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Title: Regional Hospital: Infection Control Study Module for the Certified Nursing Assistantl Purpose: This study module addresses the issues of infection control in healthcare. Competency: Follows policies and procedures to promote a safe environment Objectives: Upon completion of this module, the orientee will: A. Discuss infection control policies applicable to the institution of employment. B. Discuss proper disposal of waste. C. Discuss Standard Precautions D. Define VRE and MRSA. E. Discuss TB issues. F. Discuss HIV. G. Discuss Hepatitis B and C. Content: Refer to required Activities. Required Activities: 1. Read and study policies and procedures related to infection control in the institution of employment. 2. Visit with the Infection Control Nurse about facility policies and procedures. 3. Read in a current text or journal about the following: Mosby’s Textbook for Certified Nursing Assistant, pages 211-237. • VRE • MRSA • TV • HIV • Hepatitis B and C 4. Complete final exam with a minimum score of 90%. Approved by: Becky Finch RN Jodi Asche CNA Mary Vold RN BSN Beverly Nelson CNA Diane Vrieze RN CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/80 Name: ___________________ Score: ___________________ Regional Hospitals: Infection Control Final Exam for the Certified Nursing Assistant After you have been oriented to your institutions Infection Control/Isolation Manual complete the following quiz. 1. Infectious waste is disposed of in what color bags? __________________________________________ 2. What 3 diseases require a negative pressure room? __________________________________________ _________________________________________ , _________________________________________ 3. How soon after a blood exposure from an HIV positive source should chemoprophylaxis be initiated? ______________________________________________________ 4. What does VRE stand for? ______________________________________________________________ True or False (Circle Correct Answer) 5. T F Hand washing remains the number one method of infection control 6. T F Antitubercular medication can usually be stopped in one month because TB patients can become noncontiguous in 2-3- weeks. 7. T F Inactive TB infections always lead to active TB disease. 8. T F Always wash your hands after treating a patient unless wearing gloves. 9. T F MRSA stand for Methicillin Resistant Streptococcus Aureus. 10. T F TB test are given to employees every 3 years. 11. T F Infectious waste goes directly into a community sewer or landfill. 12. T F Standard precautions means treating all blood and potentially infectious body fluids, nonintact skin, and mucous membranes, as if they are infectious. 13. VRE: a. Is resistant to most antibiotics b. Is spread by direct contact between healthcare workers and patients c. Can be prevented by practicing good Hand washing techniques d. Is spread by contact with soiled objects in the environment e. Can live on a hard surface for a long period of time f. All of the above 14. Describe how you would clean up a blood spill in your institution. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________ CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/81 Infection Control Final Exam Answer Key 1. Red 2. TB, measles, chicken pox 3. Before 2 hours 4. Vancomycin Resistant Enterococci 5. T 6. F 7. F 8. F 9. F 10. F 11. F 12. T 13. F 14. Each institution will have own answer. CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/82 Title: Regional Hospital: Skin Integrity Study Module for the Certified Nursing Assistant Purpose: This module contains information related to the care of the skin Competency: Recognize and provide essential aspects of Certified Nursing Assistant care to the patient with impaired skin integrity Objectives: Upon completion of the study module the Certified Nursing Assistant will be able to: A. Describe the signs, symptoms, and causes of pressure circulatory ulcers B. Describe how to prevent pressure and circulatory ulcers C. Define risks related to pressure and circulatory ulcers D. Demonstrates importance of preventive measures related to pressure and circulatory ulcers Content: A. B. C. D. E. F. G. H. Stages of pressure ulcers Risks for skin breakdown Prevention measures Observing changes in skin appearance Activity Bowel and bladder incontinence Diet Special equipment Required Activities: A. Read and study Skin Integrity Study Module B. Final exam with 85% accuracy Approved By: Becky Finch RN Jodi Asche CNA Mary Vold RN BSN Beverly Nelson CNA Diane Vrieze RN Page 1 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/83 Introduction: Changes in skin integrity impose staggering expense to society in terms of actual cost and quality of life. Effective prevention and treatment of pressure ulcers is a key to reducing the cost and improving the quality of life for those at risk. Aging, illnesses, disease, decreased