mental violence that causes the destruction of a victim’s self-esteem. Many agree that this form of abuse is immensely more devastating that physical abuse; emotional and psychological abuse leaves long-lasting “scars” that rarely heal. For example, the incidence of posttraumatic stress disorder (PTSD) among abused victims is well known. This form of violence can involve name-calling, ridicule, threats, or other types of insult and degradation.

There may be a display of violent behavior (such as punching a fist through a wall) that is used to intimidate. Often there is constant verbal abuse, harassment, and excessive possessiveness. This form of abuse is systematic and purposeful, and has the effect of giving power to the abusive partner. The perpetrator’s low self-esteem stimulates insecurity and fears of abandonment that are mitigated by the victim’s growing dependence and feelings of self-worthlessness.

Among older adults, the psychological abuse typically includes verbal harassment, threats, or other forms of intimidation directed towards an elder. One very common example of harassment is the threat of placing him or her in a nursing home out of punishment. Psychological abuse is most commonly employed to control the elder’s behavior, and usually represents a life-long pattern of interaction. Interestingly, these behaviors are often not identified as abuse by either the abuser or the victim.

A particularly complicating situation involves demented elders who accuse their caregivers of emotional abuse or maltreatment. The victim who has been declared incompetent is rarely believed, and in fact, the perceived abuse might have occurred many years ago if at all. Unfortunately, the abuse may very well be real. Caseworkers investigating complaints such as these find that it is very difficult to achieve satisfactory resolution, and often resort to placing the elder in an assisted living or long-term care institution.

Over time, it is generally accepted that emotional and psychological forms of abuse will typically escalate and evolve to include physical abuse.

Environmental Abuse

Control of environment
Isolation
Restricting bank accounts
Monitoring calls and activity
- Stalking
Forgery and diversion of funds
Property extortion

This form of abuse is characteristic of domestic violence cases; perpetrators exert efforts to control the victim’s environment. Such behaviors may include isolating victims from family members, restricting access to bank accounts, following or monitoring telephone calls, and other measures (stalking). These controls allow the perpetrator to increase the victim’s dependence and create a perspective that includes no alternatives to the violent relationship. Additionally, when perpetrators destroy valued property or pets of victims, unmistakable messages regarding the victim’s vulnerability is clear.

All forms of financial and property exploitation, intentional mismanagement, and diversion of assets (economic abuse) are also considered environmental abuse. Among older adults, economic abuse typically involves stealing or misuse of property or other assets belonging to an elder, such as his or her house, bank account, pension funds or Social Security payments. Restricting access to financial reports and accounts, forging signatures on appropriate funds are other commonly reported tactics.

Economic abuse is rarely the only type of abuse, mistreatment and/or neglect involved.

Healthcare Worker’s Responsibilities

Routinely ask questions
Ask direct questions
Document findings
Assure patient safety
Review/refer to appropriate resources

So what can be done as a CNA? Well you can begin by:
• Routinely asking questions. By always asking, you allow the victim, that may be very good at hiding the abuse, the opportunity to open up.
• Ask direct questions. Just recognizing that a situation may exist can again open the door for more information that can be relayed to the nurse.
• Document findings.
• Assure patient safety.
• Review/refer to appropriate resources. Let the nurse know your suspicions and the circumstances that brought you to that conclusion. Collaborate and ensure any mandatory reporting is accomplished. The law requires it for elder and child abuse.

Healthcare Worker’s Responsibilities

Recognition
Abuser
Victim

AWARENESS
It is now recognized that all health care workers have the potential to play an important role in the prevention, detection, referral, and treatment of violence. One empathetic statement from a concerned health care worker could be the first step toward safety. Recognition of both subtle and obvious signs could lead to help for both the abuser and the victim. It may be the first time anyone calls attention to a problem, which experts all agree will only escalate.

Individuals who rely on aggressive and abusive behaviors to establish power and control over another person are called batterers or abusers. There is no abuser/batterer profile, although some common character traits are reported. Due to previous life experience, abusers/batterers have learned that it is acceptable to manage a relationship by responding abusively when they are stressed, angry, or frustrated. For various reasons, abusers usually have low self-esteem, extreme possessiveness, and strong feelings of jealousy. Abusers tend to externalize their behavior, attributing violence to stress, alcohol, or “a bad day”. Animal and pet abuse is directly correlated with human abuse. It has been said that abusers "do not count the number of legs on their victims."

During victimization, abused individuals often seek access to a variety of health professionals. An abused person suffers emotional, psychological, and physical maltreatment, which can result in both acute and chronic symptoms of mental and physical injury. Health care workers should always be alert to the red flags of battering. Clues may be subtle, but important. Does the individual minimize injuries or explain them away with statements such as “I’m clumsy”? Is someone seen often for vague, somatic complaints? Is this person having trouble with sleep patterns, or does this person appear depressed? Caring for the victim of abuse involves a combination of intuition, experience, and fundamental knowledge. It is often the experienced health care professional who initially detects an unexpected patient response, and curiosity then leads to further revelation.

Neglect is the most typical form of elder abuse in the domestic setting, exacerbated by isolation and cognitive deficits. Unlike children who must attend school, neglected and/or abused elders may remain isolated in their homes.

Healthcare Worker’s Responsibilities

Intervention
- Identify
- SAFE questions
  - Stress/Safety, Afraid/Abuse, Friends/Family, Emergency plan
- Reporting
- Immediate problems
- Expected problems

AWARENESS
Identification is the first stage of intervention. Asking directly may be the most effective method. Routine screenings are now common place for long term care facilities, emergency rooms, and other healthcare environments. SAFE questions are asked and responses are documented. SAFE is an acronym to describe the line of questioning. Here are some examples:

S is for STRESS or SAFETY - Should I be concerned for your safety?

A is for AFRAID or ABUSE - Has your partner ever threatened or abused you or your children?

F is for FRIENDS or FAMILY - Would they be able to give you support?

E is for EMERGENCY Plan - Would you like to talk with a social worker, counselor, or physician to develop an emergency plan?

Reporting is mandatory for elder and child abuse situations but is voluntary for other domestic abuse issues. Of course, addresssing any immediate issues such as trauma etc. are critical, reporting can come after the immediate threat to life and limb is alleviated.

Eventually, expected problems to come should be discussed as emergency plans need to be devised to support the victim should they decide the need to return to the environment is necessary.

Healthcare Worker’s Responsibilities

Prevention
Safety Plans
BIPs

AWARENESS
Safety considerations during a violent incident that occurs in the home or place of residence are suggested by Burnett and Adler.14 These suggestions are also helpful during a violent incident in a public place.

• Try to avoid arguments in small rooms, rooms with access to weapons (such as kitchens) or rooms without access to an outside door.
• Be aware that alcohol and other drugs will increase the likelihood of impulsive and aggressive behavior in an abuser.
• Be aware that alcohol and other drugs can decrease your ability to act quickly to protect yourself and others (children).
• Know which doors, windows, or fire escapes you and your children would use if you must act quickly to escape. Know where you will go once you leave the house or immediate area. If possible, practice taking this route.

Safety plans involve some advance thought about how to enlist help from others, and how to behave when abusive behavior escalates. Burnett and Adler suggest the following ideas:14

• If you can, tell a friend or neighbor to call the police if they hear suspicious noises coming from your home or over the telephone.
• Program your cell phone in a way that can quickly enlist the help of others (using 911 for police or fire, or a trusted friend)
• Arrange the use of a code word with children, friends or family members so that they know when they should call for help.
• Teach children how to use the telephone to contact police or fire agencies (911 if available)

Within the last few decades, professionals associated with the criminal justice system began to realize that little progress could be made to reduce the incidence of domestic violence when only the victims were identified and treated. Mental health professionals were challenged to design intervention strategies that could change abusive behavior, and so batterer intervention programs (BIPs) have been developed. Participation in BIPs are rarely voluntary, and are usually court mandated These programs, along with anger management counseling, are routinely used in several states as a legal remedy.

Elder & Child Abuse Hotline

1-800-96-ABUSE
Or
1-800-962-2873

The local shelters for domestic violence are:

Clay County
Quigley House Hotline: 284-0061

Duval County
Hubbard House Hotline: 354-3114

Summary

Domestic violence is serious and includes all types of abuse.
Domestic violence knows no boundaries of age, race, religion, or socioeconomic status and the incidence is widespread.
Identification is key to intervention.
Healthcare workers have a duty to report.

Domestic violence encompasses physical, sexual, psychological and environmental abuse. It is a serious public health issue and a major human rights concern. Perpetrators of domestic violence are held criminally liable for their actions, but the violence is often allowed to continue when the victim is too afraid to report abuse and others are not willing to get involved. In fact, the hallmark of domestic violence is that it occurs behind closed doors, and gets little attention. Health care professionals have a duty to report suspected or actual abuse, and are required by law to do so.

Domestic violence is prevalent in all groups, ages, races, religions, and economic strata. The incidence of domestic violence is widespread, but education and public awareness can stop its escalation and contribute towards prevention. The availability of many resources can assist both victims and abusers.

Health care professionals have an important role in identifying actual or suspected abuse, and then reporting it. Accurate and comprehensive documentation of suspected abusive incidents is an essential contribution towards preventing further abuse. Each health care professional is obliged to stay informed regarding the identification and treatment domestic violence in all its presentations, and to direct victims towards needed resources to promote overall safety. Domestic violence is a preventable problem but prevention is only possible through collaborative efforts involving the public, law enforcement and health care.

REFERENCES
Pence E, Paymer M. Power and control: tactics of men who batter. Duluth, MN: Domestic Abuse Prevention Project; 1986.
Bok S. Mayhem. Cambridge, Massachusetts: Perseus Publishing; 1998.
National Center for Victim Assistance: Domestic violence. Available at: http://www.ncvc.org/ncvc/main.aspx?dbName=DocumentViewer&DocumentID=32347#1 Accessed: November 17, 2006.
State of Florida Legislature. Statute 741.28. Available at: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0741/Sec28.HTM Accessed: November 17, 2006.
Margolin G. Effects of domestic violence on children. In: Trickett PK, Schellenbach CJ. eds. Violence against Children in the Family and the Community. Washington, D.C: American Psychological Association, 57-101.
Heise L, Ellsberg M, Gottemoeller M.Ending Violence Against Women. Population Reports, Series L, No. 11. Baltimore: Johns Hopkins University School of Public Health, Population Information Program.1999.
The Centers for Disease Control and Prevention and the National Institute of Justice, Extent, Nature, and Consequences of Intimate Partner Violence, July 2000.
U.S. Department of Justice. National Institute of Justice Centers for Disease Control and Prevention 1998. Available at: http://www.ncjrs.org/pdffiles/169592.pdf Accessed: November 17, 2006.
Draucker CB. Domestic violence: The challenge for nursing. Online Journal of Issues in Nursing, 7(1), manuscript #1. Available at; http://www.nursingworld.org/ojin/topic17/tpc17_1.htm Accessed: November 17, 2006.
Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, Koss M, Marks, J. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998;14(4): 245-258.
Walker L. The Battered Woman. New York: Harper & Row. 1979.
National Coalition Against Domestic Violence. Available at: http://www.ncadv.org/problem/why2.htm Accessed: November 20, 2006.
Rodriguez M, Bauer H, McLoughlin E,Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA. 1999; 282:468-474.
Burnett L. Adler J. 2001 Domestic violence. Available at: http://www.emedicine.com/emerg/topic153.htm Accessed: November 26, 2006.

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HIV/AIDs: Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

This program is going to address the information that you need to be able to meet the following objectives: First to define HIV and AIDS. Many people use these two terms interchangeably but they are not the same thing. Our second objective is to address where HIV came from and how it was first identified including the impact both nationally and worldwide. As a third objective, we’ll talk about what are the symptoms of HIV and AIDS and what is required for a diagnosis. Perhaps most importantly, we’ll describe the risk factors, the manner in which HIV is spread and how to stop the spread including workplace issues. Next, we will look at the current methods of treatment available to those afflicted with this disease. Our last objective is to discuss the emotional and legal issues involved with HIV and AIDS.

After completing this program, participants should be able to:

Define HIV and AIDS and how they affect our bodies.
Discuss the history of HIV and AIDS including statistics
State symptoms and diagnosis
Describe the ways HIV is spread, risk factors, and how to stop the spread
Tell how HIV and AIDS are treated
Discuss the emotional and legal issues involved with HIV and AIDS

Software Requirements:

PC
Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater

*Adobe Acrobat Reader
Click here to download

Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

HIV/AIDs: Human Immunodeficiency Virus
and
Acquired Immune Deficiency Syndrome

HIV or the Human Immunodeficiency Virus is the virus that attacks the immune system in the human body. AIDS or Acquired Immune Deficiency Syndrome results when the HIV virus allows specific diseases to invade the body. In this program, we are going to look at how this modern day epidemic started and how we are coping with it.

DEFINITIONS

WHAT IS HIV
WHAT IS AIDS

HIV stands for the Human Immunodeficiency Virus. HIV is a virus that infects the body and attacks the immune system. The immune system works to prevent infections from invading the body. Once HIV takes hold of the body, infections are not fought off and various diseases invade the body making the infected individual very sick. People do not really die from HIV, they die from the diseases that are able to infect their bodies because of the HIV. These diseases are ones that a person with a healthy immune system can usually fight off. When people with HIV develop specific diseases, they are classified as having AIDS. To summarize, HIV is the virus that attacks the immune system and AIDS is the condition that involves a person with HIV developing a specific disease. So, although the two terms are defined differently, the are related because you can’t have AIDS without also having HIV. 1,2

AFFECT OF HIV on HUMANS

Function of the immune system
Components of the immune system
Changes that HIV causes to the immune system

The immune system is responsible for fighting off infection in the human body. Any time a foreign object such as bacteria or a virus enters into the body, the immune system recognizes that it is not a normal part of the body and a series of reactions occur.

First white blood cells are stimulated to cause a reaction that results in inflammation. Usually, during this phase, some redness and swelling result such as what occurs with a deep scratch or being stuck by a thorn or insect. Infection does not always follow inflammation but if a disease enters the body, the response generates cells that are specific to fight the infection. These cells include T cells which actually attack the invading disease.

When HIV invades the body, it attaches itself to the T cell by using the CD4 receptor on the outside surface of the T cell. The HIV then injects its RNA into the T cell and changes the DNA of the original cell. An enzyme called reverse transcriptase is used to make this change occur. Once the T cell has been changed, when the immune system is stimulated to produce T cells, the original T cell is killed by the HIV virus. As a result, the person who has HIV can’t fight off infections effectively because the T cells can’t attack the invading disease.3

The Origin of HIV

1999 – researchers traced HIV origin to 2 simian species:

HIV 1 Central Africa (chimpanzee)

HIV 2 West Africa (sooty mangabey)

In 1999, an international team of scientific researchers discovered that the “predominant strain of HIV in the developed world” was found in “a subspecies of chimpanzees native to Africa.”4 The exact manner in which HIV was introduced to humans is still not perfectly clear, but it is theorized that it must have been from hunters exposed to infected blood from the chimps.

HISTORY of HIV and AIDS

Earliest known case
Theories
1999 researchers identify origin
First cases in the United States 1970s
“AIDS” named in 1982
1983 HIV identified as causative virus

The earliest known case of HIV has been traced back to a man in Kinshasa in the Democratic Republic of the Congo in 1959, but no one knows how he was infected. Prior to that discovery, the origins of HIV and AIDS had long been a source of speculation and theory. It was long thought that the source was from Africa but there was never any definite information related to the origin.

The first cases in the United States appeared between 1979-1981 in San Francisco and New York among males as a rare pneumonia and “other illnesses not normally found in healthy people”.4 So HIV was present in the United States since the middle of the 1970s. However, it was not until 1982 that the term AIDS was used by public health officials and tracking of the cases began. In 1983, the virus that causes AIDS was identified and was later named HIV.4

STATISTICS

United States statistics are from 2004
Estimated 1,139,000-1,185,000 people have HIV/AIDS
Deaths total 529,113
24-27% don’t know they have it
Florida second in the nation

These statistics are from the Centers for Disease Prevention and Control (CDC) and represent data collected through 2004. They are the most current statistics available from CDC.

Although HIV and AIDS are not exactly the same, for data collection purposes, the number of cases are combined. The decision to combine the numbers was made in an effort to present a more complete picture of the numbers of persons involved in this epidemic as many states have mandatory reporting of AIDS but not of HIV. Currently, it is estimated that between 1,039,000 to 1,185,000 persons in the United States are living with HIV/AIDS and 24-27% of these persons do not know they have it.

