“A Deep Dive Into CNA Training”
To get a better understanding of what CNA training includes, let’s take a close look at the following 8 very important parts of the program:
- Preventing Patient Falls
- Preventing Infections with Standard Precautions
- Isolation Procedures
- Patient Turning and Positioning
- Patient Transfers
- Respect and Dignity
- Patient Privacy and Confidentiality
- Things You Must Know About Patient Identification
Preventing Patient Falls
Why Do Patients Fall?
Falls are a very big concern in healthcare. Preventing patient falls is one of our National Patient Safety goals for long term care facilities and nursing homes. Any fall, whether from a bed, a wheelchair, chair, or stretcher, can lead to serious injuries and even death. Falls must be prevented by nursing assistants.
Patients fall because they are:
- Old and weak
- Blind, or have poor vision
- Have poor balance and coordination
- Not able to control their urine
- Not wearing proper shoes
- In an unsafe area with wet floors or tripping hazards
How Falls Can Be Prevented
Most falls can be prevented by finding out which patients are at risk for falls, and then, doing special things for these people. Nursing assistants have a very special role in the prevention of falls. They have to know which of their patients may fall, and then do special things to prevent a fall.
Below are some of those special things that a nursing assistant learns how to do through CNA training:
- Observing and monitoring the patient more often than is usual for other patients
- Giving the patient a bed that is low to the floor. Although this low bed will not prevent a fall, it will lessen any injury if the patient does fall.
- Putting a gym mat or a pad next to the patient’s bed. Again, this will not prevent a fall, but it will lessen injury.
- Having grab rails in bathrooms and throughout hallways, so the person can hold on while they are walking
- Bed and chair alarms that will alert the nursing assistant when the patient is getting up from bed or the chair without help
- Having the patient do special balance, coordination and muscle-strengthening exercises
- Giving the person their eyeglasses so they can see better
- Giving the patient their cane or walker if these things help the person walk safely
Preventing Infections With Standard Precautions
What are Standard Precautions?
In the past, nursing assistants, and other healthcare workers, did NOT do special things to prevent the spread of infection — unless the patient was known to be infected with something like hepatitis. Today, we know that all body fluids can spread infections, even when the patient and the healthcare workers do not even know they have it.
“Standard Precautions” are defined as special infection control measures that are done for and with ALL patients, whether or not an infection is present or possibly present. These special infection control measures are used whenever there is, or there may possibly be, any contact with any body fluid of the patient. At times, these standard precautions are referred to as “universal precautions.”
It is known that many infections are carried with bodily fluids. Some of these infections are:
- Hepatitis B
- Hepatitis C
What Things Are Done With Standard Precautions?
As you go through your CNA training, you will learn that as a nursing assistant, you must do these things for all patients as you apply standard precautions:
- Properly wash your hands before and after all patient contacts.
- If you are using gloves, remember to wash your hands after you take the gloves off.
- Always wear gloves when you may, or will, touch any body fluids. For example, you must wear them when you are washing a patient who is incontinent of urine and/or feces.
- Wear a mask, eye protection and a plastic apron or gown whenever you may, or will, come in contact with sprays of body fluids. For example, the nursing assistant must wear these protective items when they are in the operating room and the doctor is performing a surgery that involves sprays and splashes of body fluids.
- Dispose of all personal equipment, such as gowns, gloves and masks, in a special biohazardous waste container, not the regular trash.
- Dispose of all patient equipment and supplies in the proper biohazardous waste container after they are used — and have, or may have, some patient body fluids on them.
All of these measures prevent the spread of infection among patients and among healthcare workers.
What is Isolation?
Nursing assistants and other healthcare workers use special isolation procedures for some people who have a particular type of infection that can spread to other patients if these special things are not done. Isolation is used over and above the basic necessary hand-washing and the requirements of standard precautions.
The different types of isolation are:
- Airborne Precautions
- Droplet Precautions
- Contact Precautions
What Things are Done for Each of These Isolation Types?
The things that are done for each of these isolation types are based on the way that germs pass from one person to another. Through CNA training, you will learn about the different paths that germs travel, and which isolation type is used for each way germs pass. For example, airborne precautions stop the spread of infection for very, very tiny germs that are passed in the air, like tuberculosis (TB) and measles. Droplet precautions stop infections that are spread with larger germs that are passed in the air. Some of these infections are pneumonia, mumps and scarlet fever. Contact precautions are used to prevent the spread of infections that can be spread by just touching the area that has the germs. Examples of this type of infection are scabies, impetigo and other infections found on the skin, in a wound and in the person’s GI or digestive tract.