oxygen, surgery, poor nutrition, incontinence and steroids are some of the agents that weaken the skin. Overview: Pressure Sores: Also known as decubitus ulcers or bedsores are painful, slow healing and are easily infected. Pressure sores are fully preventable. How do pressure sores develop: Just like the word pressure means-prolonged sitting or lying in one position exerting pressure on the skin. Circulatory Ulcers: Circulatory ulcers (vascular ulcers) are caused by a decrease in blood flow through arteries or veins. Persons with diseases affecting the blood vessels are at risk for these ulcers on the legs and feet. These wounds are painful and hard to heal. Depriving the skin of oxygen and nutrients The skin loses its elasticity, strength and fatty tissue layers. This causes the skin to thin and sag. The skin is fragile and easily injured. Skin breakdown, skin tears and pressure ulcers are dangerous. The skin has fewer nerve endings. This affects the person’s ability to sense heat, cold and pain. Bruising and delayed healing results from a decreased number of blood vessels. Dry skin is easily damaged and causes itching. Daily showers or tub baths are avoided. Usually a complete bath is taken twice a week. Partial baths are taken on the other days. Circulatory Ulcers: Circulatory ulcers (vascular ulcers) are caused by a decrease in blood flow through arteries or veins. Persons with diseases affecting the blood vessels are at risk for these ulcers on the legs and feet. These wounds are painful and hard to heal. Content: A. Stages of pressure ulcers Stage 1 The skin is red. The color does not return to normal when the skin is relieved of pressure Stage 2 The skin cracks, blisters, or peels. There may be a shallow crater. Stage 3 The skin is gone, and underlying tissues are exposed. The exposed tissue is damaged. There may be drainage from the area. Stage 4 Muscle and bone are exposed and damaged. Drainage is likely. Page 2 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/84 B. Risks for skin breakdown 1. a. Confined to bed or chair b. In the same position more than 2 hours 2. Wrinkles in the sheeting and clothing 3. Ill fitted braces and casts 4. Poor nutrition: even crumbs in bed 5. Shearing force: is caused by moving tissue layers over one another and friction in bed when sliding 6. Loss of bowel and bladder control: Moisture: soften the skin layer and provide an environment for bacterial growth. This causes the skin to break down. 7. Altered mental awareness 8. Problems sensing pain and pressure 9. Circulatory problems 10. Older/frail 11. Obese 12. Very thin or malnourished C. Preventive measures 1. Turning and repositioning 2. Range of motion exercises 3. Proper nutrition 4. Skin care: moisturizer and barrier D. Observing changes in skin appearance 1. Skin color 2. Skin temperature 3. Excessive moisture or dryness 4. Darkened or reddened area-especially over bony prominences 5. Rashes 6. Swelling 7. Bruising 8. Skin tears 9. Wound/ulcers 10. Other abnormalities E. Activity 1. Turning and repositioning in bed every 2 hours 2. Place a pillow or rolled up towels to the back when turning 3. Place knees at angle when on back. Use a turning sheet 4. Reposition in chair every 1 to 2 hours. Have patient move or do push ups, etc. 5. Range of motion exercise a. Neck-turn and stretch b. Shoulders-reach up over head c. Elbow-out in front-bend up d. Forearm-twist-wrist to elbow e. Wrist-bend f. Finger-bend and stretch g. Hip and knees-lift and bend Page 3 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/85 h. Ankle-hold heel, push ball of foot and pull toes down i. Foot-twist side to side j. Toes-bend gently back and forth F. Bowel and bladder incontinence 1. Toilet frequently 2. Excessive padding causes maceration/use single layers 3. Clean with gentle soap 4. Pat dry (don’t’ rub) 5. Special attention to drying the skin folds 6. Care with bed pans a. Friction when moving on and off b. Don’t sit on too long c. Be careful not to get urine on skin G. Diet 1. Balanced and with adequate fluids. Foods rich in protein as directed by Doctor, Nurse or dietician H. Special equipment Used to reduce pressure on the skin Low Risk: 1. Overlays a. Egg crates b. Foam mattresses High risk: 2. Air cushions a. Foam b. Gel c. Air 3. Specialty mattresses a. Air mattresses b. Gel mattresses Round donuts are not recommended because they cause poor circulation Summary: Preventing pressure ulcers is much easier than trying to heal them. Good nursing care, cleanliness, and skin care is essential. Page 4 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/86 Name: ___________________ Score: ___________________ Regional Hospitals: Skin Integrity Final Exam for the Certified Nursing Assistant 1. Skin that is gone and underlying tissues is exposed. The exposed tissue is damaged. There may be drainage from the area; is what stage of ulcer? a. b. c. d. Stage Stage Stage Stage 1 2 3 4 2. List 3 risk