Total number of deaths through 2004 is 529,113 including 5,515 children under age 13.There were 42,466 adult cases and 48 cases of children contracting AIDS in 2004. According to the statistics, Blacks represent the largest number by ethnicity and in the number of cases per person in the United States. Florida ranks second in the nation for the number of new cases reported for 2004. Previously, it ranked third for years. New York is ranked first.5,6

WORLDWIDE STATISTICS

39 million people living with HIV/AIDS
4.3 million new infections in 2006
Deaths of 29 million in 2006
Leading cause of death ages 15-59
15.2 million orphans

HIV and AIDS are a worldwide problem with Africa being the continent most affected by the pandemic (worldwide epidemic) disease. There are an estimated 39 million people living with HIV/AIDS worldwide and that is about twice the number that were known in 1995. The number increased from about 8 million in 1990 to the current 39 million and continues to rise. In 2006, about 4.3 million people were newly infected including half a million children. Deaths are estimated around 2.9 million for 2006 alone. HIV is the leading cause of death worldwide for persons aged 15-59. As a result of this pandemic, 15.2 million children are orphans from losing one or both parents to AIDS—12 million of them are in sub-Saharan Africa. 5,6,7

HIV Symptoms

HIV has no specific symptoms

Extreme tiredness
Fever
Diarrhea
Headache
Sore throat
Swollen lymph nodes

When a person is initially infected with HIV, there are only flu-like symptoms that occur. HIV is a virus so the body responds to HIV as it would to other viruses. Symptoms will vary and may include malaise (extreme tiredness), fever, diarrhea that becomes persistent and worsens, headache, sore throat and swollen lymph glands which can be felt in the groin or neck area. A rash may occur. These symptoms go away and the person doesn’t realize anything more serious has occurred. Although the person does not know they have been infected with HIV, they can still spread the virus to others.1,2

Diagnosis of HIV/AIDS

HIV can be diagnosed by a simple blood test

Initial test gives a positive or negative result
If positive, a test to make sure that it is a true positive must be done
Florida law

The blood test for HIV requires having blood drawn just as for any other blood test. This test checks the blood to determine if the antibody to the HIV virus is in the blood. If the test is positive for the HIV antibody, it must be checked using a test called the Western Blot to be sure it is not a false positive. Certain diseases can give a positive result for the first test. Older tests take up to two weeks to get results but there are approved tests that take as short a time as three minutes. Home tests kits are also available. Florida requires that a person must be given informed consent before an HIV test can be performed except in some very specific circumstances.1,2

What Do Results of an HIV test mean?

Test results even if verified with a western blot test may not mean you don’t have HIV

Antibody test
Time between exposure and test
Repeat testing

In newborns, a positive test may not mean that the baby really has HIV.

If you have an HIV test, you need to know that since this is a test for an antibody, the time between when you were exposed and when you are tested is very important. It takes about six weeks to six months before you can know for sure that you did not contract HIV after an exposure. The reason is that the body must produce antibodies as the reaction to invasion by HIV. The level of the antibodies in the blood must be high enough to be detected. Therefore, repeat testing must be done to make sure that HIV is not in the blood.

In newborns, the baby’s blood may be HIV positive at birth because the mother’s antibodies can be found in the baby’s blood for 12-18 months. If the mother took medication to prevent HIV from passing to her baby while she was pregnant, the baby has a very good chance of being HIV negative.1

AIDS DIAGNOSIS

HIV positive
CD4 Count
Specific Disease

AIDS does not occur in persons who do NOT have HIV. As of January 1, 2000, for purposes of data collection, CDC combined HIV and AIDS case definition so that a person who is HIV positive and also one of the following, is diagnosed as having AIDS:1,2
1. CD4+ T-lymphocyte cell count less than 200 mm3 OR
2. CD4+ T-lymphocyte percentage of total lymphocytes less than 14 OR
3. One of the AIDS indicating conditions (see next slide)

AIDS indicating CONDITIONS

Candidiasis of bronchi, trachea , lungs or esophagus
Cervical cancer, invasive
Coccidioidomycosis ,disseminated or extra pulmonary
Cryptococcus extrapulmonary
Cryptosporidiosis, chronic intestinal (>1 mo.)
Cytomegalovirus disease (other than liver, spleen or nodes)
Cytomegalovirus retinitis (with vision loss)
Encephalopathy, HIV-related
Herpes Simplex: chronic ulcers(>1mo); or bronchitis, pneumonitis, or esophagitis
Histoplasmosis, disseminated or extra-pulmonary
Isosporiasis, chronic intestinal (>1mo)
Kaposi’s Sarcoma

Above lists half of the conditions that indicate AIDS if the person is also HIV+. If these conditions are present and the person is not HIV+, the person does NOT have AIDS.1

HOW HIV IS SPREAD

If a person is infected with HIV, you can get HIV from them by:

Having unprotected sex with them
Sharing needles and syringes to inject drugs
Being exposed to their blood and specific body fluids

If you are an HIV positive woman, you can give it to your unborn baby

HIV is a sexually transmitted disease. Having unprotected sex with an infected person can give you HIV. Sex can be vaginal, anal, or oral and the virus enters the body through the mucous membrane of the vagina, penis, rectum, or mouth. If persons who inject drugs share needles and syringes, they can become infected with the virus through blood in the syringe or needle. This is true whether the drugs are illegal ones or other types such as steroids.

Blood transfusions are a potential source of HIV exposure, but the blood supply in the United States has been tested for the HIV antibody since 1985 and since 1996 antigen testing has increased the safety. Other potential sources are organ transplants. HIV is spread not only through blood, but also through specific body fluids. These fluids are semen, vaginal secretions, cerebrospinal fluid, peritoneal fluid, pericardial fluid, amniotic fluid, synovial fluid and any body fluid that has visible blood in it.

There is no evidence to support that HIV is passed in saliva, sputum, urine, feces, tears or vomit UNLESS there is VISIBLE blood in it. Babies born to mothers infected with HIV can get HIV from the mother either during the pregnancy or through breast feeding.1,8

RISK FACTORS

The following persons are considered to be at high risk of contracting HIV

Men having sex with men
Injecting drug users
Heterosexuals having unprotected sex
Babies born to infected women

These groups of people listed here are at high risk because their sexual behavior exposes them to HIV. Previous data collection has identified men having sex with men to have the highest incidence of HIV and AIDS. Recent data shows that the highest number of new cases are related to heterosexual sex. Persons who inject drugs and babies of mothers with HIV are also at high risk of being infected with HIV.1,2,8

REDUCING RISKS

Behaviors that will reduce the risk of getting or spreading HIV are:

Abstinence
Monogamy
Condoms
Not sharing needles and syringes
Wearing PPE
If HIV+ and pregnant, take medicine

The best way to reduce your risk of getting HIV/AIDS is to change behaviors that increase your risk. Abstinence from sex is the only way to be absolutely sure that you won’t get HIV by having sexual intercourse. A monogamous relationship decreases your risk for contracting HIV from a sexual partner; monogamous means that both you and your sexual partner only have intercourse with one another. The longer that you have been in a monogamous relationship, the lower your risk factor is. If you enter into a monogamous relationship, discuss with your partner if there were partners before you and ask them to get an HIV test. If you are the one that has been in other sexual relationships, you should get tested. As a precaution, you should use a condom for at least six months to protect yourself. Latex or polyurethane condoms not only protect against pregnancy, they prevent transmission of the HIV virus if used properly.

If you are using injectable drugs, get help to stop using them and do not share needles and syringes with others who inject drugs. If you do share needles, disinfect them with a 10% bleach solution before using them.

In healthcare, wear appropriate personal protective equipment (PPE) whenever you could be exposed to blood and body fluids.

If you are HIV positive and become pregnant, you should take the prescribed medications that will prevent passing HIV to your unborn baby and don’t breast feed.1

The ways HIV is NOT spread
False information related to HIV still persists. HIV is NOT spread by:

Touching
Hugging
Kissing
Eating or drinking after an HIV+ person
Blood sucking or biting insects

HIV is not transmitted through casual contact with a person who has HIV. This includes touching, hugging, kissing, eating or drinking after the person. In a health care setting, bathing a person, brushing their hair, feeding them, handling stool or urine, or other routine care does not put you at risk. The myth still persists that HIV can be spread by mosquitoes but studies show that this does not occur. Biting insects actually inject their own saliva into a person to help them feed better.1,8

Healthcare Workers

Healthcare workers are NOT at high risk of contracting HIV in the workplace

Statistics
Types of exposures

Statistics show that even if a healthcare worker has a significant exposure to HIV+ blood &/or body fluids, the chance of the worker becoming HIV+ is less than 0.3%.1 Healthcare workers can be exposed to HIV through injury from a sharp such as a needle or broken glass, through the mucous membranes of the eyes and mouth, or through a cut in the skin. The majority of healthcare workers who have become HIV+ from a work related exposure have been stuck by a needle that has a hole in it and is used for injection purposes. However, blood exposure through the eyes has also resulted in a healthcare worker becoming HIV+.1,9

OSHA

What is OSHA?

Blood borne Pathogen Standard

PPE
Exposure Control Plan
Hepatitis B vaccine
Safety devices

OSHA (Occupational Safety and Health Administration) is a government agency that exists to ensure the safety of workers in the U.S. OSHA not only makes rules, it has the authority to enforce them. OSHA published the Bloodborne Pathogen Standard in 1991 and this requires employers to provide personal protective equipment for workers to wear when using Universal/Standard Precautions. Universal /standard precautions are used because all people should be treated as though they have a disease carried in the blood or a bloodborne pathogen. There are other parts of this standard that will be listed but not discussed—the exposure control plan, a hepatitis B vaccine program and supplying safe devices to be used by employees to prevent exposure to blood and body fluids.9

Cleaning Blood Spills

HIV is a fragile virus outside the human body

Easily killed
Drying
Bleach
Hospital approved disinfectants

HIV is easily killed because it does not live very long outside the human body. Once HIV infected blood that is outside the human body dries, HIV dies. Blood spills must be cleaned and disinfected so clean the area twice--once to remove and clean up the blood and a second time to disinfect the area. This is because the blood can inactivate the ability of the disinfectant to do its job of disinfecting. HIV can easily be killed by using a 10% solution of bleach. This means that you mix one part bleach to ten parts of water. A cleaner that has been approved by the FDA (Food and Drug Administration) as a hospital approved disinfectant can also be used to clean up a blood spill but the area still has to be cleaned twice.1,9

TREATMENT

There are many different medications available.

Effectiveness
Types
Actions
Side-effects

Although there are many different drugs available to treat HIV, THERE IS NO CURE. Neither is there a vaccine. Over the years, it has been found that the people that have the best results using medications to treat HIV are those who start on them early in the course of the disease. So, if you think that you have had an HIV exposure, get tested and seek treatment. The drugs for HIV are anti retrovirals which means that these medications work against virus that attack in the same manner as HIV. These drugs have long names like Nucleoside Reverse Transcriptase Inhibitors because they are named by where they stop the virus from entering the cell. There are numerous side-effects from these drugs just like with chemotherapy drugs such nausea, diarrhea, changes in blood tests and rash. Treatment of AIDS depends on which of the AIDS conditions develops.1

EMOTIONAL SUPPORT

Persons who are diagnosed with HIV/AIDS need a lot of emotional support and experience a barrage of emotions.

Healthcare workers must be aware of their own feelings and provide the necessary care for these patients.

Although great strides have been made in the treatment of HIV, to be given that diagnosis still is life shattering. There is no cure and treatment is lifelong and causes a lot of physical symptoms. Sometimes the physical symptoms are easier to deal with than the feelings of depression, rejection, hopelessness and anger that accompany the diagnosis. Think of how you feel when you are told that a patient has HIV or AIDS. Do you feel scared? Do you avoid going near the patient or ask others to give care? Are you repulsed and judgmental of how the person got the disease? Whatever emotions you are dealing with, the patient has probably experienced them also. Our job as healthcare providers is to meet the needs of the patient while protecting ourselves. Remember, you don’t get HIV from touching, talking or just being near an HIV positive person. BE compassionate and supportive. If you find you have difficulty giving care, talk with your supervisor and seek help in dealing with your issues.1

LEGAL ISSUES

PERSONS WITH HIV ARE PROTECTED BY THE AMERICANS with DISABILITIES ACT

FLORIDA LAW PROHIBITS RELAESE OF HIV INFORMATION WITHOUT SPECIFIC CONSENT

The Americans with Disabilities Act protects discrimination against any person considered to have a condition that severe limits their life activities. Persons with HIV and AIDS can not be discriminated against including not being hired or being fired because of their condition. Employers are not allowed to ask if a person has HIV as part of the hiring process. Insurance companies are permitted to ask this question.

In Florida, if you as a healthcare worker tell anyone who does not have a need to know that a person is HIV positive, you can not only lose your license to practice, you can be fined and imprisoned.1

SUMMARY

HIV attacks the immune system and results in AIDS when specific diseases develop.
HIV/AIDS is a worldwide problem.
HIV is transmitted by blood and body fluids through sex, sharing needles and syringes, and from mothers to their babies.
Changing behaviors can decrease your risk of getting HIV.
There is no cure and no vaccine for HIV but there are effective drugs to control it.
Healthcare workers must use PPE to protect themselves from getting HIV.
There are numerous emotions involved in having and caring for HIV patients as well as legal issues.

To summarize, the highlights about HIV and AIDS are listed on this slide.

REFERENCES

Holman JS, Ebener MK, McCarty V. HIV/AIDS update 2005-2006 edition. AKH Inc.
Shank SL. HIV/AIDS: Essentials. Course #3015. National Center of Continuing Education, Inc.
Rote NS, Huether SU, McCance KL. Hypersensitivities, infection, and immunodeficiencies. In Huether SE, McCance KL, eds. Understanding Pathophysiology . St. Louis, MO:Mosby;2000:210-212.
Centers for Disease Control and Prevention. Where did hiv come from? Available at: http://www.cdc.gov/hiv/resources/qa Accessed November 26, 2006.
Centers for Disease Control and Prevention. Basic statistics. Available at http://www.cdc.gov/hiv/topics/surveillance. Accessed November 26, 2006.
Avert. Worldwide hiv & aids statistics. Available at http://www.avert.org/worldstats.htm Accessed November 26, 2006.
The Kaiser Family Foundation. Hiv/aids policy fact sheet the global hiv/aids epidemic. Menlo Park, CA;2006.
Centers for Disease Control and Prevention. Hiv and its transmission. Available at http://www.cdc.gov/hiv/resources/factsheets/transmission.htm Accessed November 12, 2006
McCarty V. OSHA regulations for bloodborne pathogens and tuberculosis. 2006. AKH Inc.

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INFECTION CONTROL: Practices to prevent and control the spread of bacteria

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

Infection Control is extremely important for preventing and controlling infections. The emphasis of this program is on long term care facilities. We as healthcare workers must recognize where infections come from and how we can prevent them in both our patients and ourselves.

At the completion of this course, the participant will be able to:

Discuss the significance of infections for long term care facilities. I think most of us are well aware that there has been an increased need for long term care facilities and changes in the population are certainly driving that need.
State the risk factors in the elderly related to developing infections. Often people will state that the elderly are at risk for infection but there are changes over which they have no control and those changes do place them at risk..
Describe the types of infections that occur in a long term care facility. There are certain infections that the residents if long term care most often develop.
List the elements necessary for an infection to occur. Just because someone has an infection does not mean that they are contagious or that the disease will spread; there are six basic factors that must be present for an infection to occur. If one of these factors is missing, infection will not take place.
Summarize the ways to prevent infections. There are practices that can be used to both stop infections from occurring and/or prevent them from spreading to others.

Software Requirements:

Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

INFECTION CONTROL:
Practices to prevent and control
the spread of bacteria

Population of Long term Care

Elderly population is growing rapidly

Age of the elderly
Predictions of increases
Impact on long term care facilities
Financial estimates

The elderly population is growing rapidly. Currently, the elderly population is composed of those persons between the ages of 65 and 80 years of age. In 2000, there were about 34 million people in the United States who were over 65 years of age.1 That number is expected to double by 2030. Of this population, it is estimated that around 43% of them will require care in a long term care facility but not necessarily become permanent residents.1, 2 However, the number of the population who will become residents of long term care facilities is estimated to rise from the current 1.5 million people to 5 million by 2030. 1,2

The cost of health care increased by 41% between 1960—2000. In an effort to reduce rising healthcare costs over the last twenty years, the health care system in the United States has changed to reflect decreasing numbers of acute care hospitals and major growth in long term care facilities. By reducing the length of stay in acute care facilities, patients in long term care facilities are more ill than they used to be. 3 Adding to the cost of care is the number of infections that develop requiring various medications such as antibiotics.

INCIDENCE

Number of infections per facility
Difference among facilities
Statistics
Estimates of the number of infections.

The incidence of infections or how often an infection occurs in long term care facilities is usually based on the number of patient-care days. The average for infections in long term care facilities is around 4 infections per 1000 patient care days.1 Overall infection rates vary among facilities due to differences in patient populations. Infection rates also vary depending on the level of care that is provided in facilities. Some facilities provide care for patients on ventilators which may result in higher numbers of respiratory infections than those who do not provide that care. Although the majority of long term care facilities have elderly patients, there are facilities who care for younger persons suffering from various conditions. Statistics for patients over 65 years of age show that 3-15% of them will develop an infection. Based on the recent estimated number of persons in long term care facilities, approximately 150,00 and 750,000 people will contract an infection. 3

AGING and INFECTION

Specific changes occur as we age

Immune system
Skin
GI tract
Urinary tract
Upper airway

As we age, there are numerous physiologic changes that occur and some of them make the elderly more susceptible to both developing and fighting off infections. The immune system is responsible for stimulating responses in our body to produce antibodies and specific types of cells that fight bacteria and prevent infection from invading our bodies.

In the elderly, this system fails to function as effectively as it did at an earlier age. The skin loses its ability to stretch and becomes thin and easily tears. Elderly people have less acid produced in their stomach which increases the amount of bacteria that can grow. Digestion is slower due to decrease in the mobility or the ability to move the food through the gastrointestinal tract. In men, the prostate enlarges and, in women, more bacteria grows in the vaginal urethral area. Finally, there is a diminished cough reflex and therefore a decrease in the ability to clear the throat and back of the mouth of mucous and bacteria that grows there.2,4

Additional Risk factors

Chronic conditions
Medications
Indwelling devices
Increase in acuity of illness
Decreased mental status

Besides the risk factors due to physical changes from aging, other factors increase the risk of residents in long term care developing infections. Many of the residents have chronic illnesses such as diabetes, problems with bowel and bladder control, and decreased circulation to their extremities. All these conditions place them at risk for developing pressure sores that can become infected. Medication such as steroids decrease the patient’s ability to fight off infections.

