NCLEX: Specialized Care

This chapter reviews specialized care for residents experiencing more severe physical problems and psychological issues, and those who are dying.

Specialized Care: Physical Problems

Focus topic: Specialized Care

Physical problems reviewed in this section focus on acute and chronic conditions affecting major body systems.

Specialized Care

Specialized Care: Vision Impairment

Focus topic: Specialized Care

Residents with hearing and vision problems are at high risk for injury, communication difficulties, and a potential for social isolation and loss of self-esteem. Common vision problems include chronic conditions such as glaucoma, a disease in which excessive pressure builds inside the eye that can cause blindness if left untreated. Cataracts, a clouding of the lens, prevents clear vision. Macular degeneration causes the loss of central vision while leaving side-to-side, or peripheral, vision intact. Diabetic retinopathy, a complication of diabetes, causes hardening of the arteries that carry blood and oxygen to the eye as well as damaging the retina. To ensure safety and security as well as improve their quality of life, it is important to assist residents with impaired vision by following these principles:

  • Knock before entering the resident’s room, identify yourself, and announce your entry.
  • Keep the resident informed of the placement of room furniture and belongings.
  • Arrange personal articles and other equipment and supplies within easy reach of the resident and encourage their use.
  • Keep the resident’s room clean, uncluttered, and safe.
  • Maintain adequate lighting.
  • To reduce glare, keep light sources behind the resident instead of behind you.
  • Maintain the resident’s bed in its lowest position.
  • Explain everything you are about to do for the resident and alert the resident when you have completed each task.
  • Explain any extraordinary sounds in the environment.
  • Stay within the resident’s field of vision to enable the resident to focus on your face and voice.
  • Speak in a pleasant tone of voice.
  • Use a gentle touch to communicate.
  • When assisting the visually impaired resident to eat, open cartons or assist with feeding but encourage as much independence with eating as possible.
  • Use the hands of the clock to teach the resident the location of the foods on the plate.
  • Ensure that the resident can locate and touch the light before leaving the room.

EXAM ALERT
If feeding a vision-impaired resident, announce each food, allow for sips of liquids, and pace the feeding to conserve energy, ensure safety, and enhance social interaction and satisfaction with meal time.

EXAM ALERT
When assisting to walk, stand beside and slightly behind the resident who is wearing the gait belt snugly around the waist; hold the gait belt with your hands to increase your control and help increase the resident’s sense of security.

  • Always announce when you are leaving the resident’s room and make the call light readily available.
  • Keep eyeglasses, magnifying glass, or other reading devices clean, in good repair, and readily available for the resident; report any damage or loss to the nurse immediately.
  • If assisting the resident to care for an artificial eye (also called a prosthesis), follow the facility’s procedure for removing, cleaning, and reinserting it.

 

Specialized Care: Hearing Impairments

Focus topic: Specialized Care

Residents with hearing disorders have trouble understanding speech, especially fast speech; they are also confused by noises, echoes, and hollow sounds. They have trouble understanding accented speech by persons for whom English is a second language because they often pronounce syllables and words differently. Although research indicates hearing loss does not directly affect the activities of daily living (ADLs) of hearing-impaired residents, they do report a loss of interest in socializing, which affects their quality of life.

Communication principles to remember when working with hearing-impaired residents include:

  • Placing yourself directly in front of the resident prior to beginning a conversation
  • Decreasing as much background noise as possible
  • Talking in a low tone and in an unhurried manner

EXAM ALERT
High-pitched sounds are especially hard to understand for those with hearing impairments.

  • Speaking clearly and distinctly
  • Keeping objects out of your mouth when you speak and not covering your mouth when talking
  • Making short statements but long enough to help give the resident a frame of reference; for example, “The chaplain from the First Street Church is coming for a visit today.”
  • Using sign language, finger spelling, teaching posters, note pads, white board, or other visual aids to improve communication
  • Restricting conversation to one topic at a time, changing topics carefully, and giving the resident enough time to follow the change
  • For the resident who wears a hearing aid device, using the same communication techniques as with other hearing-impaired residents
  • Taking special care of hearing aids or other devices and following the facility’s procedure for cleaning and storage to prevent damage or accidental losses
  • Asking the resident to confirm his or her understanding of important information by repeating instructions

Residents with visual or hearing impairments might have other stronger senses to help offset their loss. For example, touch and smell might be stronger; for the visually impaired resident, the ability to hear might be more acute; for the hearing-impaired resident, sight might help compensate for the hearing loss. In all cases, you should encourage residents to use all the senses, called sensory stimulation, or the ability to use one’s senses. Likewise, excessive noise, sights, smells, and sounds can overly stimulate some residents. This is known as sensory overload and should be avoided, especially when the resident is suffering from undue physical or emotional stress or illness.