factors for skin break down 1. __________________________________________________________ 2. __________________________________________________________ 3. __________________________________________________________ 3. Preventive measures relating to pressure ulcers include: a. b. c. d. High fat diet Lotions containing high amounts of alcohol Turning and positioning Assisting patient in repositioning twice a shift 4. List 3 changes in skin appearance that need reporting to the nurse 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 5. True or False Frequent positioning is not recommended for skin impairment 6. True or False Range of motion exercises are not considered the Certified Nursing Assistant’s responsibility CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/87 Regional Hospitals: Skin Integrity Final Exam for the Certified Nursing Assistant 7. Effective managemtn of bowel and bladder incontinence to reduced skin break down include: a. b. c. d. Toileting frequently Reducing excessive moist padding Avoid friction when using bed pan All of the above 8. Special equipment does not include which of the following: a. b. c. d. Overlays-egg crate mattress Doughnuts Air or gel mattress Chair cushions CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/88 Skin Integrity Final Exam Answer Key 1. C 2. 3. Risks for skin breakdown 1. a. Confined to bed or chair b. In the same position more than 2 hours 2. Wrinkles in the sheeting and clothing 3. Ill fitted braces and casts 4. Poor nutrition: even crumbs in bed 5. Shearing force: is caused by moving tissue layers over one another and friction in bed when sliding 6. Loss of bowel and bladder control: Moisture: soften the skin layer and provide an environment for bacterial growth. This causes the skin to break down. 7. Altered mental awareness 8. Problems sensing pain and pressure 9. Circulatory problems 10. Older/frail 11. Obese 12. Very thin or malnourished C 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Skin Color Skin Temperature Excessive moisture or dryness Darkened or reddened area-especially over bony prominences Rashes Swelling Bruising Skin Tears Wound/ulcers Other abnormalities 5. False 6. False 7. D 8. B CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/89 Title: Regional Hospital: CVA/Stroke Patient Study Module for the Certified Nursing Assistant Purpose: This module focuses on Certified Nursing Assistant responsibilities for providing care to a client who has suffered a CVA/Stroke. Competency: Provide all essential aspects of Certified Nursing Assistant care to the patient who has suffered a CVA/Stroke. Objectives: Upon completion of this study module the orientee will be able to: A. Define CVA B. Define the Certified Nursing Assistant’s role in restorative care C. Demonstrate effective skills related to activity, mobility and positioning D. Demonstrates knowledge of aphasia E. Demonstrate ability to use communication equipment Content: A. B. C. D. E. F. Mobility Communication Elimination Skin Integrity Emotional Support & Motivation Nutrition/Diet Required Activities: A. Read Text: Mosby’s 701-703 and 809 B. View video "Lifting, Moving, Transferring Patient". C. Read and study the CVA/Stroke Study Module D. Take the final exam Approved By: Becky Finch RN Jodi Asche CNA Mary Vold RN BSN Diane Vrieze RN Beverly Nelson CNA Page 1 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/90 Introduction and Overview: A stroke/CVA is an incident in the brain caused by a blood clot or bursting of a blood vessel, allowing blood to spill out into the brain cavity. A. Common risk factors include: 1. Age 2. Family history of CVA 3. Cardiovascular disease 4. Diabetes 5. Smoking B. Symptoms 1. Weakness of one side of the body 2. Drooping of one side of the mouth or drooling 3. Swallowing difficulties 4. Slurred speech 5. Loss of vision in one eye or double vision 6. Vertigo 7. Memory difficulty 8. Personality changes C. The effects of a CVA may be temporary or permanent D. Rehabilitation then focuses on the whole person and assisting the patient to adjust to their disability through the extensive rehabilitation process A. Mobility – Proper body mechanics for Certified Nursing Assistant in lifting, positioning and transferring CVA/Stroke patient Content: 1. 2. 3. 4. 