Some of the special things, over and above hand-washing and standard precautions, that are done with airborne precautions are listed below:
- The patient is placed in a private room with a special air system that keeps the room air from entering the hallway. This type of room is called a negative pressure room.
- All healthcare workers must wear a special breathing mask, like an N-95 mask, so they do not inhale these very tiny germs.
- Movement in and out of this room is very limited. People enter only for essential care so that the door is not opened and closed on a frequent basis.
The things that are done for droplet precautions are:
- Placing the patient in a private room. It is not necessary to have a negative pressure room, but a private room is needed.
- Wearing a regular mask when going into the room. An N-95 mask is NOT needed, but a regular medical mask is needed.
- Again, movement in and out of this room is very limited. People enter only for essential care.
Lastly, special things are needed for contact precautions. They are listed below.
- Again, a private room is needed, and movement into this room is limited to only those times when care is necessary.
- Gowns and gloves are needed whenever care is given to the person. This prevents germs from touching the hands and clothing of the nursing assistant, or other healthcare provider.
All gowns and gloves that are used by the nursing assistant are considered contaminated. They, therefore, must be thrown out in a special container or bag that is labeled “Hazardous Waste.”
Patient Turning and Positioning
Why is Turning and Positioning Patients So Important?
People naturally move about in bed even when they are sleeping, as long as they are alert and able to move on their own. This movement in bed prevents skin breakdown, or bed sores, and it also helps to keep all of our joints in a normal position. On the other hand, patients who are weak, in a coma, or in pain, are not able to move about freely in the bed. The nursing assistant, therefore, must position and reposition these kinds of patients at least every 2 hours. This turning and positioning prevents problems such as bed sores and the stiffening of joints into abnormal positions.
What Positions Can Be Used with Patients?
During CNA training, the student has the opportunity to practice several positions that are used with patients. All of these positions keep the person in good body alignment. These positions are called:
- Fowler’s position
- Orthopneic position
- Dorsal recumbent position
- Prone position
- Lateral position
- Sims’ or semi-prone position
Fowler’s position is a semi-sitting position, where the head of the bed is raised up at between a 15- and a 90-degree angle. A low Fowler’s position consists of a lower angle and a high Fowler’s position consists of a higher angle, up to 90 degrees — which is straight up.
This position is good when a person has trouble breathing or swallowing. It is also preferred by many alert patients when they are awake and are confined to bed.
The orthopneic position is one where the patient is sitting in a chair, or in the bed while they are leaning forward over an overbed table. This position is preferred by patients who have severe lung disease, like COPD, when they have trouble breathing in and out. This position allows the chest to expand more fully.
The dorsal recumbent position is a lying-back position with the head supported by a pillow. It is very similar to the supine position, except that in the supine position, the person is lying on the back without a pillow.
The lateral position is a side-lying position. In this position, the person is lying on their side with the uppermost knee bent. They may be supported with a pillow behind their back and between their legs. This position is good because it keeps the person off their back, and lying on the back is the position that most likely will lead to a bedsore if the person is not turned and positioned frequently.
The Sims’, or semi-prone position, is a half-prone and half-lateral position. The person is lying on their side with the lower arm behind the back, the upper arm in front of the patient, and both knees bent. This position is often assumed by pregnant women during sleep. Nursing assistants often place a paralyzed person in this position, on the affected or paralyzed side. It, too, takes pressure off the back, which is where most bedsores form.
Why Is It Important to Get Patients Out of Bed?
Bed rest causes many problems. It can cause, among other things:
- Pressure ulcers, or bed sores
- Lung problems, like pneumonia
- Stiff joints
- The loss of calcium from the bones
- Weak muscles
Out-of-bed activity can prevent these kinds of problems. That’s why patients should be taken out of the bed to walk and to sit in a chair, whenever possible and the doctor approves it.
How to Get Patients Out of Bed Safely
Many patients need help to get out of the bed to the chair, and they also need help to move from the chair back into the bed. This movement is called a patient transfer. Patients who are weak, have a broken leg, or are paralyzed on one side are examples of patients who need help to get out of bed. CNA training includes practice in the skill of transfers, because nursing assistants perform patient transfers very often throughout the course of their work day.
Good body mechanics are needed so the nursing assistant does not hurt their back during these transfers. It is also important to get the help of another nursing assistant when one person cannot do the transfer alone safely. There are also special things that help to transfer patients safely. Examples of these things are:
- A gait, or transfer, belt that is placed around the patient’s waist during a transfer
- A mechanical lift
The Steps to Getting Patients Out of the Bed and to a Chair or Wheelchair
- Plan and get ready for the transfer. This planning is an important first step, and your CNA training will make sure you know how to do it. Get help if needed, and explain the procedure to the patient.