Specialized Care: Speech Impairment

Focus topic: Specialized Care

Remember some general principles for residents who might be dysphasic (have difficulty speaking). This condition can be due to a nervous system disorder such as a stroke (also called a cerebral vascular accident [CVA]), Parkinson’s disease, Alzheimer’s disease, or an injury that affects the speech center in the brain. Other causes of dysphasia might be a result of surgery to remove cancer from the mouth, oral cavity, tongue, or larynx (voice box) affecting speech. These residents might make sounds but cannot form words. Remember that they understand what you are saying because their speech problem has no effect on their intelligence. They often become frustrated by trying to speak clearly and require your patience as you listen to them. Do not hurry them or try to finish what you believe they are trying to say to you. Using assistive devices such as a white board, visual aids, and so on can help ease the frustration of the dysphasic resident who tries hard to communicate. Praise their efforts and encourage them to use every sense they can to convey their needs and actively participate in their daily activities.

NOTE:

Focus topic: Specialized Care

Always address each resident experiencing vision, hearing, or speech problems with respect. Avoid offensive or demeaning descriptions such as blind, deaf, mute, or disabled. Instead, use terms such as vision impaired, hearing-impaired, or disability.

Specialized Care: Respiratory Problems

Focus topic: Specialized Care

Residents might experience breathing problems that are short term, or acute, such as accidental choking, respiratory arrest, or shortness of breath (also called dyspnea) caused by an allergic reaction to a food or drug or by other medical conditions or illnesses. If left untreated, these acute conditions can become terminal. Respiratory complications can lead to hypoxia, or a lack of adequate supply of oxygen to the body tissues that damage the brain and the kidneys before other organs. Residents in respiratory distress will struggle to breathe and show signs of shock, which causes their skin to turn bluish in color (cyanosis), their blood pressure to fall (hypotension), and their pulse to rise (tachycardia). They will also become confused or combative as they lose oxygen to their brain. If this condition is not corrected, they will stop breathing, a condition called respiratory arrest. Respiratory arrest can occur very quickly if residents develop a life-threatening allergic reaction to a food, drug, or insect sting. Time is of the essence when resuscitating (saving) the resident. This might involve performing the Heimlich maneuver immediately if a parcel of food or other foreign body blocks the airway and the resident begins  choking, cannot speak, and clutches the throat. If the Heimlich maneuver is unsuccessful and the resident stops breathing, call for help and begin rescue breathing by delivering two long breaths by mouth to mouth or mask to mouth technique. Continue breathing for the resident at the rate of at least 12 breaths per minute until the resident resumes breathing or until you are relieved. For severe allergic reactions, the nurse will administer emergency drugs. Oxygen is a drug and, as such, must be administered by a licensed nurse. You can support the resident receiving oxygen by observing the resident’s response to oxygen therapy, that is, the rate, depth, and ease of his or her respirations, skin color, and alertness.

Residents may receive oxygen therapy for chronic diseases affecting the respiratory system, such as chronic obstructive lung disease (COPD), emphysema, or bronchitis. These conditions cannot be reversed and result in a constant struggle to move air in or out of the lungs. Difficult bouts of productive coughing also occur, leaving the resident exhausted. PCP, a special type of pneumonia as a complication of Acquired Immunodeficiency Syndrome (AIDS), can be lethal. Other types of pneumonia can also become life-threatening to residents already weakened by a chronic illness or condition that affects their ability to heal (referred to as debilitating). Surgery also poses a great risk for pneumonia in these residents.

EXAM ALERT
Maintain a safe environment for residents who receive oxygen. Remember to post “Oxygen in Use” signs in the resident’s room, warn visitors not to smoke (oxygen supports combustion), and report any change in the resident’s condition.

Other considerations in caring for the resident receiving oxygen include the following:

  • Position the resident to make breathing as effortless as possible.
  • If confined to bed, change the resident’s position every two hours.
  • Provide mouth care to keep the resident’s mouth clean and moist.
  • Encourage frequent rest periods and arrange activities and care to promote rest.
  • Follow standard precautions for disposing of sputum.
  • Observe special precautions for active respiratory infections, including TB.
  • Observe and record any changes in sputum (changes could indicate infection or bleeding from the lungs).
  • Observe all safety precautions for the resident receiving oxygen.
  • Encourage fluids to help thin secretions; clear liquids are best for this purpose.
  • Encourage proper food intake to maintain nutrition and energy needs.
  • Provide careful skin care, especially the nose (nares) in residents receiving oxygen by nasal prongs, and the cheeks and ears for residents wearing a face mask.
  • Keep face mask clean and placed snugly in place to assure oxygen delivery.
  • Maintain water in wall oxygen reservoir to keep delivered air moist. Change water according to facility protocol.
  • If receiving oxygen via portable tank, do not drop or damage the tank and report any leakage to the nurse; replace the tank to maintain constant oxygen supply.
  • Provide emotional care to ease the resident’s fears of not being able to breathe normally.
  • Keep the call light within easy reach of the resident.
  • Observe and report any changes in the resident’s breathing pattern.
  • Never adjust or discontinue the oxygen.