5. Body Mechanics means using the body in an efficient and careful way. It involves good posture and balance and using the strongest and largest muscles for work. Fatigue, muscle strain, and injury can result from improper use and positioning of the body during activity or rest. (See skill list) Ambulating is an excellent form of exercise. a. When a patient is ambulatory consider the distance, what the patient can tolerate and proper equipment/see Skill list) b. When a patient is using a wheelchair consider the proper position and brakes (See Skill list) Positioning of the body plays an important part in the proper functioning of the body. Good body alignment helps prevent the complications of immobility, such as contractures and muscle atrophy. (See Skill list) Falls are common emergency issues a. Certified Nursing Assistant plays an important role in preventing falls. (See Skill list) Paralysis a. Common result of a stroke is paralysis resulting in loss of feeling and movement Page 2 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/91 B. Communication 1. Receptive Aphasia is the inability to understand what others are through speech or written words 2. Expressive Aphasia is the inability to express needs to others through speech or written words 3. Communication Board a. The written word is used when a person cannot speak or hear. Provide a way for the person to send messages. A magic slate, paper, pencil, electronic talking aid, picture board or communication board can be used. C. Elimination - CVA’s can cause the loss of bowel and bladder control. Managing incontinence is an Active Restorative Effort D. 1. Bowel and bladder retraining programs are individually designed for patients who have become incontinent due to a stroke. a. The role of the Certified Nursing Assistant is to follow the Bladder/Bowel program as set up by the RN or Therapist. b. Answers call lights promptly. c. Don’t rush the patient when toileting. d. Give the patient privacy e. Avoid scolding the patient for accidents f. Change briefs as needed. g. Assist the patient if they cannot physically use the toilet. h. Keep the skin clean and dry. i. Remind patient of Kegel exercises j. Follow I&O schedule as ordered 2. Signs and symptoms to report to the nurse a. Blood in urine b. Painful urination c. Small amounts of urine d. Urgency of the bladder e. Unusual odor f. Unusual color or clarity Skin Integrity – Changes in skin integrity cause pain and discomfort. Effective prevention and treatment is the key to quality life. (See Skin Integrity Module) 1. E. Aging, illnesses, diseases, decreased oxygen, surgery, poor nutrition, incontinence, and steroids are some of the agents that weaken the skin Emotional Support & Motivation – Stroke can cause damage to parts of the brain responsible for memory, learning and awareness 1. Stroke survivors can have reduced attention spans and or deficits in short term memory 2. Stroke survivors may also have difficulties making plans, comprehending meanings, learning new tasks or engaging other complex mental activities 3. Your attitude affects the patient and has a major affect on the care you deliver 4. A disability often affects self-esteem and relationships 5. Appearance and function changes may cause the person to feel incomplete, unattractive, unclean or undesirable to others. 6. At first the patient may refuse to accept the disability, which may result in depression, anger or hostility. Page 3 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/92 F. Nutrition/Diet – Patients who have had a stroke or a CVA will need extra time and patience with eating and drinking. 1. 2. 3. 4. 5. 6. 7. 8. 9. It is an important responsibility of the Certified Nursing Assistant to provide food and fluids The Certified Nursing Assistant is responsible for delivering food trays, special supplements, and snacks The Certified Nursing Assistant will assist the patient in eating or feed the patient if there is a need The Certified Nursing Assistant is responsible for passing fresh drinking water and encouraging patients to drink enough liquid. If the patient has dysphasia supply the patient with a semi-soft diet. Explain to the patient to chew on the unaffected side of the mouth Look for pocketing of food. Add thicket to fluids if necessary Instruct patient to sit upright when eating and to tilt the head slightly forward Watch for aspiration as indicated by coughing or short of breath. Use assistance devices as needed. Take time when feeding your patient (See text) Summary or Conclusion: The Certified Nursing Assistant plays an important role in the care of the patient with a stroke. The Certified Nursing Assistant must develop sensitivity to the patient’s abilities. The Certified Nursing Assistant provides what the patient needs, but not do more than necessary. The Certified Nursing Assistant provides essential aspects of care to the patient who has suffered a stroke/CVA. Page 4 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/93 Name: ____________________ Score: ____________________ Regional Hospitals: CVA/Stroke Final Exam 1. List three types of mobility A. _________________________________________________ B. _________________________________________________ C. ________________________________________________ 1. True or False A common result of a CVA/Stroke is the inability to understand what others are communicating either through speech or written words. 