- Put no skid socks or shoes on the patient.
- Raise the head of the bed so the patient is sitting.
- Move the person to a dangling position at the side of the bed by supporting the person’s back and hips into this position.
- Let the person sit at the edge of the bed for about one minute so the person does not get dizzy when they stand.
- Position the chair or wheelchair next to the bed at an angle near the head of the bed. LOCK the wheels of the wheelchair if this is being used instead of a regular chair.
- Face the patient and help the person to stand on the count of three so the patient can help as much as possible.
- Pivot the person into the chair.
- Position the person in good body alignment in the chair.
If the person is weak, paralyzed, or has a broken leg on one side, the chair or wheelchair is placed on the opposite side. For example, if the person is paralyzed on the right side, the chair is placed on the left side so they can use their strong left side to help with the transfer. Likewise, if the person is paralyzed on the left side, the chair is placed on the right side.
Respect and Dignity
Why Are Respect and Dignity So Important?
All people have basic rights. Among them are the right to respect and dignity. Other rights are:
- Making their own decisions
- Freedom from neglect and abuse
- Control over their own money
- Religious freedom
- Competent care when they are in the hospital or nursing home
These rights must be upheld at all times, especially when the person is in the hospital or nursing home. Nursing assistants must be aware of these rights and uphold them at ALL times.
How Nursing Assistants Show Respect and Uphold Dignity
Here are some of the ways that nursing assistants who have gone through CNA training show respect and uphold dignity:
- Use good communication skills and speak to all people, including patients, in a caring, compassionate, and polite way.
- Address people by their name. Greet a patient with “Hello, Mrs. Burke.” Do NOT call them “Honey,” “Sweetie,” “Papa” or “Granny.” These nicknames do NOT show respect.
- Give the person time to talk with you and to express their feelings and questions. Do not act like you are in a hurry. Give the patient time.
- Help the person to be as independent as possible. People have a better sense of self- esteem, dignity and worth when they are able to do things for themselves. For example, a patient may be able to feed themselves, but they are slow eating their meal. A good nursing assistant will only help this person as much as needed, and then, give them the time that they need to eat their meal.
- Give patients as many choices as possible. Allow them to make their own decisions. For example, let the person pick out their own snacks and choose what they want to wear for the day.
- Keep patients clean, dry and well groomed. Dignity is taken away when the person is not neat and clean.
- Maintain privacy and keep the patient covered when they are taking a bath, using a toilet or doing other activities of daily living.
- Make every patient feel special, worthy and wanted every time you come in contact with them.
- Treat all people with the same respect and dignity that you want for yourself. “Do unto others, what you would have them do unto you.”
Patient Privacy and Confidentiality
What is Privacy and What is Confidentiality?
Privacy is defined as the person’s right to be free of any disturbance or intrusion by others. In healthcare, privacy takes several forms. Privacy is maintained during personal care, during private conversation, and in terms of the patient’s medical information.
Confidentiality is defined as a person’s right to have their medical information kept safe and without other people knowing about them and their medical condition.
How is Privacy Protected?
Through CNA training, nursing assistants learn how to protect privacy during patient care in order to maintain the person’s dignity. They learn how to keep patients covered during personal care, and they also learn to always close the doors and pull a curtain around the person to protect their personal privacy.
Patients also deserve privacy in terms of their private conversations with others. We allow patients to have quiet, personal time with friends and family members. We also do not invade the patient’s spaces. For example, you must knock on the patient’s door before entering; and you must never open a person’s closet or a pocketbook unless you are asked to do so by the patient.
How is Confidentiality Protected?
Confidentiality is a major concern in healthcare. The HIPPA law protects this right to confidentiality and it has severe consequences for those that violate it. Criminal and civil charges can be taken against those that violate it. Medical information is highly protected.
Patients have the right to have all of their medical information personal and private. Nursing assistants, and other people in healthcare, must not talk about any patient with other patients, or friends and neighbors. Patient information can only be shared with other healthcare providers who are taking care of the patient. For example, the nursing assistant can speak with the charge nurse about the patient and their condition, but they cannot tell a nursing assistant in another area about the patient and the patient’s condition. We must NEVER talk about patients in the hallways, the coffee shop, the elevator or a restaurant in the community. You never know who is listening.
