NCLEX: Promotion of Function and Health of Residents

Promotion of Function and Health of Residents: Health Maintenance and Restoration

Focus topic: Promotion of Function and Health of Residents

Health maintenance and restoration includes measuring vital signs, height, and weight. Vital signs include the temperature, pulse, respiration, and blood pressure—all essential elements of life, thus the term vital. Accurate measurement and recording are important skills in determining the overall health of the resident.

Careful attention to vital signs can save a life. Age-related factors that affect vital signs include age, sex, time of day in which vital signs are measured, illness, emotions, activity and exercise, food intake, and medications. Often, a change in one vital sign will affect the other vital signs. For example, when the resident has a fever (temperature over 101 degrees), the pulse rate andrespirations will also increase.

It is important to weigh residents carefully as ordered. Consider clothing, shoes, and other articles when weighing the resident because weight can be affected by clothing. Report any dramatic changes in weight because these changes might indicate a nutritional deficiency, fluid retention, or a serious illness.

Determining resident height is an important measure when admitting a resident; record subsequent measurements at least annually or as required by facility protocols. Changes in posture due to problems in the musculoskeletal system can be determined by monitoring resident height.

General guidelines that apply to measuring vital signs are as follows:

  • Explain the procedure to the resident.
  • Delay measuring the oral (PO) temperature at least 15 minutes for residents who have recently smoked or who have had a hot liquid.
  • Arrange the steps of measuring vital signs, height, and weight to conserve energy and increase efficiency.


Focus topic: Promotion of Function and Health of Residents

Follow product guidelines for use of tympanic thermometers, sphygmomanometers (blood pressure cuff), and stethoscope to ensure accuracy in vital signs measurement.

  • If taking an axillary temperature, make sure the axilla is dry; record the reading with an A, indicating the method used; and follow other facility guidelines for use of approved medical abbreviations or terms.
  • f unsure of any reading, repeat the procedure and report your findings.


Focus topic: Promotion of Function and Health of Residents

Blood pressure measurements should be taken in the arm which records the highest reading with the resident sitting or lying. The initial blood pressure reading should be taken in both arms with the resident lying supine, sitting, and standing; record each measurement.

  • The radial pulse (pulse felt at the wrist) should be measured for at least one minute if the resident has heart disease. When taking the apical pulse (listening to the heart beat at the apex, or tip of the heart), listen for at least one minute and record the reading.
  • Respirations (includes inspiration and expiration) should be counted for one minute, noting any difficulty in breathing (dyspnea) or pauses in the rhythm of the respirations or the pulse.
  • Review the facility’s procedure for using a wheelchair scale or other equipment for immobile residents who cannot stand on a scale.
  • Record and report vital signs, height, and weight promptly.


Focus topic: Promotion of Function and Health of Residents

Carry a small pad or other means of recording the vital signs at the bedside so you will remember them; this is especially important when completing vital signs for multiple residents.

  • Clean all vital sign equipment after each use, especially stethescope heads, to prevent cross-contamination.

Promotion of Function and Health of Residents: Psychosocial Care Skills

Focus topic: Promotion of Function and Health of Residents

Assisting residents to meet their basic needs includes their emotional and mental well-being, also called psychosocial needs. These needs are as important as the physiological needs discussed previously. All residents living in a long-term care facility are no different from other people who need to feel worthwhile, loved, and secure in their relationships with others. Having these needs at least partially met can contribute to their overall health and welfare.

Promotion of Function and Health of Residents: Emotional and Mental Health Needs

Focus topic: Promotion of Function and Health of Residents

Being mentally and emotionally healthy means being able to cope with the effects of aging, adjusting to life changes such as being dependent on others, losing loved ones and friends as well as changes in social life. Those who feel good about the past will often cope well with aging, remaining hopeful and optimistic about the future. Adjusting to aging is a difficult time for some residents who might long for those more productive years, who have lost a spouse or significant other, and who must now face the future alone and in a strange environment. Memories for them might be painful, especially if they did not achieve their life goals or regret past experiences. Leaving the familiar surroundings of home, past friendships, and past lifestyle can be depressing for the resident who feels lonely and isolated. Equally, residents might also become depressed in the long-term care environment and feel resentment toward family who, in their opinion, abandoned them. Elders, especially widows and widowers, are at high risk for suicide because they can fall deeper and deeper into depression that might go unnoticed by family, friends, or caregivers.