Devices such as catheters and feeding tubes provide a direct route for bacteria to enter the body. Today, patients are transferred from hospitals to long term care facilities in a more acute state due in part to changes in reimbursement. A decrease in the mental status of a patient places them at higher risk for aspirating while eating and causing pneumonia. 4

Cycle of Infection

In order for an infection to occur, there are specific factors are required. First of all, an infectious agent meaning something such as a particular virus or bacteria that can cause infection must be present. Two examples of commonly occurring infectious agents are the Herpes virus that causes cold sores and the fungus that causes athlete’s foot . Using these two examples, let’s move through the cycle.

Reservoirs can be people, animals and things. In this case, I have either a cold sore or athlete’s foot; my lip (for the cold sore) and my foot (for the athlete’s foot) are the reservoirs of infection or the places where the infection is growing. The cold sore is a blister and may even be leaking a little fluid and my feet have cracks on them. In both instances, the virus is being released from my body; this is termed the portal of exit. Next in the chain is the mode of transmission which means the infectious agent is passed from me to another person. This can occur through kissing or sharing a chapstick with another person and thereby passing the herpes virus to them. The fungus from my feet can be passed to another person through commonly used shower stall or implements used for a pedicure. In order for another person to become infected with either of these diseases, there must be a portal of entry on the other person’s body such as a crack in their skin on their lips, hands or feet or through the mucous membrane that lines the lips.

The final element needed for infection to be passed along is a susceptible host. This means that the exposed individual must not be immune to the disease. Some people have a natural immunity which means that for some reason they do not contract a particular disease no matter how many times they are exposed to it. Other diseases such as measles or chickenpox have vaccines which produce immunity. Once the disease is contracted by another person, the cycle continues. 6, 7

TYPES of INFECTIONS

Shingles
Tuberculosis
Skin breakdown
Gastroenteritis
Urinary tract infections
Pneumonia
Influenza

We’ve talked about the physiologic changes that occur in the elderly. Now let’s look at how those changes provide a basis for the infection that are commonly seen in long term care facilities. Because the immune system does not function as well, elderly persons generally develop more severe and longer lasting infections. Some infections such as shingles and tuberculosis can be reactivated due to the decrease in the functioning of the immune system. Skin conditions such as cellulitis and skin break down or delayed healing of a cut or wound occurs related to the thinning of the skin. Intact skin is the first line of defense against bacteria gaining access to the body. When the skin is broken or torn, bacteria can easily gain access and create infection. Decrease in stomach acid allows bacteria to grow more readily and enables bacteria such as salmonella to cause gastroenteritis. Malnutrition can result fro digestive problems and although it is not an infection, it inhibits the healing process. Urinary tract infections are promoted due to urinary retention and the increase in bacterial growth in the vaginal-urethral area. Pneumonia occurs due to the decrease in the ability to mobilizes secretions and clear mucous. Again, due to the diminished response of the immune system, elderly are more susceptible to influenza due to a decreased antibody response even if the vaccine is given. 2,4,5

BREAKING the CYCLE

Eliminate one of the required elements and the cycle stops.

Infectious agent
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Susceptible host

To stop infections from spreading, it is necessary to eliminate one or more of the required elements in the cycle of infection. Several of the elements can be eliminated through the same means. Some infectious agents can be removed through effective vaccination—the infectious disease of smallpox has been eliminated and vaccination against numerous diseases eliminates susceptible hosts. 8 Remember, reservoirs can be persons, animals or things. Sometimes the reservoir is eliminated through its death such as a rabid dog.

The reservoir can also be eliminated by the disease being treated or the course of illness resolving and the person is no longer infected. An example of this would be tuberculosis or the flu. Portals of exit and entry can be eliminated by good skin care, covering your mouth when you cough, and following guidelines related to good hygiene and food handling. In healthcare, the mode of transmission is perhaps the most important element to eliminate and we are going to spend most of our remaining time discussing how to do it.

PREVENTION

Interrupting the cycle of infection
Depends on the route through which the infectious agent is spread
HANDWASHING

In the cycle of infection, preventing the transmission or passing the infectious agent from one person to another is a vital role for healthcare workers. Some disease are passed from one person to another by coughing or sneezing. Others are passed along through touching a person’s skin or using a comb or brush. Another route of transmission is secretions or bodily fluids. No matter which of these routes transmits the disease, HANDWASHING is absolutely necessary.

According to the U.S. Centers for Disease Control and Prevention (CDC), and the Association of Practitioners in Infection Control, handwashing is the most significant procedure to reduce the spread of disease but compliance among healthcare workers is very poor. 9,10

HANDWASHING

To effectively wash your hands, you need the following:

Running water
Soap
Friction applied for 15-20 seconds
Drying the hands

Handwashing is a simple procedure that requires certain components to be done effectively. Obviously, running water is necessary and hands must first be wet before applying soap. The soap does not need to be antibacterial. After applying the soap, rubbing your hands together vigorously will dislodge any bacteria that may be on your hands. During this time, you should scrub all ten fingers, palms, and the backs of your hands including the beginning of your wrist. A lot of people seem to have a problem in determining 15-20 seconds, so I’m offering you a fun way to establish the correct amount of time to scrub. You can sing the song, “Yankee Doodle Dandy” from the beginning up until the line that ends with “born on the fourth of July” and you will have washed long enough. Next, rinse your hands under the running water and then dry them. 11

Handwashing

Before and after eating
Using the restroom
Patient contact
Soiled items
Visibly dirty

Most of us know when to wash our hands but let’s just review—before and after eating; anytime you use the restroom; all patient contact such as turning a patient or holding onto them to assist them to ambulate; anytime a soiled item is touched such as linen, trash, or garbage. Basically, good hygiene practices should prevail and anytime your hands are visibly soiled, they need to be washed. Patients need to be instructed in good handwashing practices also and the same procedure and times apply everyone. When you wear gloves, remember this important rule: WEARING GLOVES DOES NOT MEAN THAT YOU DON”T HAVE TO WASH YOUR HANDS! 11

Alcohol Hand Rubs

Centers for Disease Control and Prevention (CDC) Guidelines
Centers for Medicare and Medicaid (CMS).

In October, 2002, CDC released guidelines related to the use of alcohol based hand rub products. Basically, the ruling states that a 70% alcohol based hand rub can be used unless hands are visibly soiled. These should be used as an adjunct to soap and water and not in place of them. It is recommended that hands be washed with soap and water every 10 times when using the alcohol product. Fire regulations initially prevented the mounting of containers of alcohol rub products outside patient’s rooms, but a final rule was passed in September, 2005 allowing wall mounting of such containers in egress hallways. There are specific regulations that must be followed as to hallway widths, etc. The advantage of being able to wall mount such containers is they are readily accessible and their visibility seems to encourage handwashing. 12,13

FOOD SERVICE

Proper temperatures
Prompt eating
Bacteria

Food preparation is not a function that healthcare workers are generally involved in, but making sure that the food is served at the proper temperature is. Food is prepared to achieve a specific temperature and is to be maintained at a specific temperature until eaten. For residents who eat in the dining hall, maintaining the temperature is accomplished through various means. When patients are bedridden, trays of food are delivered by means of a system that maintains the appropriate temperature.

Your responsibility is to have the patient ready and able to eat prior to removing the tray from the mechanism that is providing temperature control. Once the tray is removed from the temperature controlled device, don’t let the food sit at the patient’s bedside or bacteria will grow and intestinal illness can result. Due to medications and physiologic changes, the elderly are at higher risk of contracting such illnesses.

Handling Linen

NEVER carry linen against your body
Don’t take linen from one patient to another
Don’t throw linen on the floor
Don’t “fan” the sheets
Place soiled linen in a bag

Linen can be a source of infection and must be handled carefully. Whether linen is clean or dirty, never carry it up against your body. Never carry linen in and out of different patient’s rooms. Soiled line should not be thrown on the floor.

Place soiled linen in a hamper or bag or whatever means is provided by your facility. In some facilities, if linen is wet, it must be placed in a plastic bag—check the policy for your facility. When changing bed linens, don’t fan the sheets as this causes air currents that can spread microorganisms or “germs”. Bagged soiled linen should be kept in a specific area until it is collected to be washed. Depending on the company that washes the linen, isolation linen may have to be specially labeled. Again, check on the policy for the facility in which you work.

Protecting Yourself

Gloves
Gowns
Masks
Goggles

As all of us perform our various jobs related to caring for our patients, we need to protect ourselves from being exposed to infectious agents. Whether you wear gown, gloves, mask, and/or goggles depends on the type of contact you are going to have with the patient. If you are changing soiled bed linen, you will need both a gown and gloves. Gloves protect your hands and the gown prevents contact with your clothing and arms.

If you have a patient in isolation for MRSA, you should be wearing gown, glove, and mask if bed bathing the patient or changing bed linen. Depending on procedures that may be performed in your facility such as suctioning, you may need to wear goggles to prevent splashes to your eyes. 14

Bloodborne Pathogens

Hepatitis B
Hepatitis C
HIV (Human Immunodeficiency Virus)

Different diseases are contracted through different methods of exposure. Healthcare workers are at risk of contracting some specific diseases that are transmitted through the blood or body fluids. The Occupational Safety and Health Administration (OSHA) developed specific regulations to protect healthcare workers from being exposed to the diseases of Hepatitis B, Hepatitis C, and HIV for which they are at higher risk than other occupations. These regulations are referred to as the Bloodborne Pathogen Standard. 14

OSHA RULES

Personal protective equipment
Exposure control plan
Hepatitis B vaccine

The OSHA regulations state that your employer must provide personal protective equipment including gowns, gloves, masks and goggles for employees who through their job may be exposed to blood and body fluids. Sizes of these items must be appropriate for the person using them. The gloves must be made of latex or non-latex products but may not be vinyl. Gowns should not permit the blood or body fluids to penetrate the gowns.

Any and all employees who are at risk of exposure through the job they perform must be identified through an Exposure Control Plan. The plan must also state what happens if an exposure does occur. The process must include an evaluation to determine the level of exposure, and, if indicated, follow-up must be provided including bloodwork ,medication, and counseling. Additionally, all employees must be offered the hepatitis B vaccine. If you don’t want it, you can not be forced to take it but you must sign a paper saying you are refusing it at this time. You can always change your mind and have your employer give it to you. There is no vaccine for hepatitis C or HIV. The only protection available for a work setting is the use of personal protective equipment.

Employers must not only provide the equipment, they must enforce policies requiring employees to use it. Failure to use these protective items may result in a loss of job. You must know what the policies are for your facility. 14

HIV

HIV is NOT transmitted through causal contact such as touching or hugging.

HIV exposure in a work setting occurs from blood or specific body fluids

Exposure can only occur if the patient has HIV

Healthcare workers are at greater risk of contracting Hepatitis B than HIV

Healthcare personnel are appropriately concerned about being exposed to HIV since there is neither a vaccine or a cure for this disease. The primary means of transmission of HIV is having unprotected sexual intercourse with a person who has HIV. For healthcare workers, risk of HIV exposure is through blood or specific body fluids. These body fluids include semen, vaginal secretions, pleural fluid, pericardial fluid, cerebrospinal fluid, amniotic fluid, synovial fluid, peritoneal fluid and any body fluid with VISIBLE blood in it. HIV is not transmitted through saliva, sputum, urine, stool, sweat, nasal secretions, or tears UNLESS there is VISIBLE blood in it. Remember that you can only receive an exposure if the patient has the disease and you have a significant exposure. Contact with a patient who has HIV does not expose you through casual contact such as touching or bathing the patient or even hugging the patient. No isolation is required for patients with HIV or Hepatitis B. UNIVERSAL/STANDARD Precautions must be used. Remember, these precautions are used for ALL patients whether we know they have the disease or not. In a work setting, even healthcare workers who are exposed only have a 0.3% of becoming infected. Without the hepatitis B vaccine, chances of contracting Hepatitis after an exposure are around 30%. 15

STANDARD PRECAUTIONS

Standard Precautions include Universal Precautions which are mandated by the OSHA Bloodborne Pathogen Standard.

Standard/Universal Precautions are for ALL patients and apply to the handling of Blood and body fluids that can transmit HIV and Hepatitis B or C.

Additionally, with Standard Precautions, ALL body fluids are considered to be infectious.

Under the OSHA Bloodborne Pathogens Standard, all healthcare workers are mandated to follow Universal Precautions. This means that ALL patients are regarded as having the bloodborne diseases of HIV and Hepatitis B and Hepatitis C. Universal Precautions were combined with a system called Body System Isolation providing for the use of personal protective equipment not only for blood and body fluids related to HIV and hepatitis but for ALL body fluids. Thus Standard Precautions came into play and are recommended by CDC to prevent transmission of diseases. In other words, under Universal Precautions, if urine has visible blood in it, personal protective equipment should be worn; under Standard Precautions, such garb is used for handling All urine whether there is blood visible in it or not. 14

CLEANING BLOOD SPILLS

MUST BE “DOUBLE CLEANED”
The presence of blood can inactivate the ability of cleaning products to disinfect
Wipe up the blood FIRST
CLEAN the spill up using the approved product for your facility.
Apply the approved disinfectant to the contaminated area to DISINFECT it.

If blood is to be cleaned up, it must be cleaned prior to disinfecting the area. Blood can inactivate the disinfecting properties of products and so the amount of blood must be cleaned up first. Paper towels can be used and discarded in a hazardous waste container. Next, clean the area either with soap & water or an approved disinfectant. Apply the disinfectant again to disinfect ithe area. Be certain to use the product that is approved by your facility. A 10% solution of bleach can be used as a disinfectant, but remember that bleach is a strong chemical and can cause skin irritation and holes in clothing due to splashes. The bleach solution must be poured out and mixed new every 24 hours in order to maintain potency. All cleaning solutions that are mixed in a secondary container must be labeled and dated.

A secondary container means that the container is not the original container the product is distributed or bought in. HIV is a fragile virus and is easily killed outside the body including dryng. Hepatitis is a much hardier virus and lives a much longer time outside the human body than HIV. 14,15

HANDLING NEEDLES & SHARPS

Needles shall not be bent, broken, or removed
NEVER recap a needle by pushing the cap over the needle
Discard needles in a puncture resistant container
Broken glass

Most healthcare workers who have been exposed to HIV and hepatitis have been injured by a needle or other sharp item that was contaminated with infected blood. OSHA has specific rules that prohibit needles from being bent, broken or removed from the syringe or tubing to which they are attached. Needles may not be recapped once the protective cap is removed from the needle unless absolutely necessary and then, a one hand technique must be used. The one hand technique requires sliding the needle back into the cap while the cap is not being held (it can be laying on a bedside table). Special containers that can’t be punctured by sharp objects must be used to throw away used needles and syringes. If glass that is contaminated with blood or body fluids is broken, a dustpan and brush must be used to pick up all broken pieces before cleaning up the blood and the fluid.14

WASTE HANDLING

Special bags
Biohazardous Waste Emblem
Storage
Disposal

OSHA also regulates the handling of any and all contaminated trash. Trash that has blood and body fluids must be discarded in trash bags that are a specific thickness and color and must have the biohazardous waste emblem on the outside of the bag (see next slide). If the trash is kept in a area prior to being picked up by a designated biohazardous waste handler, the area of storage must be locked and the international label must be on the outside of the access door. Special regulations have been established for companies who haul away biohazardous waste. 14

Required Emblem

This is the biohazardous waste emblem that is required by OSHA to be placed on all waste that is considered contaminated with blood and body fluids. It must also be on the outside door for any and all areas in which any such contaminated trash or linen is stored until being picked up for disposal. 14

ISOLATION

Type depends on how the disease is spread---cycle must be broken

Airborne
Droplet Precautions
Contact

Isolation of persons with specific diseases prevents the passing of the disease from one person to another thereby taking the step of transmission out of the cycle of infection. For example, tuberculosis is spread by a person coughing and another person breathing in the contaminated air. Tuberculosis requires Airborne isolation including special masks and rooms with special ventilation to prevent it from spreading in facilities.

Most long term care facilities do not have these types of rooms and the patients are transferred to acute care facilities. Other diseases such as meningitis are spread through the tiny droplets of moisture in the exhaled air from the ill person to another person within 3 feet of them.

Droplet precautions require a mask but no special ventilation to prevent the spread of disease.

Contact isolation is used to prevent spreading disease after coming in contact with a person who has the disease such as diarrhea caused by an infectious organism, shingles, MRSA (Methicillin Resistant Staph Aureus),VRE (Vancomycin Resistant Enterrococcus) and C. Difficile (Clostridium difficile which causes foul smelling diarrhea). Having contact with the person or soiled bed linen saturated with liquid stool from that person, or drainage from a wound or infected sore, and then not washing your hands will spread the disease. Wearing gown, gloves and even a mask prevents your skin from being contaminated by the organism that causes the disease.

HANDWASHING must be done after gloves are removed. 16 It is important to remember that with these isolations we are isolating the DISEASE and not the patient. These patients need to feel cared for and communicated with probably more than thry normally would.

SUMMARY

The elderly are at increased risk for infection
We can prevent the spread of infection by stopping the cycle
HANDWASHING is the most important prevention component
Healthcare workers need to follow OSHA guidelines to protect themselves
Isolation may be needed for specific diseases
Know and follow your facility policies

As healthcare workers in long term care facilities, an important fact to remember is that the elderly are at increased risk for infection due largely to physiologic changes that occur as we age. However, we can stop the spread of infection by eliminating one of the six factors necessary to cause infection—the “germ”, the reservoir where the infection is growing, either the portal of exit or the portal of entrance, method to transfer the “germ” from one person to another or a susceptible host. To prevent transfer of germs from one person to another, handwashing is vital and must be done with running water, soap, fifteen-twenty seconds of friction applied to the hands, and drying the hands—don’t forget to sing “Yankee Doodle Dandy.”