Healthcare workers can share information only with the people that the patient chooses to get it. Many healthcare facilities list the names of people that the patient wants to be able to get information about them and their condition. Other facilities give the patient a secret pass code that they can share with friends and/or family members so that they can get patient information.
Technology poses a lot of risks in terms of confidentiality. For example, many hospitals have patient information and records on the computer. It is very important to keep the computer screen out of the view of others. It is also important to log off when you are done.
Cell phones are also a problem in healthcare. Some careless people take photos of patients. This is a violation of HIPPA. Others may post information about patients on social media, such as Facebook. This is also prohibited.
Some of the other things that are also done to protect confidentiality are:
- All patient charts and medical records must be kept in a safe place, so that only people caring for the person can read them.
- You must never look at, or read, the medical records of patients that you are not taking care of.
- Do NOT talk about your patients when you go home. It is against the law to tell your family member or neighbor about a patient and their condition.
Things You Must Know About Patient Identification
Why is Proper Patient Identification So Important?
OOPS! Oh, no. Someone has taken the wrong patient to the operating room. OOPS! Oh, no. You’ve sent a urine specimen to the lab with the wrong patient’s name on it. OOPS! Oh, no. The nursing assistant got the wrong patient out of the bed into the chair. OOPS! Oh, no. The nursing assistant took vital signs and documented them on a different patient’s medical record, or chart.
Sadly, all of these mistakes could have been prevented with a couple of simple steps. Proper patient identification must be done before anything else is done for or with a patient. Many mistakes are made because a person was NOT properly identified. Some patients get surgery when a patient identification mistake is made; some patients get the wrong medicine when they were not properly identified; other patients do not have their correct vital signs documented in their chart because the nursing assistant did not properly identify the patient. Mistakes like these are very dangerous. Some patients can even die when a mistake is made in terms of their identity.
These mistakes can happen during all different phases of treatment and care. It is VERY important to match the person’s identity with the treatment or care that is ordered. For example, if a nursing assistant is assigned to collect and label a urine specimen, the nursing assistant must identify the patient and then make sure that that the urine specimen is actually ordered for this patient. Most, if not all, of these mistakes can be prevented with a couple of very simple steps that you will learn during your CNA training. These steps must be done every time you are ready to do something for or with a patient.
Our nation publishes National Patient Safety Goals every year. Each and every year there is a patient safety goal that addresses the correct procedure for proper patient identification. According to the the National Patient Safety Goal of 2016, patient identification must use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.
Patient Identification Bands
There are several types of patient identification bands. Some are handwritten and placed on the patient’s wrist when they enter a hospital or nursing home. Other identification bands can be printed with a computer and then placed on the patient’s wrist. These days, many healthcare facilities make bar-coded patient identification bands. Nursing assistants and other healthcare providers use a hand-held scanner to read these bar codes.
All types of identification bands, or bracelets, have basic information on them that will help to identify a patient, including the patient’s name, room number, and the patient’s birthday and/or age. Some hospitals may also add the patient’s gender (male or female), the name of the doctor, and any allergies. Bar-coded wristbands can contain an even larger amount of information than these basics.
Bar-coded wrist bands are the best type of patient identification band. They hold a great amount of information that is also duplicated on some types of patient supplies and equipment. For example, the person’s medicines and their laboratory specimen containers will have a label with the same information on it. It is, then, quite simple to scan the medicine, or container, and the patient’s identification band to make sure they match. When they match, you have prevented an error or mistake.
Handwritten identification bands have a couple of problems. The handwriting may be sloppy and hard to read, and the writing may fade out over time. Computer-generated identification bands also have some problems. They, too, may fade out over time. Both of these types are also subject to human error, more so than bar coded identification bands. For example, the person writing the band information may spell the last name as “Johnson”, instead of “Johnston” and/or they can write a birthdate of 1/29/1969 instead of 12/29/1969.
All patient identification bands can also come off, or get pulled off by a patient. This is a disadvantage of all types of patient identification bands.
What Kinds of Patients Are At Greatest Risk for Identification Mistakes?
Some kinds of patients are at greater risk for identification mistakes than others. Below are examples of patients who are at the greatest risk for mistakes:
- Infants and young children
- People that are not awake and alert (decreased level of consciousness)
- People that speak a foreign language that you do not speak
- People who cannot hear
- Adults and children with a developmental disorder or another problem that affects their thinking
- People with severe mental problems
Infants and children can pose a threat when it comes to patient identification. Infants and young toddlers will certainly not be able to tell you their name. They also cannot question an aspect of care. Young children may be able to tell you their name, but they also are not likely to question something that you are ready to do. You must be very careful with these age groups. Photographs are often used as one form of identification for these age groups.