2. List three ways used to communicate with the patient who cannot speak. A. __________________________________________________ B. __________________________________________________ C. __________________________________________________ 3. The role of the Certified Nursing Assistant for bowel and bladder retraining include: A. B. C. D. Give patient privacy during toileting Scolding the patient for accidents Restrict fluids Change briefs every shift 4. True or False Can a stroke cause damage to parts of the brain responsible for memory, learning and awareness? 5. True or False Patients who have had a stroke or a CVA will not need extra time with eating and drinking. CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/94 CVA/Stroke Patient-Final Exam Answer Key 1. A. Ambulation B. Transferring C. Positioning 2. True 3. A. B. C. D. E. Magic slate Paper/pencil Electronic talking aid Picture board Communication board 4. A 5. True 6. False CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/95 Title: Regional Hospital: Mandatory Reporting Study Module for the Certified Nursing Assistant Purpose: This module outlines what constitutes pediatric and dependent adult abuse and the reporting process. Competency: Recognizes all essential aspects of pediatric and dependent adult abuse. Objectives: Upon completion of this module, the orientee will be able to: A. Discuss the nurse’s role as a mandatory reporter. Content: A. Child Maltreatment B. Elder Neglect and Abuse C. References Required Activities: A. Read and study contents of module B. Complete final exam with a minimum score of 90% Note: This study module does not meet Iowa Code education requirements for mandatory reporters. Approved by: Becky Finch RN Jodi Asche CNA Mary Vold RN BSN Beverly Nelson CNA Diane Vrieze RN Page 1 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/96 Content: A. Child Maltreatment A child’s right to grow and develop to full potential and to be free from harm is highly regarded and protected by all states. Each state has it’s own law pertaining to child maltreatment. The following categories of maltreatment are clearly defined by each state: • Physical abuse • Physical neglect • Sexual abuse • Emotional abuse • Emotional neglect • Medical deprivation • Educational deprivation • Intentional drugging • Abandonment • Munchausen syndrome by proxy • Definitions The following are definitions of child maltreatment as stated in the Code of Iowa. Child-any person under the age of eighteen. Child abuse-Any non-accidental physical injury, injury which is at variance with the history given of it, or injury which is suffered by a child as the result of the acts of omissions of a person responsible for the care of the child. The commission of a sexual offense with or to a child as a result of the acts or omissions of the person responsible for the care of the child. The failure on the part of a person responsible for the care of the child to provide adequate food, shelter, clothing, or other care necessary for the child’s health and welfare when financially able to do so or when offered financial or other reasonable means to do so. A parent or guardian legitimately practicing religious belief who does not provide specified medical treatment for a child for that reason alone shall not be considered abusing the child, however this provision shall not preclude a court from ordering that medical service be provided to the child where the child’s health requires it. Person responsible for the care of a child-A parent, guardian, or foster parent, a relative or any other person with whom the child resides, without reference to the length of time or continuity of such residence; an employee or agent of any public or private facility providing care for a child, including an institution, hospital, health care facility, group home, mental health center, residential treatment center, shelter care facility, detention center, or child care facility, or any person providing care for a child, but with whom the child does not reside, without reference to the duration of the care. • Code of Iowa The purpose of the Code of Iowa is to provide the greatest possible protection to victims or potential victims of abuse through encouraging the increased reporting of suspected cases of such abuse, insuring the thorough and prompt investigation of these reports, and providing rehabilitative services, where appropriate and whenever possible to abused children and their families which will stabilize the home environment so that the family can remain intact without further danger to the child. Page 2 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/97 • Categories of Child Maltreatment There are three main categories of child maltreatment: neglect, physical abuse, and sexual abuse. Following is a brief look at these categories and the types of injuries or manifestations that you as a nurse may see in the hospital setting or encounter in the community at large. Neglect-One half of all reported cases of child maltreatment is due to neglect. Ignorance or a child’s needs and lack of resources are the main