OSHA has established guidelines that when properly used will protect healthcare workers from contracting bloodborne pathogens at work. These precautions address personal protective gear and are primarily related to Hepatitis B and C and HIV. Universal/Standard precautions must be used for ALL patients regardless of their disease. Specific diseases require additional isolation precautions. It is your responsibility to know and follow the policies of the facility in which you work. Only by following the rules and breaking the chain of infection can we prevent the spread of infections both for our patients and for ourselves.

REFERENCES
Bentley, D., Bradley, S., High, K., etc. 2000. Practice guidelines for evaluation of fever and infection in long-term care facilities. Retrieved 10/24/06 from http://www.journals.uchicago.edu/CID/journal/issues/v31n3/000710/000710.text.html
Nicolle,L.E., Strausbaugh, L.J., and Garibaldi, R.A. Infections and antibiotic resistance in nursing homes. Clinical Microbiology Reviews. 1996, p1-17.
Jarvis, W. Infection control and changing health-care delivery systems. Emerging Infectious Diseases. 2001;7(2):170-173.
Smith, P.W., Rusnak, P.G. Infection prevention and control in the long-term-care facility. American Journal of Infection Control 1997;25:448-512.
Nicolle, L.E. Infection control in long-term care facilities. Clinical Infectious Diseases. 2000;31:752-756.
NHS Education for Scotland (NES). Infection for nursing students. Chain of infection: diagram & explanation. Retrieved 10/24/06 from www.nes.scot.nhs.uk
Rhoton, B. Handwashing…basic infection control. Retrieved 10/19/2006 from http://www.nusc.edu/catalyst/1997/col12-19handwashing.htm
Centers for Diseases Control and Prevention. Smallpox fact sheet. Retrieved 10/26/06 http://www.bt.cdc.gov/agent/smallpox/overview/disease-facts.asp
Centers for Disease Control and Prevention. Stopping the spread of germs at work. Retrieved 10/15/06 from www.cdc.gov/flu
Larson, E. APIC guideline for handwashing and hand asepsis in health care settings. American Journal of Infection Control 1995; 4:251-169.
Centers for Disease Control and Prevention. OPRP-handwashing guidelines. Retrieved 10/26/06 from http://www.cdc.gov/nceh/vsp/cruieslines/handwashing_guidelines.htm
Centers for Disease Control and Prevention. Hand hygiene guidelines fact sheet. Retrieved 10/19/06 from http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm
Department of Health and Human Services. Centers for Medicare & Medicaid. Final rule. Federal Register 2006;71(184):55327-55329.
U.S, Department of Labor Occupational Safety and Health Administration (OSHA). Regulations (standards-29cfr) bloodborne pathogens—1910.1030. Retrieved 11/07/06 from http://www.osha.gov
Holman, J., Ebener, M.K., McCarty, V. HIV/AIDS update AKH Inc. 2005.
Garner, J.S. and the Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals . Infection Control Hospital Epidemiology 1996; 17:53-80 and American Journal of Infection Control 1996;24:24-52.

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NUTRITION in the ELDERLY: Providing Nutritional Diets & Proper Food Handling in Long Term & Assisted

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

Nutrition in the elderly is challenging. Personnel in long term and assisted living care facilities must know what the nutrition requirements are for the elderly and how to meet these requirements for them. Proper handling of food is vital to prevent food borne illnesses that can interfere with proper nutrition.

At the completion of this course, the participant will be able to:

State the nutritional needs of the elderly. As we age, our nutritional requirements change necessitating dietary adjustments.
Describe the physical changes that occur in the elderly that affect their nutritional needs. After we identify the changes that occur, we will look at how each of these changes impacts nutrition.
List the various problems that interfere with providing nutritional diets to the elderly. Besides the changes that occur involving the functioning of the body, there are social, financial, and psychological changes that lead to insufficient nutrition. A lot of these changes cannot be controlled.
Discuss ways to overcome obstacles to the nutritional needs of the elderly.
Explain the proper way to handle food to prevent causing illness. If food is not stored, prepared and served properly, illnesses can result.

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Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

NUTRITION in the ELDERLY:
Providing Nutritional Diets & Proper Food Handling in Long Term & Assisted

Nutritional Needs in the Elderly

Caloric intake
Meat, fish, and other proteins
Breads, pasta and other carbohydrates
Fats

Fewer calories are needed as we age starting from around age 35. The changes in the needed calories depend on each person but usually must be reduced by 5-20% between the ages of 35 to 70. People over age 70 have specific nutrient needs but fewer calories are required. As with any other periods of time in our lives, too many calories will result in being overweight and can induce health problems. Obviously, if weight loss is a problem, caloric intake needs to be increased rather than decreased. Aging does not change the recommended number of servings per day for proteins, carbohydrates or fats. Proteins include meat, poultry, fish, cheese, and legumes such as beans and nuts. Carbohydrates are provided through bread, cereal, and pastas. Fats, of course, are oils, butter, margarine and are also part of the meat and dairy products that are eaten. To meet the needs for these requirements and at the same time reduce calories lean meats, whole grain bread, and lower fat dairy products should be eaten. Sweets must also be limited.1

Nutritional Needs in the Elderly Continued

Vitamins
Minerals
Fluid
Fiber

The need for vitamins and minerals do not decrease as we age but, in fact, increase. The elderly need more calcium, iron, complex vitamin B and zinc than they previously required. Many elderly do not drink enough fluids.

Recommendations are that elderly people need at least 8 glasses of water a day not including coffee, tea or other types of beverages. Drinks with caffeine such as coffee and tea are diuretics and cause water to be pulled from the body and eliminated. Water intake is extremely important along with fiber to aid in proper elimination and prevent constipation. Fiber can be provided through whole grains such as wheat bread and fresh vegetables and fruits and nuts.1 Fiber supplements may also be included in the diet.

Reasons for the Nutritional Needs for the Elderly

Bone density

Bone density decreases with aging especially in women after menopause. This condition is called osteoporosis. Bone density is the amount of bone tissue in a certain amount of bone. The actual strength of the bone is determined by its density. Loss of bone density increases the chance of fracturing bones and can cause the spine to compress (this is why a lot of the elderly appear to have either a hump on their back or seem stooped over). The compression can be so severe as to cause a loss of height. These changes can also make it more difficult to breathe and create pressure on the stomach and intestinal tract.

Above shows a picture of two very different bone density images. The one on the right has a lot of dark areas signifying places where bone no longer exists. This person would be at much higher risk for breaking a bone than the person with the bone image on the left. Hip fractures are a greater risk when bone density is poor, making the need to prevent falls again crucial. A diet high in calcium helps to protect against these bone changes.

Reasons for the Nutritional Needs for the Elderly

Intestinal function
Effect on healing
Eyesight

The GI tract of the older adult is slower both in moving the food through the tract and in digestion of the food. A lot less secretions to aid in digestion are produced. To counteract these effects, water intake and foods high in fiber are required. If laxatives are relied on to keep bowel function normal, absorption of nutrients is diminished.

Wound healing is slower if there is inadequate nutrition. Besides protein and carbohydrates, vitamin K and the mineral zinc are needed for the body to heal wounds. Macular degeneration is another age associated bodily change. To slow the onset of this change, a wide variety of nutrients are necessary including zinc, vitamin C, E, beta-carotene, zeaxanthin and lutein.2

Reasons for the Nutritional Needs for the Elderly continued

Taste
Memory
Hearing
Chronic conditions

If the sense of taste is diminished, zinc helps to improve it. Vitamin B12 is implicated in preventing memory loss and hearing loss that occurs with aging. Vitamin B12 absorption decreases with aging. As a result, foods rich in vitamin B12 must be eaten regularly. Vitamin E may be a deterrent to Alzheimer’s if it is obtained through diet and not supplements. Chronic conditions such as hypertension, heart disease, renal disease, and diabetes present challenges to providing for nutritional needs in the shadow of dietary restrictions.2

Obstacles to Elderly Nutrition

Limitations due to aging
Medical conditions
Lifestyle changes

Providing good nutritional meals for our elderly population does not appear to be especially difficult until we look closer. The physical changes that occur in the elderly present challenges to meeting their nutritional needs. These changes result in a decreased ability to be able to chew foods including many of those that are recommended such as nuts, fresh fruits, vegetables and meats.

Medical conditions such as diabetes, high blood pressure, and kidney disease require special dietary restrictions and can result in failure to meet nutritional needs. Many elderly are faced with extreme changes in their lifestyle such as becoming a resident in a long term care facility. Although mentally they may understand the necessity of such a decision, the loss of independence can be difficult to accept and may have occurred as the result of the death of their life long mate or other loved one. Feelings of isolation, uselessness, depression, and even a foreboding of death will all prevent them from eating.2,3

FACTORS AFFECTING ELDERLY NUTRITION

Changes in sense of taste and smell
Visual changes
Difficulty chewing
Changes in the GI tract
Lack of money
Loneliness
Medications

There are a variety of factors that impact nutrition for the elderly. One of the physiologic changes is a decreased ability to experience certain tastes and to appreciate the aroma of food. The ability to see clearly and accurately decreases with aging so food not only doesn’t smell and taste as good, but it doesn’t look as good either. Tooth loss, gum disease, and ill fitting dentures all result in a difficulty to chew a lot of different foods and further interfere with enjoying the taste of the food. Two additional processes that tend to decrease nutritional health are a decrease in stomach acid and a slowing of the movement of food through the gastrointestinal (GI) tract. Aside from these physical changes, a lack of money may cause the elderly to have to buy cuts of meat that aren’t as tender or to purchase other cheaper but less nutritious items.

A factor that is often overlooked is loneliness. Eating is generally a social function during life and when lifetime partners or others are no longer there to enjoy dining with, there is a lower interest in eating. Another cause that may be overlooked are the effects that various medications have on the appetite and their decrease of different senses. Additionally, an elderly person will have a lifetime of beliefs concerning what foods they can and can’t eat due to what may cause a “sour stomach” or various other discomforts.2,3

Meeting nutritional needs

Lower Fat
Lower sugar
Increased fiber
Water

To meet the reduced caloric needs of the elderly while providing the necessary protein, reduced fat dairy products and lean cuts of meat should be provided. Complex carbohydrates such as whole grain bread and pasta should be provided instead of white bread and foods high in sugar. Whole grains will serve a dual purpose by increasing fiber that is needed to help maintain bowel function. Fiber can be provided through vegetables, fruits, cereals, and nuts.

Remember… 8 full glasses (8 ounces each) are recommended as a daily requirement and should not include coffee, tea, cola, etc. A decreased thirst sensation is not uncommon as we continue to age, so being aware of water intake is a function that you as a CNA can and should monitor. Fiber and water help to prevent constipation to which the elderly are prone. 1,2,3

Food Selection

Foods need to be rich in nutrients
- Calcium
- Iron
- Vitamin D
- Zinc
- Vitamin B12
- Vitamin E
- Vitamin C

By selecting foods that provide more than one dietary requirement, nutritional needs can be more easily met. Selecting low fat dairy products and lean red meats not only provides protein, but also provides calcium and iron. For residents of long term care facilities (as with anyone else who does not get consistent exposure to sunlight), milk fortified with Vitamin D is a must. We’ve already discussed the importance of zinc for the elderly but the daily requirement is only 15 mg/day. This can be obtained through a vitamin supplement but is also provided by eating a variety of foods including seafood, meats and eggs.

Vitamin B12 is also provided through meats, chicken, seafood and eggs whereas Vitamin E is obtained from whole grains, nuts, seeds and vegetable oil. Vitamin C & E, zinc, and the nutrients needed to slow the eye changes related to aging are all provided by eating at least five servings of fruits and vegetables that are dark green, orange, or yellow.1,2,4

Overcoming Obstacles

Variety
Softer foods
Color
Texture
Portion size
Special diets

If mealtime is boring and the food is not appetizing, important nutrients will be missed. Elderly people can readily get stuck in a pattern of what they eat and, like all of us, resist change. If they are used to having stewed chicken and mashed potatoes for supper, don’t try to change everything all at once.

Try adding a new food but still include smaller portions of the food they are used to eating. Make the change gradual. Fresh fruits and vegetables provide the best amounts of nutrients but remember that many elderly people have chewing problems and it may be necessary to soften these items through steaming or even pureeing them. They should be softened only as much as required—pureed peas aren’t appetizing looking. Select foods of different colors and textures to make the meal more appealing. Mix foods that should be served cold with ones that are served warm. Smaller portion sizes at actual mealtimes with healthy snacks in between should be considered if not much is being eaten at meal time.

As already mentioned, medical conditions can require dietary limitations especially of salt and sugar. Alternative flavorings should be tried such as lemon and milder spices that do not contain sodium. Don’t forget to have the dietician involved and talk with residents to discuss solutions to providing nutrition.2

Aids to Eating

~ Activity ~
~ Socialization ~
~ Medication changes ~

The elderly are no different than anyone else in that decreased activity generally results in decreased appetite. Even a slight increase in activity such as a short walk in the hall can be beneficial from both a physical and nutritional perspective. For those who can’t tolerate walking, sitting in a chair and performing an activity such as playing cards is more activity than lying in a bed. Playing cards actually is a socialization activity also. People who interact with others have more interest in doing things including eating. Remember the earlier statement about eating being a social activity. If residents can eat their meals in the dining area rather than by themselves, it can be an inducement to eat along with others. The dining area should be well lighted and have windows so a good view of the outside can be seen. Don’t forget that medications can have side-effects that affect appetite. Some medications cause nausea, others leave an unpleasant taste in the mouth and still other inhibit the appetite. If you talk to your patient and the correlation is made between a medication and not being able to eat, the possibility of changing to another medication should be addressed with the physician.

Importance of Proper Food Handling

Statistics --- 75 million!
Sources of contamination
Risk Factors

If food is not handled properly, nutrition can be impacted resulting in illness that will prevent both the ingestion and absorption of nutrients. Statistically, the Centers for Disease Prevention and Control (CDC) reports that an estimated 75 million people in the United States contract a food related illness each year but many of these illnesses are not diagnosed or reported. Of the people who contracted such diseases, over 300,000 required hospitalization in 1999 and 5,000 of them died.5,6

Food can become contaminated with bacteria prior to ever being prepared at facilities. Vegetables can be contaminated during the growing or harvesting process. Raw food such as meat, eggs, and seafood are not sterile and can be contaminated during the production process. Did you know that eggs can be contaminated while still in the shell? In the United States, food is irradiated with gamma rays to destroy living bacteria in specific foods but all precautions for preventing food borne illnesses via food handling must still be followed. A major risk factor for the elderly to contract food borne illnesses is the decrease in their ability to fight infection since the immune system works less effectively in the elderly.5 The guidelines that we are going to discuss should apply in food handling in all circumstances not just in long term or assisted living care facilities.

Food Handling in Long Term and Assisted Living Care Facilities

Preparation
Service
Storage

To prevent causing illness related to food handling, there are three broad categories that we will address—preparation, service, and storage of food. The most important factor to preventing food borne illness is to practice good basic hygiene throughout the entire process. So, of course, good handwashing is the cornerstone for prevention of the transmission of disease. The Association of Professionals in Infection Control and Epidemiology (APIC) recommends washing hands before and after eating, before, after and during food preparation and handling.6 Let’s look at each of the three area in food handling more in depth.

Food Preparation

Cutting boards
Knives and other utensils
Raw vs. Cooked
Thawing
Cooking temperature
Reheating

To begin with, facilities should always obtain food from reliable sources to decrease the possibility of receiving food that is already contaminated. Raw meat, poultry, and seafood should NEVER be cut, chopped or diced using the same cutting device such as a knife or by using the same cutting board UNLESS the utensil and board are properly washed in between. These items must be washed with hot soapy water, rinsed and dried before reuse or storage. Cooked foods should NEVER be placed on dishware that raw foods were on without prior proper washing.5,7

Meats should not be thawed at room temperature. Thaw either in the refrigerator, microwave, or in water—directions are frequently written on the packaging of large items such as turkeys. All foods should be cooked thoroughly and a meat thermometer is recommended. Again, often the suggested safe temperature can be found on the outside of packaged meat. Marinating foods should be in the refrigerator and not left at room temperature. Sauces and gravies should be brought to a boil and foods containing raw eggs should not be eaten.5,7

Leftovers must be promptly refrigerated at temperatures that will cool it within two hours. Foods that sit at room temperature for 2 hours or more may not be safe to eat. Foods that are reheated should be heated thoroughly.5,7

SERVING FOOD

Proper set up
Proper temperature
Proper clean up

As previously stated, hands need to be washed prior to eating. Helping residents as necessary to wash their hands prior to eating is an important role for the CNA. For residents to enjoy eating, the presentation of the food must be pleasant and the environment conducive to eating. In the dining hall, good lighting and proper temperature will add to the pleasantness of the environment. Encourage but don’t force residents to sit with others to add social enjoyment to the meal. If patients eat in their rooms, make sure nothing undesirable is in the area or on the table or tray on which they are served their food. This includes items such as bedpans, urinals, suctioning equipment, etc.

The food itself should be maintained and served at the proper temperature—hot foods hot and cold foods cold. Clean tables, chairs and eating utensils are a must. If trays are used, keep the door to the food warmer shut between getting trays. Do not place dirty trays in the food warmer until all trays with food have been served.