The child’s parent or guardian is a great help to you when you are caring for an infant or young child. They will be able to tell you the patient’s name, birth date, etc., and they will also be able to question an aspect of care. For example, if the nursing assistant is caring for an infant and is ready to feed the infant formula, the infant’s parent or guardian will be able to question the formula and tell you that the infant does not get formula but, instead, gets breast milk. When something like this happens, you must immediately stop. You must speak to the nurse about this issue and again verify the patient’s identity. An educated patient, or family member, is a great defense against errors and mistakes.
When a person is not alert, confused or not able to think well, the nursing assistant must also do special things to identify the person. CNA training includes learning about how to use these special things. For example, the nursing assistant may ask the family member or a friend to help with the identification process because the patient may not be able to state their own name. The patient’s family member or friend may also be able to question something you are about to do. This adds to patient safety. For example, if you are about to take the person out of bed to a chair, the family member may say, “My mother is not allowed to get out of bed, according to the doctor.” This information is good. You will then stop what you are doing, speak to the nurse and reconfirm the patient’s identity.
People who do not speak English may not be able to understand what you are saying or what you are asking them. For these people, you should use a family member, an interpreter, or a picture to ask them what their name is and to explain what you will be doing for or with them.
Patients who cannot hear also have to be identified in a special way. You may want to use writing to communicate, or ask a family member to help so a mistake is not made. The patient should also wear their hearing aid at all times. Do not say to the deaf person, “Is your name Thomas Atkins”? The patient may not hear you. They may smile and nod their head, even though they are NOT Thomas Atkins. Instead, ask them what their name is and what their birthday is.
Beware of Same Names and Look-alike Names
Use extra caution when you have 2 or more people with the same name on the nursing unit. Many mistakes happen when 2 people have the same last name. For example, a nursing assistant may write the vital signs of Mary Taylor in Merry Taylor’s chart. You must be very, very careful when two people have the same last name. Double-check the name before you do anything.
The same problems happen when you have 2 or more people with a similar name on the nursing unit. For example, you can mix up Rodgers and Rogers, and Berk and Burke. Again, double-check the name before you do anything.
Beware of Using Room Numbers
Never use room numbers to identify a patient. Patients very often move from room to room and even sit on other patients’ beds, especially when they are confused. Room numbers are NOT a good patient identifier. For example, when you are asked to collect a urine specimen, you must check the identity of the patient before collecting the urine sample and sending it to the lab. For example, if you need to collect a sample from Ryan Simpson in Room 433, you cannot assume that you have the right man when you walk into room 433 and you see a patient sitting on the bed. That man sitting on the bed may not be Ryan Simpson at all. He might be a person who just walked into Mr. Simpson’s room to answer the ringing phone and then sat down on a bed to rest for a moment. A room number should NEVER be used as a patient identifier.
Instead, CNA training will teach you that these patient identifiers can, and MUST, be used:
- The patient’s first, middle and last name
- A secret code or word that was given to the patient when they entered the hospital or nursing home
- The person’s full telephone number, including area code
- The person’s full address
- The person’s Social Security number
- The month, day and year that the person was born
- A patient photograph
Proper Patient Identification Procedure
The Step by Step Procedure for Good Patient Identification
- Greet the patient by using their name.
- Introduce yourself to the patient.
- Explain what you are going to do with and for the patient before giving any care.
- Look at the patient’s identification band for the first and last name of the person and other information that you can check. Scan the bar code if the patient’s identification band is barcoded.
AND then do at least TWO of the following with the patient or family member:
- Ask the person to state their full first, middle and last name.
- Check this name against the patient’s identification band
- Ask the person to tell you their “secret code” number or word that they were given when they came into the hospital.
- Check this “secret code” against the patient’s identification band or patient record.
- Ask the patient to tell you their full telephone number including the area code.
- Check this phone number against the patient’s medical record.
- Ask the patient for their address.
- Check this address against the person’s medical record.
- Ask the patient to tell you their Social Security number.
- Check this Social Security number against the patient’s Social Security number that is listed in the patient record.
- Look at the person’s face.
- Compare this face to the photograph in the patient record.
Summary: Patient Identification
Nursing assistants, and all other healthcare providers, MUST identify patients accurately before any aspect of care is given. Deadly errors can happen when a patient is not properly identified. Do NOT ever skip this important patient identification process, even if you are very busy.