Chronic or long-term respiratory problems such as emphysema and bronchitis might lead to apnea, or respiratory arrest, which means that the resident stops breathing. The resident will require assistance to breathe artificially with the help of a mechanical ventilator. The ventilator enables oxygen and carbon dioxide to be exchanged. The ventilator tubing connects to a tracheostomy, or permanent surgical opening into the trachea, the air passage from the throat to the lungs. Ventilator-dependent residents must rely on others for their care. Conscious residents might be very frightened by the ventilator and their inability to talk; some might be comatose, or unaware of their surroundings. Special considerations in caring for the ventilator resident are as follows:

  • Remember that you are caring for a human being, not a machine.
  • To protect the resident’s airway, work with another caregiver to move the resident.
  • Measure, record, and report vital signs, noting any change in respiratory effort.
  • Provide personal care and ADLs that protect the resident’s airway.
  • Provide frequent oral care.
  • Keep the ventilator connected to the electrical outlet, and tubes connected and free of kinks.
  • Provide for frequent position changes and rest periods to conserve the resident’s energy.
  • Keep the call light within easy reach of the resident and answer it promptly to help allay resident fears.
  • Speak to the unconscious, comatose resident on a ventilator as though the resident can hear you.

NOTE:

Research shows that comatose persons can often hear but cannot communicate.

  • Offer emotional support.
  • Report any signs of respiratory difficulty or ventilator alarms to the nurse immediately.
  • Never adjust the ventilator settings or remove a resident from a ventilator.

Specialized Care: Cardiovascular Problems

Focus topic: Specialized Care

Cardiovascular problems involve the heart and blood vessels.

Heart Disease

Focus topic: Specialized Care

Heart disease kills more elders worldwide than any other disease. Diseased blood vessels can prevent adequate blood circulation, which can result in pain, disability, and death. The arteries supplying the heart muscle (coronary arteries) can become narrowed (arteriosclerotic) over time or blocked by a buildup of plaque (a patch inside the artery’s lining caused by accumulated fats or calcium also called atherosclerosis). The narrow or blocked artery cannot deliver oxygen to the heart muscle, causing chest pain (angina), which can worsen with any type of strenuous activity. Arteriosclerosis is also responsible for a temporary condition in which the resident experiences dizziness, light-headedness, or confusion due to an inadequate supply of oxygen to the brain, known as a transient ischemic attack (TIA). The resident is at high risk for falling during a TIA. Should this occur when assisting the resident to walk, stop the walk, ease the resident to the floor, stay with him or her, and call for help. Any condition that causes the blood flow into and outside the heart can also threaten the resident’s life. This is one reason why an accurate and thorough description, recording, and reporting of any abnormal pulse rate or rhythm is so important.

EXAM ALERT
A blood clot can develop in a sclerotic coronary artery, stopping the oxygen supply to the heart muscle, which leads to a heart attack, or acute myocardial infarction (AMI). This is a life-threatening emergency requiring emergency care and transportation to the hospital emergency room.

Following a heart attack, the heart is often weakened and loses its ability to pump adequately, which can lead to congestive heart failure (CHF). CHF causes a buildup of fluid in the lungs, resulting in dyspnea and a wet cough or swelling of the extremities (edema). A sudden, severe episode of dyspnea, edema, and urine retention can result in death.

Circulatory Conditions

Focus topic: Specialized Care

Arteries or veins in the circulation of the lower extremities can also be blocked by a clot (thrombus), which can cause swelling, pain, and disability. Signs of thrombosis (a blood clot in the vein) include a reddened, warm area in the lower leg, swelling, and pain, which increases with movement.

If a thrombus becomes dislodged from a vein in the lower extremity, it becomes a traveling clot meaning it moves to the heart, lungs, or brain, causing a heart attack, respiratory distress, or a stroke. Report all resident complaints of sudden pain or dyspnea immediately because these are considered emergencies.

CAUTION:

Focus topic: Specialized Care

If the resident complains of pain in the lower leg or dyspnea, do not massage the affected leg, ambulate the resident, or bend the toes of the affected leg upward because these movements help to dislodge a clot.

Clots in the arteries of the lower extremity can slow or stop circulation. The resident will complain of pain, coolness, and a pale color in the affected leg, which is a condition requiring immediate surgery to restore adequate circulation.

Hypertension

Focus topic: Specialized Care

Hypertension, or high blood pressure, is defined as unusually high blood pressure for an individual, usually exceeding 140/90 after two consecutive readings in the same arm. Hypertensive individuals are more prone to develop heart disease or other medical conditions. Although the cause of hypertension is unknown, diet, obesity, the effects of diabetes, and other lifestyle factors affect blood pressure. Hypertension can affect all body systems, damage organs, and become lethal because it can lead to a stroke. Specialized care of residents with cardiovascular problems or hypertension is similar and includes the following:

  • Follow the plan of care very carefully to promote healing and prevent further complications.
  • Provide foods and fluids, and monitor I & O as prescribed to provide energy and prevent edema.
  • Assist in monitoring the resident’s prescribed dietary restrictions regarding salt, fat, sugar, and fluid.
  • Modify ADLs and care activities to save energy and promote rest.
  • Provide exercise as tolerated to maintain function and activity level.
  • Monitor vital signs and report any changes immediately to the nurse.
  • Provide comfort measures and emotional support.
  • Closely observe and promptly report any changes in the resident’s condition.

FURTHER READING/STUDY:

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