After eating, residents should again wash their hands. Don’t let food that should be kept cold or warm sit at the bedside. If food is kept for a resident, label it, and refrigerate it. When dishes are washed, hot soapy water should be used or a dishwasher set at sanitizing temperature for each cycle. These temperatures are: 160-180 degrees for prewash, 150-170 degrees for washing, and 180-195 degrees for final rinse.6

FOOD STORAGE

Time
Temperature
Size

All foods should be refrigerated or frozen within two hours of preparation. After this time period, bacteria will begin to grow and quickly multiply. The bacteria does not cause visible changes to the look or smell of the food. Refrigerating food once the bacteria has started to grow will stop the spread of the bacteria but does not destroy it. The same thing is true for freezing foods contaminated with bacteria. Cooking foods to the proper temperature will kill bacteria if the raw food has been contaminated. The food must be placed in a refrigerator that the temperature is 40 degrees or cooler; freezers should be set at 0 degrees. When packaging leftovers for refrigeration, use small containers and do not tightly pack the food into them. All dressing or stuffing should be removed from meats and poultry prior to refrigeration. Whether food is placed in a refrigerator or a freezer, there must be room allowed for air flow to maintain the proper temperature. A good rule to follow before eating any food is WHEN IN DOUBT THROW IT OUT. 5

Symptoms of Foodborne Illnesses

Symptoms are similar to the “flu”

Nausea
Vomiting
Diarrhea
Cramps
Fever
Malaise

In general, illnesses that are related to foods will all cause the same type of symptoms and if not severe, many people just think they have an intestinal “bug” or flu. The symptoms of nausea, vomiting, diarrhea, stomach or abdominal cramps, fever and malaise (a feeling of exhaustion and lack of energy) can range from mild to severe. The time in which the symptoms begin related to when the food was eaten will also vary depending on what organism is causing the illness. If any of the residents develop these symptoms, the time between eating the food and the beginning of the symptoms should be noted and reported.5

TREATMENT

Diagnosis
Routine care
Severe cases

If a foodborne illness is suspected, laboratory tests should be conducted including a stool culture. The food itself can be tested for bacteria, viruses, parasites and/or toxins. Some cases will only be treated symptomatically by limiting foods and increasing fluid intake, taking a medication to lower an elevated temperature and placing the patient on bed rest. Other cases may require antibiotics and possibly hospitalization.5

Summary

The elderly require more vitamins and minerals, fiber, and water but fewer calories.
Physical changes that occur in the elderly and affect their nutrition include tooth loss, gum disease, decrease in the five senses, and side effects of medications.
To provide proper nutrition to the elderly, foods that are high in nutrients, low in calories, good tasting, and edible are needed as well as an environment that combats loneliness.
Proper food handling includes precautions during preparation, serving, and storage of foods to prevent food borne illnesses which can be severe in the elderly.

The elderly require more vitamins and minerals, fiber, and water but fewer calories. The physical changes that occur in the elderly and affect their nutrition include tooth loss, gum disease, decrease in the five senses, and side effects of medications. To provide proper nutrition to the elderly, foods that are high in nutrients, low in calories, good tasting, and edible are needed as well as an environment that combats loneliness. Proper food handling includes precautions during preparation, serving, and storage of food to prevent food borne illnesses which can be severe n the elderly.

REFERENCES
Nutrition 70 and beyond: what you need to eat. Retrieved 11/09/2006 from http://www.aarogya.com/familyhealthlifestyle/senior/nutri.asp
Anderson, J.E. Nutrition and aging. Colorado State University Cooperative Extension—Nutrition Resources. Retrieved 11/07/2006 from http://www.ext.colostate.edu/pubs/footnut/09322.html
Kurtwell, P. Growing older, eating better. Retrieved 11/07/2006 from http://www.seekwellness.com/nutrition/aging.htm
National Resource Center on Nutrition, Physical Activity and Aging. Dietary guidelines for Americans 2005. Retrieved 11/07/2006 from http://www.health.gov/dietaryguidelines/dga2005/document/
Midwest Gastroenterology Center. Patient education. Foodborne illness. Retrieved 10/28/2006 from http://www.midwestgastro.com
Pyrek, K.M. Hospitals can be a hotbed of cross contamination opportunities. Retrieved 11/07/2006 from http://www.vpico.com/articlemanager/printerfriendly.aspx?article=61117
Cichocki,M. HIV and the importance of food safety. Retrieved 11/07/2006 from http://aids.about.com/od/nutrition/a/hivfoodsafe.htm

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OSHA Bloodborne Pathogens Standard: What You Need to Know!

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

After you complete this program, you will be able to tell what the role of OSHA is and why the Bloodborne Pathogen Standard was developed. You will also be able to identify personal protective equipment and when it is needed for you to safely do your job. Additionally, you will be able to discuss the use of universal precautions and various issues related to workplace safety. OSHA has included in this standard specific practices that are forbidden in the workplace setting because they place you at risk of being exposed to blood and body fluids---you must know what these are. In handling biohazardous waste or anything that has been contaminated with blood and body fluids, you must be sure that you follow specific guidelines and clean all environmental surfaces properly. Lastly, OSHA has outlined the responsibilities of the employer to provide protection in the workplace, but has also listed things that you as the employee must do to comply with this standard. Let’s look at who OSHA is.1

After completing this program, participants will be able to:

State the role of OSHA and the purpose of the Bloodborne Pathogen Standard
Discuss personal protective equipment, universal precautions, and workplace safety issues
List workplace activities that are prohibited and those that are required by this standard.
Describe proper cleaning techniques and handling of biohazardous waste.
Discuss both the employer’s and employee’s responsibilities to meet this standard

Software Requirements:

PC
Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

OSHA Bloodborne Pathogens Standard
What You Need to Know!

This regulation was developed specifically for those persons working in the healthcare industry to prevent exposure to diseases transmitted in blood and body fluids.

OSHA

WHO or what is OSHA?
Why did this standard develop?
Why does the healthcare industry listen to their regulations?

OSHA stands for the Occupational Safety and Health Administration, an agency of the federal government responsible for providing a safer working environment in the United States. Although this agency is usually associated with industrial type jobs, it published the Bloodborne Pathogen Standard to protect healthcare workers in the workplace from diseases carried in the blood particularly HIV and Hepatitis B.1 OSHA not only has the power to develop regulations, it also has the authority to enforce them. CDC or the Centers for Disease Control and Prevention is also a government agency but it has no power of enforcing the guidelines that it develops. OSHA can levy heavy fines if its regulations are not followed. Since OSHA has the authority to enforce the regulations that it issues, healthcare facilities must comply.

Bloodborne Pathogens

HIV
Hepatitis B
Hepatitis C

Although there are other diseases that are transmitted in blood and body fluids, the emphasis of the OSHA Bloodborne Pathogen Standard is to prevent transmission of HIV and Hepatitis B and C to healthcare workers while at work. HIV is the virus that causes AIDS and there is no vaccine to prevent its transmission. There is no cure for HIV. HIV is known to be transmitted in blood and specific body fluids. These body fluids include semen, vaginal secretions, amniotic fluid, pericardial fluid, peritoneal fluid, cerebrospinal fluid, pleural fluid, synovial fluid and all body fluids that have VISIBLE blood in them.2 Hepatitis B is a disease that can be fatal if contracted but it can be prevented with a vaccine. Healthcare workers are at greater risk of contracting Hepatitis B than of contracting HIV. Hepatitis C can also be fatal but there is no vaccine to prevent it. Both Hepatitis B and C affect the liver and they can become chronic conditions. Although there is treatment for both Hepatitis B and C, there is no cure for either.1

Personal Protective Equipment (PPE)

Purpose of PPE
Types
- Gown
- Gloves
- Mask
- Goggles
- Shoe covers
- Surgical hoods

Since HIV and Hepatitis B& C have such potentially fatal outcomes, OSHA has mandated that all employers must provide the necessary equipment to protect employees from being exposed to blood and body fluids. The equipment must be available free of charge, in varying sizes and must be of good enough quality to provide protection when used. None of this PPE can be sent home with the employee to wash or clean. As a result, much of the equipment used is disposable. Gowns should cover the employee’s body except for the neck and head and should resist absorbing blood or body fluids. Gloves should be offered in various sizes and a nonlatex glove must be available for latex sensitive persons. Masks and goggles must fit properly. In some situations such as an autopsy, shoe covers and surgical hoods are required. All equipment should be removed and replaced when it becomes soiled with blood or body fluids.2

UNIVERSAL/STANDARD PRECAUTIONS

USED FOR ALL PATIENTS
PURPOSE
RESPONSIBILITIES

Universal and Standard Precautions mean that you wear the necessary PPE to protect yourself from being exposed to blood and body fluids. They are used for ALL patients. We use them for ALL patients because you can’ t tell just by looking at an individual if they have a bloodborne pathogen or not. Universal precautions are used when potential contact with blood or any of the body fluids that transmit HIV may be contacted. Standard Precautions are used for all blood and body fluid. Many facilities have adopted Standard Precautions since Universal Precautions are included in them. Since there is no vaccine for HIV, our best protection is to prevent exposure to ourselves. Wearing PPE is one of the ways to do that. The employer has an obligation to provide the PPE but the employee has a responsibility to use it. OSHA further mandates that the employer must make sure employees use PPE, so it can be grounds for dismissal if you fail to do so. Check to make sure you know the policies for your facility.1

WORK PLACE SAFETY
Engineering controls including:

Hand washing facilities
Eye wash stations
Specimen containers
Sharps containers
Safety devices
Labeling
Employee education

“Engineering controls” are the terms used to describe the workplace safety features that the employer provides to protect the employee from injury in the workplace. Under the OSHA Bloodborne Pathogen Standard, employers are required to provide handwashing facilities which includes sinks, running water, and soap. Alcohol based handwashing products can also be provided. Eye wash stations must be available and easy to use in order to flush the eyes if an exposure to the eyes occurs. All specimen containers must be leak proof for all stages involved in specimen handling. Containers for sharps must be puncture resistant. A biohazardous waste emblem must be clearly seen on the outside of all sharps containers and trash that is contaminated with blood and body fluids. The emblem must be fluorescent orange or orange-red with a contrasting color such as black for the symbol. If available, safety devices must be evaluated and used to protect accidental needle sticks or other injuries. These evaluations must be conducted by a group that includes non-managerial personnel. All employees must be educated regarding the use of safety devices.1,2,3

PROHIBITED ACTIONS

Eating, drinking, smoking, applying lip balm or handling contact lenses
Recapping, bending or removing contaminated needles and sharps
Putting food/drink with blood/body fluids
Putting sharps in a full container
Mouth pipetting/suctioning blood/body fluids
Picking up broken glassware by hand
Reaching into containers of contaminated sharps

There are specific actions that OSHA mandates employees may not perform in order to prevent exposure to blood and body fluids. These include eating, drinking, smoking, applying lip balm or handling contact lenses in the work area if a potential for exposure exists. Contaminated needles can not be recapped, bent or removed unless no alternative is feasible and then a mechanical device or one handed technique can be used. Food and drink can not be placed in refrigerators, freezers, shelves, cabinets, countertops, or benchtops where blood, body fluids or other infectious materials are present. Sharps can not be placed in a sharp container that is already full; the type of sharps container may not appear full but if there is a line marking it as full, do not put any more into the container. In order to obtain specimens, you can not use the technique of mouth pipetting or suctioning in which suction is applied through a glass straw using the mouth. Broken glassware can not be picked up using your hands, a device such as a dustpan must be used. Finally, do not reach into a container of contaminated sharps to retrieve anything that has been placed into the container.1,2

REQUIRED ACTIONS

Discard contaminated sharps ASAP
Perform procedures involving blood and body fluids as safely as possible
Place all specimens in containers that will not leak
Wash hands as soon as possible after removing gloves and other PPE

Besides the actions that are prohibited, certain actions are also required. These include discarding contaminated sharps as soon as possible; don’t lay the syringe and needle down to “quickly” do just one little thing—discard the syringe and needle or other sharp first. In performing procedures that will cause blood or body fluids to be generated, wear all the PPE necessary; if you are assisting with an insertion of a gastric tube, wear goggles and gloves and possibly even a gown. All specimens must be placed in containers that will not leak or spill during collection, transport, and/or handling—don’t use containers with ill fitting lids. Last but not least, wash your hands as soon as possible after removing gloves or other PPE—this must take place BEFORE you do anything else. Remember, wearing gloves NEVER takes the place of washing your hands and do NOT wash with the gloves still on.1,2

Cleaning and Disinfection

All areas contaminated with blood and body fluids must be cleaned and decontaminated
Based on area to be cleaned, nature of contamination and procedures performed in the area.
Written schedule for each area

Surfaces that are contaminated with blood and body fluids must be cleaned before they can be disinfected. Even if an item is to be sterilized, it must be cleaned first because sterilization will not remove the dirt. As a result, items or surfaces that are contaminated with blood and body fluids must be cleaned twice—once to remove the dirt and a second time to disinfect. Specific products must be used and the facility in which you work will select the ones that are approved for various tasks. The FDA (Food and Drug Administration) is the agency responsible for designating what specific products can be used for killing tuberculosis and other bacteria. If there is enough blood or body fluids present, the fluid should be wiped up first and then the area should be cleaned and disinfected. Paper towels or other disposable items may be used to wipe up the blood and body fluids which must then be properly disposed of. Each area needs a written schedule as to cleaning—for example, public restrooms may be scheduled to be cleaned every 4 hours. All unusual spills should be dealt with immediately. Work areas must be cleaned after completion of a task and at the end of each shift.1,2

More Cleaning

Protective surface coverings
Reusable receptacles
Laundry

In addition to the areas already discussed, all coverings that are used to protect equipment or other surfaces must be removed and replaced whenever they are visibly soiled or at the end of the work shift if contaminated during that shift. All receptacles that are reusable that may become contaminated with blood or body fluids must be inspected on a regular basis, cleaned, disinfected and replaced if necessary. All laundry must be handled as little as possible and bagged at the site of use. If Universal/ Standard Precautions are not used, the laundry must be labeled if contaminated. Wet laundry must be placed in a bag or container to prevent leakage. If an off site laundry is used, all laundry must be labeled for safe handling PRIOR to transport of the laundry. Any equipment that is contaminated with blood and/or body fluids must be cleaned and disinfected prior to reuse or prior to repair work.1,2

Biohazardous Waste

All waste that is contaminated with blood or body fluids is biohazardous.
Items that are not sharp
Sharps
Transport
Storage
Emblem

All waste that is contaminated with blood or body fluids requires special handling in healthcare facilities. Items such as dressings that are saturated with blood or body fluids, must not be placed in regular trash. These items require a bag that meets specific requirements to prevent leakage and alert all handlers as to the potential risk. These bags are usually red and have a biohazardous label on the outside of the bag so that it is clearly visible. This trash must be kept in a designated locked closet or other locked area with a biohazardous emblem on the outside entrance. Sharps are disposed of in specially designed boxes that are constructed to seal tightly and be puncture resistant. This is not the same as puncture proof so care must be used in handling these boxes. Again, the boxes must have the biohazardous emblem on the outside and be stored in a locked area just as the biohazardous trash.1,2

Exposure Control Plan

Purpose is to identify personnel at risk of exposure to blood and body fluids related to their job and practices to protect these employees
Must be written
Available to all employees
Reviewed and updated annually
Revised as necessary

The Exposure Control Plan must be developed by employers to identify personnel at risk of exposure and to specifically identify processes used to either eliminate or reduce the exposure. In deciding who is at risk of exposure due to their job, the employer may not include the use of PPE. In other words, the plan must consider the risk based on the fact that the employee doesn’t have PPE on. This plan must be in writing and readily available to employees and/or OSHA inspectors at all times. The plan must be reviewed every year and reflect any changes in job descriptions, new job positions and current policies and practices. Additionally, if changes occur prior to the annual review, the Exposure Control Plan must be revised to include the changes.1,2

Exposure Control Plan

Classifications of employees at risk
Procedures that involve risk of exposure
PPE provided
Selection process for PPE
Work practices to protect employees
Engineering controls
Hazard communication
Hepatitis B vaccination program

The specific information that must be included in the Exposure Control Plan is listed on this slide and we will address each one.

Classification of employees must be categorized as those who definitely have a risk of exposure, and those who have a possible risk of exposure. Some categories of employees may have a combination of both depending on work factors. For example, housekeeping employees who only do office work are not at risk whereas the housekeepers handling contaminated trash are at risk.
All procedures or groups of procedures that create a risk must be stated.
Personal protective equipment must provided as well as the process by which it is selected—cost alone can not be the deciding factor. Personnel involved in direct patient care must be included in selection of equipment.
All work practices used to protect employees must be included such as eyewash stations and labeling biohazardous waste.
Engineering controls such as the special hoods used in the laboratory or disposable suction containers must be part of the plan.
Employees must be warned if they are exposed to any hazards in their work environment such as formaldehyde or other chemicals.
Finally, the Hepatitis B vaccination program must be in the plan and must include information on how to get the vaccine, your right to refuse and the records that are kept be the employer.1,2

Hepatitis B Vaccine Program

Risk of Hepatitis B to healthcare worker
Offered free of charge to at risk workers
Provided within 10 days of initial assignment and after training
Employees who don’t need it
No prescreening of employees
Declination statement

The hepatitis B program is required by OSHA for all healthcare workers at risk of exposure to blood and body fluids. Although many healthcare workers are concerned about being exposed to HIV, they are at greater risk of contracting either Hepatitis B or C. Both these diseases attack the liver and can destroy its functioning.