Caring about residents as well as for them is a key ethical component of nursing assistant practice. It is often easier to meet the physical needs of residents than to address their psychosocial and emotional needs. Actions, however, speak louder than words such as spending time with residents, listening to them, showing interest in them and their lives, and encouraging social interaction with others. Being kind, considerate, and compassionate are attributes described in Chapter 1, “What You Need to Know to Prepare for the Exam”; they bear repeating here as well. Demonstrate your genuine concern and acknowledgement of each resident as a worthwhile person who deserves your respect and positive regard. You can encourage residents to participate in their care and activities, which will help improve their sense of independence, self-control, mood, and outlook. Encouraging family members and friends to visit and involving residents in activities helps to meet their social needs. Being observant when working with residents by watching and listening for cues to their mood is very important because you will spend more time with them than any other care giver. Report any signs or symptoms of depression to the nurse so that interventions can be made to protect the resident and improve his or her quality of life in the long-term care facility.

Promotion of Function and Health of Residents: Cultural Needs

Focus topic: Promotion of Function and Health of Residents

Be aware of residents’ unique needs, desires, and meaning in life based on their cultural practices. This is particularly important when planning care for residents that will satisfy them and build their trust.

Promotion of Function and Health of Residents

Residents’ cultural beliefs affect how they view illness or infirmity and, more importantly, how they respond to health problems. For example, people from certain non-western cultures believe that seizures result from the wandering of the soul, a supernatural cause. They might seek treatment from a shaman, or community healer who can perform a ritual to restore their soul. This is different from western cultural beliefs in the scientific explanation of seizures as being caused by a neurological abnormality. This cultural conflict could impact the resident’s acceptance of traditional medication to treat a seizure.

Another example of cultural differences is the value in North American society in individualism, or the ability to take care of self and remain independent of others. Asians, Africans, and Hispanics, however, rely on active family and community support and involvement in their care. This might be seen, for example, in an Asian elder who refuses rehabilitative care after hip surgery until her family can be present.

Many Southeast Asians use folk remedies while Haitians and South Americans might use herbals, or potions, and wear jewelry (amulets) to ward off evil spirits that cause illness. Native Americans use prayers, chanting, and herbs to treat illness, often thought to stem from supernatural as well as physical causes.

Certain cultures also respond differently to pain and suffering. Asians might become stoic and choose not to report pain while Hispanics might complain quite vocally when distressed.

These are only a few examples of how cultural differences of residents might affect their health and illness behavior. You must be able to understand each resident in light of his or her culture, being careful not to dismiss his or her beliefs or minimize the role that culture plays in health and well-being. Accepting cultural differences demonstrates your ability to truly accept all residents with dignity and care.

Promotion of Function and Health of Residents: Spiritual Needs

Focus topic: Promotion of Function and Health of Residents

Spirituality is defined as finding the inner meaning, or essence of life. Spiritual health refers to the wholeness of a person and the ability to connect with something larger than self. This sense of completeness or self-fulfillment is called self-actualization and, according to psychology, meets the highest level of basic human needs. Spirituality might be expressed by residents who find meaning in nature, music, or other expressions that reflect their beliefs of a supreme being or higher power. Healthy people have a positive spirit, meaning they find hope and confidence in the future. They view life with a sense of humor. The human spirit is also a powerful force in life when a person faces difficulties or life crises. The opposite of spiritual health in this case is called spiritual distress, or the feeling that the future is hopeless. Spiritual distress can lead to or increase the severity of illness or infirmity. Research describes elders who lose the will to live due to spiritual distress and, despite interventions to the contrary, die soon after hopelessness occurs.

Spirituality is often linked with an organized, formal religion that includes rituals and other behaviors that express faith; however, spirituality is not directly connected to religion. The freedom and opportunity to observe religious practices enables the resident to meet his or her spiritual needs and, thus, is important to maintain.

The best way to support resident’s spiritual needs is to find out what matters most to them. Listen to what they say about spirituality and their spiritual needs. Establishing a caring relationship with residents, known as rapport, will help residents more openly talk about their spiritual needs and how you can support them. The following principles apply when addressing residents’ spiritual needs:

  • Organize care to enable residents the opportunity to practice their own religion.
  • Handle any religious objects used by the resident with care and respect.


Focus topic: Promotion of Function and Health of Residents
Praying with residents or participating in their religious practices is appropriate but not required.

  • If you are uncomfortable with participating in the resident’s religious practices, consult with the licensed nurse who can refer the resident to a religious counselor or volunteer to assist them with making religious services or other forms of spiritual expression possible.
  • Stay open to residents whose beliefs and spiritual practices might differ from your own.
  • Be careful not to ignore, disapprove of, or judge a resident’s spiritual practices.


Focus topic: Promotion of Function and Health of Residents
Do not impose your own religious beliefs on residents. This is a form of prejudice, which is unacceptable in a health-care environment.

  • Respect the resident’s choice not to participate in religious activities.
  • Encourage residents to express other forms of spirituality that do not include religious activities.
  • Express your own spirituality to impart hope and a sense of humor when relating to residents.