contributing factors to neglect. Most serious is a parent’s failure to recognize emotional nurturing as an essential need of children rather than emotional nurturing as being viewed as spoiling the child by giving him/her attention. Some of the manifestations of physical neglect include: • Lack of food and water • Lack of adequate shelter • Lack of adequate supervision • Lack of adequate medical care • Lack of adequate education Some • • • • • • • of the behavioral indicators of physical neglect may include a child that is: Dull or inactive Very passive or sleepy Demonstrating self-stimulating behaviors such as thumb sucking or rocking back and forth continually Begging or stealing food Absenteeism from school Drug or alcohol addiction Vandalism or shoplifting Emotional neglect can be manifested in various ways and may include: • Failure to thrive • Feeding disorders • Enuresis • Sleep disorders Behavior indicators may include: • Lack of social smile and stranger anxiety withdrawal • Fearful behaviors • Antisocial behavior, such as destructiveness, stealing, cruelty • Lack of emotional and intellectual development • Suicide attempts Emotional abuse is the deliberate attempt to destroy or significantly impair a child’s self esteem or competence. Emotional abuse includes verbal abuse, which is probably the most common type of abuse suffered by a child. It includes using the child as a scapegoat, using put-downs with a child, humiliating and labeling the child and also having unreasonable expectations of the child. Page 3 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/98 Failure to thrive is one of the most common types of neglect that the nurse in the hospital will see. Failure to thrive is used to describe a child who is not growing according to predictable patterns. Failure to thrive can be brought on by an organic cause such a congenital heat defect, endocrine dysfunction, or malabsorption syndrome. When all organic causes have been ruled out, then the search for a cause starts with the parents. Failure to thrive can also be caused by nutritional, parental, or environmental deprivation. The primary age groups affected with failure to thrive are the infant and toddlers. This is a period of rapid physical growth, brain growth, and developmental achievements. The impact of poor nutrition and lack of stimulation can be devastating, but can be reversed if caught early enough. Some of the characteristics that contribute to failure to thrive in children include: • A history or a poor childhood experience on the part of the caregiver. • An infant’s personality that is totally different from what the parents expected. • Failure of the parents and child to bond at birth. This may be due to a premature birth where the infant required special care that prevented the parents from participating in the bonding process with the child. This may never be reversed unless the parents are allowed to participate in the care of the infant from the time he/she is born. The clinical criteria for failure to thrive is usually: • Weight below the third percentile with subsequent weight gain in the presence of adequate nutrition and nurturing • Absence of systemic or congenital disease • Developmental delay that improves with appropriate stimulation The clinical signs of deprivation may include: • Flat head • Patchy hair • Distended abdomen • Lack of subcutaneous fat in the gluetal region and cheeks • Poor skin condition • Developmental delay in all areas • Limited ability to engage in social interaction • Ravenous appetite, or totally uninterested in food • Posture that is unpliable, stiff, rigid, floppy Parents usually relate a history of feeding problems and vomiting. Upon assessment, the nurse may find that the diet history given by the parent is inappropriate for the child based on his/her age. The most important contribution that the nurse can make is to educate the parents in proper infant care and nutrition. Many times failure to thrive can be reversed through education and by encouraging the parents to assume nurturing roles. Physical Abuse-This is the category of child maltreatment that most people think of when they hear the work child abuse. There are three main characteristics that influence the potential of abuse: parental, child and environmental. Parental characteristics include: • Had physical punishment used on them as a child • Have difficulty controlling aggressive behaviors • Free expression of violence in the family • Social isolation • Few supportive relationships • Frustration • Anxious behavior • Low self-esteem Page 4 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/99 Child characteristics include: • Temperament that is not tolerated well by parents • Position in the family • Physical needs • Disabilities • Insensitive to parental needs • Illegitimacy • Unwanted pregnancy and/or birth • Brain damage • Hyperactivity • Coming from a broken home • Prematurity (due to