There is no vaccine available for Hepatitis C. The Hepatitis B vaccine is safe and effective. It must be offered to all employees determined to be at risk of exposure to bloodborne pathogens. After training and within ten days of the initial assignment, the vaccine should be offered. An explanation as to how the vaccine is administered and possible side effects must be provided and the employee must give written consent. Employees who have a medical contraindication or were previously and successfully vaccinated against Hepatitis B, do not need to receive the vaccine. Employers are not allowed to prescreen employees by requiring bloodwork for the antibody prior to giving the vaccine. Employees who decide not to take the vaccine can change their minds later and receive it. At the time that the employee decides not to take the vaccine, a declination statement must be signed.1,2

Post Exposure Requirements

Even with precautions, exposures may occur. If one does occur, the employer must provide the employee with specific follow up to determine it the employee contracted hepatitis or HIV.

If an exposure occurs to an employee, the employer must provide follow-up through a written medical evaluation of the exposure, bloodwork on both the employee and the patient if known, and record keeping. The written evaluation must be provided within 15 days of completion of the evaluation to the employee. The employee will be given the information necessary to decide if they want to participate in follow-up through a periodic blood testing program and to receive prophylaxis if indicated. If the employee decides initially not to participate in follow-up, the employer must draw blood and hold it for 90 days. This blood is kept for the 90 days in case the employee changes their mind and wants follow-up. Counseling and reevaluation are provided as indicated. If prophylaxis is medically indicated, it must be provided by the employer free of charge.1,2

EMPLOYEE Responsibilities
Employees must:

Use PPE
Follow policies and procedures
Report all exposures

We have discussed the employer’s responsibilities but the employee also has responsibilities to prevent exposure to bloodborne pathogens. Employees must wear the personal protective equipment to protect themselves from accidental exposure. Additionally, they must follow ALL policies and procedures such as not recapping and labeling biohazardous waste must be followed. Finally, be honest and report all exposures even if you failed to follow policy.1,2

Employee Education
Employers are required to provide all employees with education related to bloodborne pathogens. This training must be provided:

Free
During working hours
At time of initial assignment
Annually
Any time a new task is added.

As stated on the slide, employers are also required to educate their employees on bloodborne pathogens. The training is to be free, during working hours and at the time of initial assignment. Many facilities provide this as part of orientation. Additionally, this training is required on an annual basis and at any time a new task is added that is at a higher risk level than the other tasks.1,2

Records Requirements Types

Training records
Employee medical records
Sharps injury log

Information required for each type

Retention of records

Employers are required to maintain specific records and to have the records available to OSHA inspectors. These records include the training records, employee medical records and a sharps injury log. Training records must include the names of all present at the training as well as each job title, the date(s), and the instructor along with the instructor’s qualifications. These must be maintained for three years from the date of training. Employee medical records must be kept separate and confidential from personnel records. They are covered by the same laws as all other medical records and can’t be released without the employee’s written permission. These must be accessible for the duration of the employee’s time of employment plus 30 YEARS. The sharps injury record is a log of all employee occupational injuries and illnesses. This log is confidential and must contain not only the type of injury but also the equipment involved and a detailed explanation as to what happened. These records must be kept as stated in regulation 29 CFR 1904.6. 1,2

SUMMARY

OSHA’s Bloodborne Pathogen Standard
Universal/Standard Precautions
Personal Protective Equipment (PPE)
Safe workplace practices
Hepatitis B vaccination program
Employer requirements
Employee requirements

In summary, OSHA is a regulatory agency that has specific rules for protecting employees from exposure to bloodborne diseases of HIV and Hepatitis B and C. Universal or Standard Precautions are for all patients and for all blood and body fluids even though HIV and Hepatitis B & C are only transmitted by specific body fluids. Personal protective equipment or PPE is provided by the employer for use by employees when performing job tasks that could expose them to blood and body fluids. PPE includes gowns, gloves, goggles and masks. There are specific practices in a work setting that OSHA forbids such as recapping a needle, storing food or drink with specimens, and appropriate labeling of all biohazardous waste. Employees at risk of exposure to blood and body fluids must be offered the hepatitis B vaccine within 10 days of initial assignment, free of charge and can decide to refuse it and later change their minds and receive it. The employer must have an exposure control plan that identifies each employee by job title and their risk of exposure. All policies and procedures related to bloodborne pathogens must be included. Records for training, the employee’s job related medical record and the sharps injury log must be maintained by the employer. Employees must know and follow the employer’s policies and procedures to protect them from exposure to blood and body fluids.1,2

REFERENCES

McCarty V. OSHA regulations for bloodborne pathogens and tuberculosis. 2006. AKH Inc.
U.S. Department of Labor Occupational Safety and Health Administration (OSHA). 1991. Regulations(standard 29cfr) bloodborne pathogens—1910.1030. Available at http://www.osha.gov. Accessed 1/04/07.
U.S. Department of Labor Occupational Safety and Health Administration (OSHA). 2001. Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; final rule.-66.5317-5325. Available at http://www.osha.gov . Accessed 1/04/07.

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Pain Management: Hurting is Never Acceptable

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

This activity will explore the recognition of pain, the various types and causes, as well as the different things that can influence how we feel pain. There are certain barriers to controlling pain so we will identify them and address ways that the barriers can be overcome. The CNA’s role is crucial in supporting comfort measures that relieve discomfort so measures that can be initiated by the CNA will be presented.

Upon completion of this course, the participant will be able to:

Recognize the presentation of pain
List different types and causes of pain
Discuss the things that influence the feeling of pain
Describe the barriers to pain management and ways to overcome them
Identify comfort measures that can be performed by the CNA

Software Requirements:

PC
Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater

*Adobe Acrobat Reader
Click here to download

MAC
Internet Explorer is not supported on the Mac
Mac OS 10.2.8
Safari<

Instructor: Lori L. Ley, RNC, MSN

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

Pain Management:
Hurting is Never Acceptable

The topic of pain can draw strangers into conversations. Whether you’re the new mom on the block, a casualty of an accident, or a child who has had to get stitches, the question that people will almost universally ask is, “Did it hurt much?” Think about it; few people have not experienced pain and although it is not something to be desired, there is a certain appeal to sharing experiences related to who’s pain was the worst and what was required to relieve it. Pain is a true common bond that exists amongst us. So let’s talk about it.

History of Pain

Pain is not a new thing by any means. In ancient civilizations, stone tablets were used to record information about treating pain. The use of the sun, heat, water, and pressure were all described as ways to treat pain. Later, people believed that pain was caused by evil spirits or the use of magic. They tried ceremonial rites and sought treatment from those in the society who could come up with cures through the use of herbs or other natural means. The Greeks and Romans first came up with the idea that pain might actually be related to the brain and the nervous system but documentation to support this idea did not exist before the Renaissance. It is Leonardo daVinci who is credited with recognizing the brain and spinal cord as being responsible for transmission of sensation.1

The modern idea of a “pain pathway” was actually described by a man named Rene’ Descartes in 1664. He drew a picture showing how pain felt in the foot would travel up the body, to the brain and ring a bell. It wasn’t until the 19th century that it was discovered that opium could treat pain effectively and eventually it was with the use of the opium, morphine, codeine, and cocaine that led to the discovery of aspirin.1

Other facts

50 million Americans live with chronic pain
25 million suffer acute pain resulting from surgery or accidents (2 out of 3 have lived with this pain for > 5 years)
36 million Americans missed work
83 million said pain affected their ability to participate

Arthritis, lower back, bone/joint, muscle, fibromyalgia

Pain has become a silent epidemic in America. About 50 million Americans live with chronic pain caused by a disease, disorder or accident. An additional 25 million suffer from acute pain associated with surgery or accidents with 2 out of 3 having lived with that pain for over 5 years. Approximately 36 million Americans missed work due to pain in 1999 while at least 83 million reported that pain affected their ability to participate in some sort of activity.2

The most common types of pain are arthritis, lower back, bone or joint pain, muscle pain, and fibromyalgia.

What is Pain?

An unpleasant sensation.
Whatever the person experiencing it says it is…whenever the person experiencing it says it does.

Pain can be defined in many ways including “an unpleasant sensation associated with real or possible tissue damage and transmitted by specific nerve fibers to the brain where its conscious recognition may be changed by different things”.3 Other definitions include “whatever a person experiencing the pain says it is, existing whenever the person says it does.”4 It is the latter definition that we as healthcare workers must acknowledge and embrace.

Pain is subjective and is perceived differently from person to person.

Classification of Pain

Pain comes from the stimulation of nerve receptor sites (found all over the body) that send a message through the pain pathways to the brain were the message is perceived and processed.

Pain can be classified according to where the pain comes from in the body. It is then described as being pain that is either nociceptive or neuropathic.

Nociceptive pain is either somatic or visceral pain. Somatic pain comes from the bone, joint, muscle, skin or connective tissue due to injury (including surgery) and is either surface somatic pain or deep somatic pain. Surface somatic pain is usually sharp and described as burning or pricking. Deep somatic pain is dull, aching and localized.

Visceral pain comes from internal organs such as the liver, gallbladder or intestines. Visceral pain usually results from inflammation or compression and is described as pressure, stabbing, or cramping and may or may not be local to one area. Generalized pain occurs when hollow organs such as the intestines are involved.

Neuropathic pain results from nerve damage involving either distant or central nerves. Examples of neuropathic pain include pain felt from shingles (post-herpetic neuralgia) or pain that occurs in an amputated arm or leg (phantom limb).

Both nociceptive and neuropathic pain can be either acute or chronic.

Acute pain can range from being mild to severe and can last for a moment or for months (based on the cause). It has a definite beginning and usually ends when the source of the pain is corrected or its healed but can turn into chronic pain.

Chronic pain persists and doesn’t respond well treatment. Many people with chronic pain also suffer psychologically which can contribute further to the pain.

Why do I need to know this?

Pain is one of the most common concerns for older adults
Nurses and physicians hesitant to use scheduled pain medication
- Elimination
- Absorption
- Possible drug interactions
Physician involvement less than in acute settings
Bulk of care activity performed by CNAs that have little training in pain management

So why do I need to know this? Well, for many reasons, one being that pain is one of the common concerns for the older adult and those that care for them. The effects can be widespread as depression, poor socialization, sleep and walking problems often occur for those dealing with pain.5

Nurses and doctors are sometimes hesitant to use scheduled pain medication because the older person’s body doesn’t metabolize as efficiently as it did years before. The kidneys and the liver slow done a bit and the ability for them to get rid of the medication can take longer as a build up of medicine can occur in the resident’s system. Another challenge can be that the absorption of medicine is impaired, meaning that the ability to achieve maximum pain control requires careful consideration of the balance between the absorption and the elimination of the pain medication. Add the other important point of all the drugs that older adults may be on and you have a very complicated picture when it comes to pain management in the LTC resident.

In one study, two thirds of the LTC residents had chronic pain and one half of those residents’ pain was not detected by their treating doctor.6 Physicians can be less involved in the care of the LTC resident. This can lead to other issues related to pain control in the elderly as less involvement may mean less communication and longer periods of time can go by without appropriate medical intervention.

Another issue with pain management in the LTC resident is the fact that the CNA provides so much of the bedside care and they receive very little training in the recognition and management of pain factors. The CNA may not recognize some of the subtle signs that the older adult may display, other than actually saying they are in pain. This brings us back to the reasons why it’s important that the CNA know the signs and how important it is to report these to the nurse. The CNA can play one of the most important roles in the overall pain management team approach.

Others barriers to effective pain management

Adequate pain management is affected by other factors that are related to the healthcare professional, the resident and the long term care system itself. Pain management takes a team effort.

The barriers that interfere with pain management for healthcare professionals include inadequate knowledge and/or assessment skills, concern about the use of controlled medications both in terms of effectiveness and addiction, and the attitudes of each healthcare professional related to pain management. As a result, physicians may fail to order either adequate doses of medication or timely intervals. Nursing assistants may fail to communicate key observations while nurses may fail either to administer medication in a timely manner or to report the ineffectiveness of the medication to the physician. Personal attitudes by the physician, CNA, or nurse may inappropriately judge the patient’s use of pain medication or other relief measures.

Education of healthcare professionals along with a desire on their part to deal effectively with patients’ pain can correct these barriers.

Signs of Pain

Pain – under recognized on the resident with cognitive impairment, sensory, speech, or language problems-can’t express themselves
Responses vary widely
- Body language
  - Facial expression and grimaces
  - Refusals to move, being stiff in moving or limited movement in general
  - Grouchiness, moaning, crying, yelling or screaming
  - Change in behavior or social patterns
- Culture

Looking for the signs of pain goes beyond the spoken word. Pain is routinely under recognized in the resident with cognitive impairment, sensory, speech or language problems. But just because they cannot say they are in pain doesn’t mean it is not present. Watching for other signs and then reporting these signs becomes a crucial part of care for the CNA.7

The responses to pain may vary widely among residents. Some don't feel pain as much as others. Some may ignore it while others may even deny they have pain because they are afraid it may mean they have problems that they don’t want to deal with. This can contribute to delays in treatment for other health issues that could be managed better in the earlier stages…some cancers being one of those problems.

Looking for signs in the body language of the resident can be very helpful. Reporting these to the nurse is an important part of the CNA’s role in pain management.

Responses to pain can also be related to their culture. Some display lots of emotion during pain, others may be very stoic. In some cultures, showing or admitting to pain is a sign of weakness. Others believe that pain is some type of punishment from a higher power or deity.

Other signs of pain

Anxiousness
Loss of appetite
Weight gain or loss
Change in sleep patterns
Decreased ROM
Changes in vital signs
Withdrawal
Depression

There are many clues that the CNA should observe for and report.

Anxiousness
Loss of appetite
Weight gain or loss
Change in sleep patterns
Decreased ROM
Changes in vital signs
Withdrawal
Depression

All of these can be a red flag that can signal the resident is having pain. Report these changes to the nurse immediately.

Signs of Pain (continued)

Pain scales
Wong-Baker Faces Pain Rating Scale

A resident's pain is a very serious condition as it will affect their well-being and quality of life. You should regularly ask them if they have pain, especially if they display some of the signs presented earlier. Their reporting of pain is the most accurate indicator that it exists so never discount that and always act upon and report the complaint to the nurses. Even though they may smile, talk to others unhampered, or sleep well, if they complain of pain don’t try to second guess them or make assumptions, it is real and should never be ignored.

Various pain scales exist today and your facility probably has a specific one that they use routinely. Follow your facility policies and use the scale they require.

One of the scales available is the Wong-Baker Pain Scale.8 This particular scale is useful for the elderly person that is cognitively or speech impaired as it allows them to point to the face that best matches their pain level and offers a clear description of their pain without words.

Face 0 = very happy because they don’t have pain right then
Face 1 = hurts a little bit
Face 2 = hurts a little more
Face 3 = hurts even more
Face 4 = hurts a whole lot
Face 5 = hurts as much as you can possible imagine although they don’t have to be crying or look like this to feel this bad

To use this scale you should point to each face using the words to describe the pain intensity. The resident should then choose the face that best describes how they feel.

Signs of Pain (continued)

Verbal Scale

Numerical Scale

PAINAD Scale
FLACC Scale

With a verbal scale, the resident can describe the degree of their discomfort by choosing one of the vertical lines that corresponds best to the intensity of pain they are feeling. This is a good way to explain early postoperative pain, which is expected to go away over time. This scale can be used to determine if their recovery is progressing in a positive direction.

A numerical pain scale allows the resident to describe the intensity of their discomfort in numbers ranging from 0 to 10 (or greater, depending on the scale). Rating the intensity of the pain is a way of determining if the treatment used is working or not.

The PAINAD Scale is a more complicated scale that the nurse may use to focus in on specific pain issues. This scale was developed especially for the Alzheimer’s patient and involves multiple assessment criteria that extends beyond the capabilities of the CNA but it is still important to know what the scale is should the word “PAINAD” be used in shift reporting or other communication.9 The scale deals with scoring of breathing patterns, vocalization factors, specific facial expressions, generalized body language, and consolability.

The “FLACC” scale is another type of sale that can be used on the cognitively or speech impaired resident as it takes into account non-verbal methods of observational data to determine the presence or level of pain.10 FLACC stands for face, legs, activity, cry, and consolability which are all used to come up with a score from 0 to 10.

A combination of any or all of these scales can be helpful in gathering as much information as possible about the pain the resident is experiencing and whether the methods used to treat the pain are effective.

Reporting Pain

Your contribution to the nursing assessment is important!

Vital Signs
Location of pain
Movement of pain to other areas
Time it started
Level of the pain described
Things that improve or worsen the pain
Changes in the pain or cycles of pain
History of the pain or management of the pain
Current routine for managing the pain
How the pain effects ADLs
Abnormalities seen at site of the pain
Other abnormalities such as nausea, vomiting, strange movements, lack of movement, facial or verbal expressions
Responses to pain medication

A nursing assessment of the pain and all the factors that may affect the perception and communication of these factors among team members is very important to effectively managing the pain and providing comfort and well-being for the resident.

These are some of the elements that you as the CNA can contribute to the overall care and assessment by monitoring and reporting promptly to the nurse:

Vital signs (with other factors) can sometimes show a change that will alert the nurse to the pain or relief.

Location of the pain, radiation or movement of the pain to other areas should be described to sort out whether this is a new development or an ongoing chronic issue.

Time, level of pain, duration, things that help or make it worse can help in the decision making for pain relief factors. While changes in the pain or cycles of the pain, knowledge of the history and current successes will also promote the ability to adapt and individualize the management of the pain.

The effect of pain on the resident’s ability to sleep, eat, have relationships, concentrate and generally take care of oneself can assist the team in determining if a problem is getting worse or needs more aggressive management.