Promotion of Function and Health of Residents: Sexual Needs

Focus topic: Promotion of Function and Health of Residents

Sexuality, or expressing one’s sexual needs for intimacy is important to residents and should not be ignored. Physical sexual expression involves more than love-making and includes touching, caressing, cuddling, and other forms of human touch. Psychologically, love and affection and a sense of belonging also involve sexual expression. Contrary to popular belief, sexual desire does not decrease with aging. However, the physical response to desire can be affected by neurological and circulatory changes due to conditions such as diabetes, cardiovascular disease, or chronic illness. It is important for you to be aware of your own feelings about sexuality to help residents meet their sexual needs.

Equally important is your knowledge that residents have a right to express their sexual feelings and must be given such opportunities as are appropriate in the long-term care setting. It is important to provide privacy for residents who need to express their sexual desires. Displays of affection toward you or other residents are normal according to the customs of common courtesy and social etiquette. However, you must frankly and clearly confront sexual behavior that is unacceptable to you or others. For example, if a resident makes unwanted sexual advances toward you or another resident, firmly and specifically state your objection to the advance. This includes flirting, which the resident might defend as merely teasing. Such defense is unacceptable, even if prompted or aided by illness, medication, or mental state. Kindly inform the resident that the behavior must stop immediately. Be as specific as possible,for example, “I need you to remove your hand from my breast immediately.” Serious breaches of etiquette related to sexuality should be reported immediately to your supervisor in order to protect yourself and other residents.

Promotion of Function and Health of Residents: Data Collection and Reporting

Focus topic: Promotion of Function and Health of Residents

Your ability to observe residents while caring for them is an essential skill you bring to work. Collecting data and reporting changes in residents’ conditions can be life saving. You spend the majority of your shift providing direct care to residents, which is a good time to learn from them what is happening to them and how they are progressing with their plan of care. Small changes in condition can make a big difference in a resident’s well-being. For example, noticing a resident not talking with you as much as the day before might signal a developing infection or change in neurological status or mood. Changes in vital signs that might not seem alarming to others might alert you that the resident needs further assessment by the nurse. Assisting the resident with ADLs gives you the opportunity to use your sense of smell, touch, sight, and hearing to detect changes in the resident that warrant follow up. Using your senses helps validate what you can directly observe, also known as objective assessment. Subjective findings are those observations you conclude from what the resident reports to you that cannot be seen directly; these are also referred to as symptoms. Resident’s statements of pain, distress, or general health belong to this category of observation and can be as significant as your direct observations. Be careful not to underestimate subjective reporting and take the resident’s report at face value. Ignoring the resident’s statements can cause you to miss important clues to health changes that could become life-threatening if left unattended.



Focus topic: Promotion of Function and Health of Residents

Following your gut, which means your intuition or hunch, is actually based on past experience with residents and can serve you well in your work to keep residents safe and secure; don’t ignore your intuition, but act on it.

General guidelines for data collection and reporting resident health status are as follows:

  • When reporting changes in a resident’s condition, use his or her own words as much as possible to promote objectivity and accuracy.
  • Ask the resident to repeat any statements regarding his or her condition to be sure you understand what is being reported to you.
  • Report any change in
    . Vital signs, including weight changes
    . Skin changes, including, but not limited to, cyanosis (blue skin color); size or appearance of moles or other skin lesions; skin temperature; and rashes or redness
    . Weakness or dizziness; syncope (fainting)
    . Signs or symptoms of abuse or neglect
    . Edema anywhere in the body
    . Mood changes or any change in resident behavior
    . Coughing or spitting up blood
    . Vomiting
    . Diarrhea or constipation
    . Environmental hazards
    . Any suspicions that cannot be verified but that still cause you any undue concerns for the resident’s welfare

Recording resident information is another important task you perform daily. Recent changes in technology now might require a basic ability to use the computer or other electronic devices for documenting/recording care and observations. It is important to use correct grammar and spelling as well as acceptable medical terms and abbreviations.


Focus topic: Promotion of Function and Health of Residents

Review medical terms and abbreviations on the Cram Sheet to help you prepare for the WE.

If recording your observations and care on a written form, be sure to document in blue or black ink only and print legibly, accurately, and completely to ensure proper documentation of what occurred while working your shift. Sign your name and title to all entries. Record your work promptly to ensure accuracy and completeness; make corrections as needed according to the facility’s guidelines. Never erase, scratch out, or use a liquid eraser to correct your charting.Remember that the resident’s chart is a medical record and, as such, is a legal document and can be used in court.


Focus topic: Promotion of Function and Health of Residents

Always record your work as though an attorney is reading it.

Seek help from the nurse or your supervisor in charting situations that require consultation to ensure that your documentation is thorough, concise, and as objective as possible.




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