failure to bond) • Difficult pregnancy, labor, delivery Environmental characteristics include: • Chronic stress • Divorce • Poverty • Unemployment • Poor housing • Frequent relocation • Alcoholism • Drug addition • Crowded living conditions When these characteristics combine, there is an increased likelihood of physical abuse. Following is a body systems review of some of the different types of injuries that you might find on a physical assessment. It is important to remember that symptoms of physical abuse are not limited to the following list and should be suspected when the story of the injury does not fit with the injury itself. • The Head Intracranial injury is the leading cause of death in child abuse. The estimated incidence of head trauma is 25% among all cases of child abuse. There are two primary mechanisms of injury causing craniocerebral trauma. First, a direct blow to the head by a hit or a kick. Second, trauma may occur from violent shaking. Some • • • • • • • • • • • • • • • of the types of injuries that may be seen are: Shaken baby syndrome Subdural hemorrhages Retinal hemorrhages Cerebral edema Bruises Linear “slap marks” Bruised ear lobes Torn frenulum Broken teeth Patches of hair missing Fractures of facial bones or skull Lacerations Hemorrhage of the sclera Bite marks Burn marks Page 5 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/100 The presence of significant head trauma in infants should be carefully considered as indication of abuse. Recent studies find that accidental trauma rarely, if ever, causes intracranial injury in infants. • • • • • • • • • • Burns Linear and parallel lesions from belts or other objects Bruises Rib fractures Abdominal injuries • Intestinal perforation • Bladder injuries • Pancreatic injuries • Liver injuries • Kidney injuries • Pancreatic pseudocysts Lacerations Petechia Welts Pinch marks Abrasions The symptoms of abdominal trauma are: • Pain • Tenderness • Rigidity • Guarding • Decreased or absent bowel sounds • Distention • Asymmetry of the abdomen • Positive hemoccult • Bloody nasogastric drainage • Vomiting A common birthmark that may be mistaken for a bruise is Black, Hispanic, Mediterranean, or Oriental descendants are the Mongolian Spot. The spots are usually located on the lower back and buttocks and have even color with distinct borders; they do not change color over time. Bruises that should raise suspicion are in various stages of healing and are located in areas where a child would not usually sustain a bruise during normal activities. • The Extremities The extremities are a common place that injuries will be seen. Children do have accidents, sometimes causing serious injury, but the index of suspicion should be raised if the child is not capable of producing the force necessary to cause the type of injury seen. Some of the injuries that may be seen are: • Lesions that have well defined borders • Bruises • Scratches • Fractures • Dislocations Page 6 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/101 • • • • • • • Abrasions around wrist or ankles Burns Periosteal shearing Subperiosteal hemorrhages Epiphyseal separation Metaphyseal fragmentation Squaring of the metaphysis Fractures or skeletal injuries to children under two years of age should be suspicious of child Abuse. Certain types of fractures have been closely identified with inflicted trauma. These are: • Posterior rib fractures (see in infants that were picked up and squeezed) • Corner fractures of the long bones (from twisting or yanking) • Spiral fractures of the long bones (from severe twisting) A skeletal survey should be done on any child who presents with injuries that indicate possible a abuse. Bone scans can detect trauma that is only hours old Burns that are highly suggestive of child abuse are contact burns and submersion burns. Contact burns may be seen in children of all ages. The distinguishing feature of these burns is the The regular shape or pattern from the instrument used such as cigarettes, iron, and heaters. submersion burns usually occur when a child is forcefully held in hot water and have four common characteristics. • Distinct lines of demarcation • Absent splash marks • Areas of clear skin or mild burn surrounded by second and third degree burned tissue • The extremities, genitals, and buttocks are commonly involved Any of the above burns should be reported to the local Department of Human Services. Another type of physical abuse is chemical abuse. This may be seen when a child is admitted to the hospital repeatedly for drug overdoses or when a childe has a sudden unexplained hypoglycemia episode which may be the result of insulin administration. Some of the behavioral indicators that may be manifested by the child that has been physically abused include: • Wary of physical contact • Fear of parents • Fear of going home • Lies very still and surveys the environment • Inappropriate reaction to injury, such as failure