Watch and report for other abnormalities that may be indicators of the existence or levels of pain and the responses the resident may have to the management methods or medication being used to control the pain.

All of these should be reported in a timely manner as the longer pain exists, usually the more intense and more difficult it is to control. Report using the most objective means possible, usually the actual words or comments by the resident are the best. As a nursing assistant, you are not directly responsible for pain management but your observations and nursing care is very important because you work so closely with the resident.

Discomfort Comfort

Plan and time procedures around pain medication times
Provide privacy and comforting environment
Positioning
Bed positioning, linen straightening and pillow support
Avoid sudden, jerky movements
Speaking in soft, comforting manner
Passive ROM
Backrubs, massage, relaxation and imagery
Cool and warm packs
Provide hygiene measures

Providing comfort measures is an important step in interrupting the cycle of discomfort. The CNA can do many things to make a resident more comfortable. If unstable or you question if a resident should be up and ambulating or moving around due to dizziness etc., report to the nurse and do not attempt to get them up. Fall risks climb greatly when pain medications are in a resident's system.

Begin by ensuring there are no surprises. Tell the resident everything you are doing and plan to do. By doing this you will avoid startling them and causing sudden movement which can in turn cause more pain. This will also give the resident some knowledge as to what kind of pain they may be facing. If possible, ensure that any activity is planned around pain medication and encourage the resident to take the medication so that the activity causes as little discomfort as possible. Pain medication effects should be at their peak when planning for procedures or things like bathing, eating, ambulating etc. Always accompany the medicated resident to ensure their safety while performing these activities.

Provide a private, comforting environment by addressing temperature and lighting. Eliminate any unpleasant sights, sounds, and odors. Play some soft music if available.

Positioning is very important. Assist the resident in assuming a comfortable position that can relieve pain or muscle spasms. You can change the bed angle to support or relieve any pressure on painful or injured areas, straighten linens to control bunching and pressure points, and use pillows or other support devices to align body parts and keep painful extremities out of uncomfortable positions.

Avoid sudden, jerky movements. Be gentle and relieve anxiety by saying comforting words of encouragement and providing emotional support while moving painful areas. Do passive range of motion (ROM) exercises to keep joints from getting stiff and to maintain mobility. If the care plan allows, offer food and beverages often. Providing backrubs, massage, relaxation or the use of imagery can be very effective in some residents. Providing cool or warm packs to affected areas can relieve some discomforts. Ensure good hygiene such as proper mouth care, washing face and hands before and after eating a meal, and place a cool, damp washcloth on the resident’s forehead.

General Principles related to pain…

Ask about pain regularly.
Believe the patient's and family's reports of pain and what relieves it.
Choose appropriate pain control options.
Deliver interventions in a timely, logical, and coordinated fashion.
Empower patients and their families.

According to the National Guideline Clearinghouse on pain management, these general principles should always be followed. They can be easily remembered as the ABCDE principles.11

Ask about pain regularly.

Believe the patient's and family's reports of pain and what relieves it.

Choose appropriate pain control options.

Deliver interventions in a timely, logical, and coordinated fashion.

Empower patients and their families.

Summary

Pain is whatever the person experiencing it says it is…whenever the person experiencing it says it exists.
Pain is either nociceptive or neuropathic and either chronic or acute.
Pain is one of the most common concerns for older adults and can be influenced by numerous factors.
There are many barriers to pain management, including communication
The CNA has many alternatives to support the comfort of residents.

To summarize, the CNA plays an important role in the process of pain management in the LTC resident.

Education of the CNA regarding the pain process, their role in observing, monitoring, and reporting the pain of each resident supports any successful facility pain management plan. Remember that:

Pain is whatever the person experiencing it says it is…whenever the person experiencing it says it exists.

Pain is either nociceptive or neuropathic and either chronic or acute.

Pain is one of the most common concerns for older adults and can be influenced by numerous factors. Many of these factors can be controlled by the environment that the CNA places the resident in. Some cannot be controlled such as culture o the resident experiencing and reacting to the pain.

There are many barriers to pain management, including communication. Remember, effective pain management uses a team approach where all the healthcare members and the family must come together for the resident and openly discuss methods for recognition, comfort and the relief of pain.

And finally, the CNA has many alternatives to support the comfort of residents. They should consult with the nurse regarding the plan for management of each resident’s pain.

REFERENCES

National Institute of Neurological Disorders and Stroke. Pain: hope through research. Available at: http://www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm Accessed December 13, 2006.
American Academy of Pain Management. Pain issues: pain is an epidemic. Available at: http://www.aapainmanage.org/literature/Articles/PainAnEpidemic.pdf Accessed December 15, 2006.
Pugh MB senior ed.,Werner B managing ed.,Filardo TW new terms ed., Binns PW et al copy eds.Stedman’s Medical Dictionary. 27th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000.
Ersek M, Carmencita MP. Pain. In: O’Brien PG, Giddens JF, Bucher L,eds. Medical-Surgical Nursing. 6th ed. St.Louis, Mo: Mosby 2000:131-159.
American Geriatrics Society. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. J Am Geriatr Soc 1998;46:635-651.
Sengstaken EA, King SA: The problems of pain and its detection among geriatric nursing home residents. Journal of the American Geriatrics Society 1993;41:541-544.
Agency for Healthcare Research and Quality. Pain management in the long-term care setting: percentage of patients with documented reduction of pain symptoms. Available at: http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=6456&ss=1 Accessed: December 26, 2006.
Hockenberry MJ, Wilson D, Winkelstein ML. Wong’s Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p.1259. Used with permission. Copyright, Mosby.
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4:9-15.
Merkel S, et al. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurse, 1997; 23(3):293-297.
National Guideline Clearinghouse. Pain management guidelines. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=9744&nbr=5217&ss=6&xl=999 Accessed: December 26, 2006.

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Resident's Rights and Responsibilities: Protection for Residents in Long Term Care Facilities

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

This program addresses the rights and responsibilities of residents in long term care facilities. Each right will be separately addressed and your role as a CNA related to each right will be covered.

OBJECTIVES

Discuss the Ombudsman Program related to long term care residents
Identify various rights of the residents in long term care facilities
Discuss the way to provide these rights
Describe the role of the CNA in meeting patients rights
State the ways to report violations of residents rights

Software Requirements:

PC
Internet Explorer 5.5 or greater
Firefox
Windows 2000 or greater

*Adobe Acrobat Reader
Click here to download

MAC
Internet Explorer is not supported on the Mac
Mac OS 10.2.8
Safari
Firefox

*Adobe Acrobat Reader
<a href="http://www.adobe.com/products/acrobat/read

Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

RESIDENTS RIGHTS and RESPONSIBILITIES: Protection for Residents in Long Term Care Facilities

Ombudsman Program

Older Americans Act
Requirements for states

Ombudsman
Purpose

In 1972, the Ombudsman Program was begun as part of the federal Older Americans Act. This legislation is administered through the Administration on Aging and requires every state to create a program composed of regional or local ombudsmen. The purpose of the ombudsman is to act as an advocate for long term care residents by monitoring the care provided in the facilities and to represent the needs of the residents at governmental agencies. Although some of the ombudsmen are paid for their services, others are volunteers. Additionally, the ombudsman provides information to families and the general public concerning long term care issues.1,2

Providing Information

Florida State Law
Residents
Staff

In accordance with Florida Statute, Title XXIX, Chapter 400, section 400.022, all nursing homes must post a public statement listing the rights of each resident. Facilities may choose to post this information in a common area such as the entrance lobby. Information on Residents’ Rights must be provided to the resident or the resident’s legal representative BEFORE the person becomes a resident of the facility. Additionally, all staff members must be given a copy of the residents’ rights and must receive training regarding them. As a staff member you must not only know what the rights are, you must understand them and how they are provided. 3,4

SPECIFIC RIGHTS
There are 22 specific rights which will be covered one at a time.

#1. Right to civil and religious liberties

#2. Right to private, uncensored communication

As stated on the slide, there are 22 specific rights that Florida law lists for residents in long term care facilities. As a CNA, you must know what each one means and how to provide them for residents.

#1 The first right is for civil and religious liberties. Basically, this means that just because a person becomes a resident in a long term care facility they still have the same rights as every other American citizen. This includes the right to free speech, the right to move about freely in the parts of the facility provided for residents, and the right to associate with persons of their choice. They specifically can’t be denied the right to practice a religion of their choice. You can help residents to feel comfortable by talking to them about current events or other socially acceptable topics and not talking to them as though they were a child. Keep in mind that just because one resident wants to associate with another resident, they each have to right to choose who they do and do not want to associate with.

#2 The second right, the right to private and uncensored communication means that residents must have access to a phone, be able to send and receive mail without having it opened, have visitors both during regular visiting hours and at other times as dictated by special circumstances. Rules and regulations of the facility must be incompliance with Medicare and Medicaid regulations as outlined in the Social Security Act. Included in these regulations is the stipulation that a resident can’t lose their bed if they have an overnight visit. Depending on the plan of care for the resident, not only family and friends are allowed to visit but people who provide other services desired by the resident must be permitted. This includes such things as a barber, hair stylist, nail technician, or community based group. If the resident desires services from outside sources, the CNA can get them the phone number to call or assist as needed in setting up the service.4

Rights # 3 & # 4

#3. Right to deny or grant access of visitors

#4. The right to present grievances

#3. Residents have the right to deny access to persons of their choosing but they can not be denied access to their physician or any representative of the federal or state government including but not limited to the Agency for Health Care Administration (ACHA), ombudsman, or police officers. If a representative of the State Long-Term Care Ombudsman Council has permission from the resident or the resident’s legal representative, the facility must allow examination of the resident’s clinical records by that representative. This allows an investigation into complaints that the resident may lodge against the facility.

#4.The residents must be permitted to offer grievances or complaints regarding their care, facility policies, staff, or other residents without fear of any reprisal. These grievances or complaints must be addressed in a prompt manner by the facility. Furthermore, the resident can not be denied access to ombudsman or other advocacy groups. In either situation, when a resident has a complaint, it should be taken seriously and the CNA may be the person to whom the resident tells the complaint. You should report the complaint to your supervisor unless it is a simple matter that you can handle within your job description. Often handling the initial dissatisfaction prevents it from becoming a major complaint that is reported to an outside agency 4

Rights #5, #6 & #7

#5. Right to organize group meetings

#6. Right to participate in activities

#7. Right to request report of inspections

# 5. The right to organize groups means that residents can arrange family gatherings with their own family or between their family and others. They can also have a get together with other residents. You as the CNA can help to facilitate such gatherings and guide the choice of time and place to prevent conflict with other gatherings.

#6. The right to participate in activities including religious and social whether inside the facility or not. As a general rule, the facility is not required to provide transportation, but should assist the patient to be able to attend such things. For example, the local church may have transportation available for those wanting to attend services who have no means of transportation. You could call to find out and help the resident make the arrangements.

#7. The right to request a report of recent inspections of the facility by either state or federal agencies. This information must be shared within a reasonable length of time but the resident must be reasonable in making the request. The information provided must include the facility plan to correct any violations that were identified. You as the CNA should know who to ask to obtain the report.4

Right # 8

#8 The right to manage their own financial affairs

Delegation of authority

Accounting of funds by the facility

Funds management upon death of resident

One of the major rights is #8, the right to manage their own financial affairs. Too often, this right is one that is taken away by the family and sometimes by the facility due to good intentions. Sometimes the elderly person has difficulty in handling their finances such as writing checks, remembering to pay bills, or not remembering where they put their money. They can decide to pick someone to do it for them. A legal power of attorney for financial matters must be obtained and usually involves a family member or close friend. If the facility acts as the financial representative, the money must be placed in trust. The facility can’t require a resident to deposit money with the facility. However, if the resident opts to hold money at the facility, the resident must give written authority to the facility to keep the money safe, manage it, and also account for it. In either situation, specific guidelines must be followed:

The resident’s money can not be mixed in with the facility money.
Each resident must have a separate account.
A quarterly report stating the transactions that have been made with the money must be made to the resident or the person responsible for the resident.

In case of death of the resident, within 30 days, the personal funds of a resident that are on deposit at the facility, must be given with interest due to the administrator of the estate. In the absence of an administrator, the money must be given to the person designated on the beneficiary form or in accordance with next of kin outlined in state law.

You as the CNA should not hold any money for a resident or be named as the financial administrator for the estate or be the beneficiary of funds from any of the residents in your care. This can be misconstrued as a conflict of interest should something happen to the resident.4

Rights # 9, 10, & 11

#9 Right to be informed of all services available and related charges

#10 Right to be informed about their medical condition and their plan of care

#11 Right to refuse medication and treatment

#9. The right to be informed of all services that are available within the facility and the charges associated with the services not covered by Medicare or Medicaid. Additionally, charges for services that are not included in the cost of the daily rates and the refund policies of the facility. This information must be given to the resident before admission to the facility. As an employee, you should be aware of what services are not included in the daily rates BEFORE you give out any information to the resident or their family.

#10. Residents have the right to know what their medical diagnosis is and plan of care for them. Unless the resident has been declared incompetent, they must be a participant in planning and accepting the plan of care for them.

#11. All residents have the right to refuse medication and treatment, but they must be told of the consequences of such refusal. If the resident is incompetent, the person legally responsible for them must be notified of the refusal and the consequences. All of this information must be documented in the medical record.4

Rights # 12 & #13

#12. Right to be provided a full spectrum of care that meets standards of the community and the licensing agency.

#13. Right to Privacy

#12. Residents are entitled to be provided with all the services that are needed in a full spectrum of care. If the facility is not able to provide the services that meet the standard of care, then the services must be provided through contract with a facility or service that does provide it. For example, if there are no physical therapists employed by the facility, an agency providing such services must be contracted by the facility. Not only must the physical needs of the residents be available, but social and mental health services must also be provided.

#13.The right to privacy is one that can easily be overlooked in a long term care facility since the residents move about and are often in common areas. Due to privacy of medical conditions, medications and treatments should not be administered in common areas where others can readily hear what is being said and done. Residents are entitled to have a room and anyone entering must knock on the door unless medical condition of the resident dictates otherwise. Personal belongings should be secure and accessible. You need to be certain that the residents are provided the utmost privacy when bathing, toileting or dressing and undressing.

Rights # 14 & #15

#14. Right to be treated fairly with dignity and respect and be informed of services

#15 Right to be free of mental and physical abuse including restraints

#14 All residents must be treated with dignity and respect by all persons who have contact with the resident. Anyone providing a service in the facility to the resident should provide verbally and in writing an explanation to the resident. If you as an employee see a person with whom you are not familiar, stop the person and question who they are. Do not assume that everyone wearing scrubs or a lab coat is “OK” to be in the facility.

#15. Residents have the right to be free of any form of physical or mental abuse including restraints. A restraint is anything including a chemical or drug that prevents the resident from being in control of their own movements and decisions. Restraints may be used only in cases of emergency whether it is physically tying the patient down or giving the patient a medication to sedate them. Physical restraints may only be applied by a qualified licensed nurse (or physician) under a specific order from a physician and the restraints must be for a specified period of time. All information related to the use of the restraint must be documented by the nurse. The physician must be notified every time a medication is used specifically as a chemical restraint. Verbally intimidating a patient to change behavior is not allowed as it is considered a type of a restraint since the residents must rely on the staff to care for them. This includes such statements as “If you don’t sit down, I’ll lock you in the closet.” Patients can not be isolated for punishment or staff convenience. Restraints are only to be used for resident’s protection.4

Rights # 16 & #17

#16 Right not to be involuntarily transferred or discharged by the facility except under specific conditions.

#17 Right to freedom of choice of physician, pharmacy, and activities

#16 is a complicated right that states residents may not be unwillingly or involuntarily transferred or discharged by a facility except under specific circumstances. These circumstances include medical reasons and the welfare of other residents. The resident must be given at least 30 days written notice and the resident and family must be included in selecting a new facility. The 30 days is waived only in case of emergency that is determined by a licensed staff member or in the case of conflicting rules and regulations that govern Medicare and Medicaid. Any facility licensed by Medicare or Medicaid cannot discharge or transfer a resident for nonpayment of a bill. For other payment source nonpayment, 30 days notice is required to the resident or responsible party. Any facility licensed by Medicaid that attempts or requires a waiver of the right pertaining to nonpayment will be subject to disciplinary actions.

#17. The right to freedom of choice of physician, pharmacy and activities. A resident cannot merely be assigned to a physician without first discussing it with them. If the resident is dissatisfied with their physician, they must be allowed to fire that physician and have a different physician. Some facilities use specific companies to provide medications. If the resident can choose to use a community based pharmacy but the one chosen must provide medications in the same manner as the rest of the facility. This means that if the facility has unit dose as the style of medication delivery then the resident must choose a pharmacy that provides unit dose. 4

Rights # 18, 19, & 20

#18 Right to retain and use personal belongings

#19 Right to a copy of the rules of the facility and the resident’s responsibilities

#20 Right to prior notice of a room change

#18. Residents have the right to retain and use personal belongings such as those shown on the slide unless the patient’s condition contraindicates the use of specific items. If not medically allowed, the physician must document the contraindication in the resident’s medical record. The amount of clothing and personal possessions allowed is based on space available for each resident and the rights of other residents cannot be infringed upon. As a CNA, you can help residents to organize and best use the space available to them and try to resolve any issues pertaining to space usage by residents.

#19. Resident’s rights must be given to each resident in writing. The only resident responsibility that is specifically defined in the Florida statute, Chapter 400, is that each resident has the responsibility to obey the rules and regulations of the facility. Each resident is also expected to respect the personal rights and property of the other residents. Another expectation is that the resident and/or their legally responsible representative is truthful in the information that they provide about the resident.

#20 Each resident must be given prior notice to a change in their room. For example, if the resident has an overnight stay outside the facility, their room cannot be changed in their absence.4

Rights #21 & 22

#21 Right to be told about the bed reservation policy of the facility

#22 In Medicare and Medicaid facilities, the right to challenge discharge or transfer

#21 When a patient is hospitalized, each facility must hold or reserve the resident’s bed based on the source of the payment for the room. For a single hospitalization with a private pay resident, the bed is held for 30 days provided the nursing home receives reimbursement. Residents who are recipients of Medicaid will have their beds held for up to 15 days unless the agency determines that the resident will not be returning or if the homes occupancy rate ensures availability of the bed for the resident. Each resident must be given notice within 24 HOURS of hospitalization. You need to know this information so that you do not make false promises to the residents concerning their return.

#22. If a facility decides to transfer or discharge a resident who is the recipient of Medicare or Medicaid, the resident has the right to challenge the decision. The rules related to transfer and discharge of residents are covered under #16 right.4

Implementing Residents’ Rights

Staff Training
Statement of Rights
Required contact information

Other requirements for long term care facilities related to residents’ rights include the education and training of all staff members. The facility must address staff education in a written plan and training must include how the resident or the resident’s legal representative receives the information required by the statute. Staff must receive in writing a statement that is boldfaced concerning the residents’ right to file a complaint and the number for the central abuse hotline and information on the ombudsman including name, address, and phone number(s).4

Protection of Rights

Annual Inspection
Discussion with Residents
Consultation with Ombudsman

The state will conduct an investigation of any and all complaints and conduct an annual inspection of the facility to determine if residents’ rights are being adequately provided and protected. This inspection will include private conversations with selected residents who are representative of the population of the facility and the ombudsman council that represents that particular service area.4

Reporting Violations

Immunity from liability
Falsifying a report

Florida statute provides immunity from prosecution to anyone reporting or testifying in regards to violations or suspected violations of residents’ rights. However, if the court decides that the person has falsified a report or basically had no reason for the complaint, the person filing a false report can be prosecuted.4

SUMMARY

The ombudsman program was established to provide advocates for long-term care residents
The State Laws of Florida list 22 rights that must be provided by long-term care facilities for residents
Facilities are required to give a copy of these rights to residents BEFORE they are admitted
Residents have the responsibility to follow the rules of the facility
Facilities must post the resident rights including how to report complaints
CNAs must know what resident rights are and what behaviors can violate these rights
False reporting can result in prosecution but you can not be prosecuted for filing an actual violation

Above summarizes the resident rights and the role of the CNA in providing them.

REFERENCES
Department of Health & Human Services. Administration on Aging Homepage. Available at: http://www.aoa.gov/eldfam/Elder_Rights/LTC/LTC.asp Accessed January 23, 2007.
National Long Term Care Ombudsman Resource Center. Where Can I Go For Help? Available at: http://www.ltcombudsman.org/static_pages/help.cfm Accessed January 23, 2007.
Florida Long-Term Care Ombudsman Program-Department of Elder Affairs. Residents’ Rights. Available at: http://ltcop.myflorida.com/residents_rights.jsp Accessed January 23, 2007.
Online Sunshine. The 2004 Florida Statutes. Title XXIX. Chapter 400. Available at: http://www.leg.state.fl.us Accessed February 1, 2007.

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Risk Management & Employee Responsibilities: It's Not Just the Reporting!

noemail@akhealthcare.com — Sun, 01 Jan 2012 13:00:00 GMT

Objectives:

This activity will cover the risk management side of long term and assisted living care, with a focus on the responsibilities of the certified nurse assistant. Reporting is not the only role that the CNA has related to risk management. Taking an active, not reactive, position in identification of the potential for accidents, falls, hazards etc. is a key component to successfully maintaining a safe environment for both you and the residents of your facilities.

OBJECTIVES
   1. Discuss the purpose of healthcare risk management and the role of the CNA
   2. List the requirements of the State of Florida.
   3. Describe the importance of attitude and intervention related to risk management.
   4. State the difference between an accident and an incident.
   5. Discuss when an incident report should be filed and the information required.
   6. Describe proper documentation of an incident or accident in the medical record.
   7. State the legal aspects of incident reports.

Software Requirements:

<td style="border-right: #ece9d8; padding-right: 7.5pt; bo Instructor: Virginia McCarty, RN, CIC, LHRM

Release Date: 1-Jan-12 8:00 AM
Expiration Date: 31-Jan-14 8:00 AM

Risk Management
&
Employee Responsibilities:
It’s Not Just the Reporting!

The Purpose of Risk Management in Healthcare

Healthcare facilities have risk management programs to:

protect residents and staff
prevent loss of revenue
protect the reputation of the facility

Risk Management programs in healthcare facilities are established for several different reasons. First of all, risk management should exist to protect both the residents and the staff members of a facility from injury within and on the premises of the facility. Facility assets must also be protected through property theft prevention and prevention of lawsuits. When these first two objectives are met, the reputation of the facility is protected.

Role of the CNA
As a CNA, you can participate in risk reduction by:

Following policies and procedures
Being aware of your surroundings
Correcting potentially unsafe conditions
Reporting to your supervisor

Employees play a vital role in risk management since they are the ones who are in contact with residents, other employees, and the environment within the facility. To protect yourself and the facility from potential legal issues, you must know and follow the policies and procedures of the facility in which you work. This includes everything from the type of shoes you wear to work— to releasing information concerning the residents of the facility.

Keep in mind that the policy related to the type of shoes allowed was established for multiple purposes including your safety at work. For example, a nonskid shoe may be required because the floors are tile and that type of shoe prevents slipping easily. A “closed toe shoe” will provide protection from sharp objects and the potential for injury if you bump into a bed or other structure while performing your duties. Releasing confidential information on either residents or the facility can be the grounds for a lawsuit and damage the reputation of the facility.

It is important to be aware of your surroundings and if you see a potentially harmful situation, correct it. A resident may have a shoe untied or water may be spilled on the floor. Don’t decide to fix such hazards “later on”; fix it when you see it. When a situation arises that you do not know how to handle, contact your supervisor immediately. Also, file an incident report which we will discuss more in depth later in this program.

Florida Statutes
Chapter 400.147

Internal risk management and quality assurance program

Designated person
Committee
Incident reporting system
Education and Training

The Florida Statutes, Chapter 400.147, states that every nursing home shall have an internal risk management and quality assurance program. Specifically, the law states that there must be a designated person to be the risk manager who is responsible for the overall program—you as an employee need to know who that person is. The facility is also required to have a committee consisting of the risk manager, the administrator, the director of nursing, the medical director and three other members of the facility staff that meet monthly.

Policies and procedures must be developed and enforced related to the investigation of specific adverse incidents. All healthcare workers in the state of Florida have an affirmative duty to report adverse incidents to the risk manager. An affirmative duty to report means it is not your choice whether to report or not, you must report per state law. The incident report must be filed within 3 days to the risk manager or the risk manager designee. All non-physician staff is required to have risk management education in orientation and one hour of such training annually.1

Requirements Continued

Analysis of grievances
Types of adverse incidents
Code 15s
Sexual Misconduct

Additional requirements of the state related to a risk management program are to analyze the grievances and adverse incidents that are reported within the facility. The analysis should include the types of grievances related to patient care , any violations of resident’s rights, the approaches used to reduce the occurrence and severity of grievances and the support given by the facility to implement and facilitate these approaches.

The state defines an adverse incident as an event that the personnel in the facility could have controlled but failed to do so and the result was a serious outcome for the patient. The statute lists the following as adverse incidents that must be investigated and reported within 15 days of the occurrence and are thus termed “Code 15s”:

Death, brain or spinal damage
Permanent disfigurement; fracture or dislocation of bones or joints
A limitation of neurological, physical, or sensory function
Any condition that required medical attention to which the resident has not given his or her informed consent, including failure to honor advanced directives; or any condition that required the transfer of a resident, within or outside the facility, to a unit providing a more acute level of care due to adverse incident, rather than the resident’s condition prior to the adverse incident; abuse, neglect,
or exploitation as defined in s.415.102;
Abuse, neglect and harm as defined in s. 39.01; resident elopement;
"An event that is reported to law enforcement.”
If a resident falls and requires surgery as a result of the fall, and the fall resulted from our failure to have safe equipment for transport, it must be reported within 15 days. Sexual misconduct allegations against a person employed by the facility who has direct contact with the residents must be investigated and the allegations reported to the facility administrator. The resident representative or guardian must be notified of the allegations and the investigation.1

Attitude
First Impression

You never get a second chance to make a good first impression---don't forget that.

The attitude you portray is the initial impression you make on people. A smile says that you are friendly and willing to help whereas a sullen expression says to others, “leave me alone.” In your role at the nursing home, you are the person having a significant amount of contact with the residents. They and their families need to feel comfortable in the knowledge that you will provide for their needs. Think about your own reaction to people. If you are in a store and need help, you are going to approach the person who is smiling and seems friendly, not the one looking straight ahead and appearing disinterested. Your attitude will go a long way in making residents and their families satisfied. A friendly, helpful attitude gains you the respect not only of the residents but of your co-workers. Additionally, it pays to be nice because people seldom sue people that they like.

Intervention
DO something when situations aren’t right

Decide what is wrong
If it can be fixed immediately, fix it
If you need help, get it
Communicate
Report

In addition to having a good attitude, intervening at the time an issue or situation is identified is extremely important. Managing the risks that occur within a facility requires the attention of everyone as no one person can be the eyes and ears for the entire facility.

Whenever you recognize that either a danger exists or a situation has developed that can lead to an accident or injury, you should decide what’s wrong and then act. Sometimes fixing the situation is easy like wiping up spilled water that is on the floor. Other times, the problem is more complex as seen here. Suppose a chair has a loose leg on it. You know that the leg of the chair is eventually going to break and could cause harm to someone. Don’t pretend not to see it. Remove the chair or turn it to make it inaccessible, tag it for repair, and follow the facility procedure to have maintenance come take the chair for repair. If you need help to correct a situation, get it. Communicate with other staff members and residents as appropriate. File a report with the supervisor as indicated.

Incident Reports

WHAT is an Incident Report?

WHY are Incident Reports important?

WHEN should you file an incident report?

Your facility has a system for reporting events that are out of the ordinary and is generally referred to as an Incident Report. Incident reports require specific information so that an investigation can be completed on all significant events that occur. The events may seem minor but if a series of the same event is occurring within the facility, it can be much more important than you think.

When the incident reports are reviewed by the Risk Manager for your facility, trends can be identified. Perhaps there is a safety issue related to the condition of the wheelchairs throughout the facility. By reporting incidents, corrections can be made before an injury occurs.

An incident report should be filed as soon as possible when an event occurs and generally before your shift ends. All incident reports must be reviewed by the Risk Manager with in 3 business days after the occurrence of the incident.1 Incident reports are used for all incidents and all accidents. Some facilities may have an additional form for reporting accidents if it involves a motor vehicle.

Incident and Accidents

Aren’t incidents and accidents the same thing?

What’s the difference?

Incident reports can be filled out for either an accident or an incident. You’re probably thinking, “Aren’t they the same thing?” Actually, no, they are not. An incident is an event that occurs. An accident is an unintentional event that usually results in harm or injury. So an accident can be an incident but not all incidents are accidents. In the picture on this slide, this could be an incident such as a heavy object falling through the floor. However, if the heavy object fell on someone and injured them, then it is an accident.2

WHAT should be reported?

Accidents
Missing items
Violations of policy and procedures
Equipment failures
Confrontations that escalate
All incidents that are out of the ordinary

There are numerous things that occur that are out of the ordinary. This slide lists quite a few. Missing items should be reported whether they belong to an individual or the facility. All violations of policy and procedure should be reported as all employees are expected to act within the policies and procedures. If someone fails to place a “wet floor” sign when mopping the floors or improperly restrains residents, an incident report should be filed.

Equipment that fails to function as it is intended needs to be repaired or replaced. Confrontations between residents, employees, physicians, or visitors should be reported if they escalate to a point of concern. All incidents that are out of the ordinary should be reported especially if it is possible or likely to recur or if injury could result to anyone or the facility. An example of a potential injury to the facility would be a visitor taking pictures and asking staff about security measures or being contacted by a lawyer or a reporter concerning the facility or residents.

Information Needed

In filling out an incident report, there is specific information that must be included.

Name of the person(s) involved including witnesses
Date and time of the event
Brief description of the event
All persons who were notified of the event
Corrective actions already taken

When filling out an incident report, it is absolutely necessary that you complete all the information that is asked for on the form. Do not leave spaces blank. Include the names and at least the phone numbers of all witnesses.

In describing the event, include only the FACTUAL information not your opinion of what occurred. For example, if a wallet is missing, do not state that John Smith may have taken the money because he has been working a lot of overtime to pay his bills. However, if you saw John Smith in the room ten minutes before the wallet was noticed missing, you state that fact in the report. KEEP IT BRIEF!! If you notify your supervisor, the resident’s physician, the police or others, put that in the report. If a person has fallen and you remove the rug or item that caused the fall, say so in the report.

DO NOT REPORT

The purpose of an incident report is to alert others especially the risk manger to events that need to be investigated and corrected.

Do NOT use the incident reporting system to target an individual or pursue your own personal agenda.

As stated above, incident reports serve a purpose of notification of situations that require investigation and correction. If you have a personality conflict with a coworker or another individual, filing numerous reports to make that person look bad should not be done. However, if the individual is failing to follow policy and procedure, then it should be reported.

DOCUMENTATION

If an incident or accident occurs involving a resident, the facts of the event must be documented in the medical record of the resident.

DO NOT DOCUMENT THAT AN INCIDENT REPORT WAS FILED

Incident reports are created to be used as internal reporting mechanisms. Filing an incident report should not be documented in the medical record nor should the physician write an order for one to be filled out. However, if there is an accident such as a resident falling, the fact that the fall occurred must be documented in the record including any injuries, persons notified, and treatment that the resident received. In other words, all the information that will be included on the incident report. Simply do not write in the medical record that the incident report was filed. In Florida, incident reports are not admissible as evidence in court, but if they are part of the medical record, they could be.1

LEGAL ASPECTS

YOUR LEGAL INVOLVEMENT

The person who files an incident report can NOT be sued because they filed the report

In Florida, you don’t have any civil liability and can’t be sued for filing an incident report.1 The incident report is not punitive—in other words, you will not be punished by your employer for filing an incident report.

SUMMARY

The main purpose of Risk Management is to protect the people, finances, and reputation of the facility.
Florida requires healthcare facilities to have risk managers who report specific events and manage a facility incident reporting system.
The CNA’s role in risk management is to report all unsafe conditions, correct the condition as soon as possible, have a good attitude, and report all incidents to your supervisor.
Incidents are any and all unusual events and accidents are incidents that result in harm.
Always completely file out an incident report and NEVER record doing an incident report in the medical record.
ALWAYS document the facts of an incident report in the resident’s medical record when the resident is affected.
In Florida, the person who files an incident report can’t be sued for filing it.

In summary, the main purpose of Risk Management is to protect the people, finances, and reputation of the facility. Florida requires healthcare facilities to have risk managers who report specific events and manage a facility incident reporting system. The CNA’s role in risk management is to report all unsafe conditions, correct the condition as soon as possible, have a good attitude, and report all incidents to your supervisor. Incidents are any and all unusual events and accidents are incidents that result in harm.

Always completely file out an incident report and NEVER record doing an incident report in the medical record. ALWAYS document the facts of an incident report in the resident’s medical record when the resident is affected. In Florida, know that the person who files an incident report can’t be sued for filing it.

REFERENCES

Statutes & Constitution: View Statutes. The 2006 Florida Statutes. Title XXIX. Chapter 400. Nursing homes and Related Health Care Facilities. Available at: http://www.leg.state.fl.us Accessed February 13, 2007.
Definitions from Dictionary.com. Available at: http://dictionary.reference.com/browse/accident Accessed February 13, 2007.

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OBJECTIVES

RESIDENTS RIGHTS and RESPONSIBILITIES: Protection for Residents in Long Term Care Facilities

Ombudsman Program

Risk Management & Employee Responsibilities: It's Not Just the Reporting!

The Purpose of Risk Management in Healthcare

Healthcare facilities have risk management programs to:

Role of the CNA As a CNA, you can participate in risk reduction by:

Florida Statutes Chapter 400.147

Requirements Continued

Attitude First Impression

Intervention DO something when situations aren’t right

Incident Reports

WHAT is an Incident Report?

WHY are Incident Reports important?

WHEN should you file an incident report?

Incident and Accidents

Aren’t incidents and accidents the same thing?

What’s the difference?

WHAT should be reported?

Information Needed

DO NOT REPORT

The purpose of an incident report is to alert others especially the risk manger to events that need to be investigated and corrected.

Do NOT use the incident reporting system to target an individual or pursue your own personal agenda.

DOCUMENTATION

If an incident or accident occurs involving a resident, the facts of the event must be documented in the medical record of the resident.

LEGAL ASPECTS

YOUR LEGAL INVOLVEMENT The person who files an incident report can NOT be sued because they filed the report

SUMMARY

Click here to begin evaluation

Role of the CNA
As a CNA, you can participate in risk reduction by:

Florida Statutes
Chapter 400.147

Attitude
First Impression

Intervention
DO something when situations aren’t right

YOUR LEGAL INVOLVEMENT

The person who files an incident report can NOT be sued because they filed the report