to cry from pain • Lack of reaction to frightening events • Apprehension when hearing other children cry • Indiscriminate friendliness and displays of affection • Acting out behaviors such as aggression or seeking attention • Withdrawal • No reaction during physical exams Page 7 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/102 • Sexual Abuse Sexual abuse is the least reported by all of the types of child abuse. It is the type of abuse that can cause the most long-lasting affects and carries the most social stigma. Some of the physical indicators of sexual abuse include: • Bruises, bleeding, laceration, or irritation of the external genitalia, anus, mouth or throat • Torn, stained or bloody underclothing • Pain on urination or pain, swelling, and itching of the genital area • Penile discharges • Sexually transmitted disease, nonspecific vaginitis, or venereal warts • Difficulty walking or sitting • Unusual odor of the genital area • Recurrent urinary tract infections • Pregnancy in the young adolescent Behavioral indicators may include: • Withdrawing or daydreaming • Pre-occupation with fantasies • Poor peer relations • Sudden changes, such as anxiety, weight loss or gain, or clinging behavior • Excessive anger at the non-abusive parent (for not protecting them from abuse) • Regression • Sudden onset of phobias or fears • Running away from home • Sudden emergence of sexually-related problems including excessive masturbation, sexual play, promiscuity, and overtly seductive behavior • Substance abuse • Profound personality changes • Declining school performances • Suicide attempts or ideation When sexual abuse occurs it is especially important for the nurse interviewing the child to be sensitive and discrete and to take every effort to make the child comfortable. If the child becomes upset, then the interview should stop until after the child has settled down. It is also important not to touch the child without his/her permission. • Nursing Responsibilities • • Legal Issues As a nurse you are a mandatory reporter in all fifty states. If you suspect child maltreatment you are required by law to report it to the Department of Human Services in your area. As a mandatory reporter you are required to make an oral report to the DHS within 24 hours and a written report within 48 hours from the oral report. A detailed list of what must be included in the report as well as a sample of the form is included in the policy. As a part of your orientation it is required that you read this policy. The law also protects you from civil suits in the case that a reported child abuse was unfounded as long as you had a reasonable cause to report it. Page 8 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/103 • Care of the Child When the abused child is admitted to the hospital it is important that he/she feels comfortable and not threatened during all procedures and interviews. During the interview explain to the child the purpose of the interview and that the child did nothing wrong. Ask open-ended questions that allow the child to talk in his/her own terms about what happened. Be sure to allow the child to ask questions and answer them honestly. The child should be treated as a child with the usual physical needs, developmental tasks, and play interests; not as a dramatic victim of abuse. The nurse must also encourage and facilitate a continuing relationship with his or her parents because the goal of treatment for an abused child and his/her family is to keep the family unit intact. • Care of the Family When interviewing the parents be sure to explain the purpose of the interview; reassure the parents that they did the right thing by bringing the child for care. Use open-ended questions and ask the parents how the child was injured. Advise the parent of your legal obligation to report cases of suspected abuse. Reassure the parents of your continued support. It is important for the nurse to examine his or her own feelings about abuse. Interviews must be conducted with genuine concern and not with accusations and punishment. Many times the parents are also victims and need your support and help. Unless the nurse’s attitude is positive, abusing parents will not be motivated to charge. When parental ignorance of child rearing practices has played a part in the abuse, the nurse can educate the parent(s) regarding children’s physical and emotional needs. Because of the parents’ own child rearing, they may not be aware of nonviolent methods of discipline, such as time out or consequences. They may also need help in dealing with their frustrations so that they do not take their anger out on the child. The nurse has a unique opportunity to serve as a positive role model by showing parents the correct care of a child and by being a nurturing caregiver. Prevention of child abuse is the ultimate goal of any pediatric area. This is an extremely difficult goal, but nurses play an important role by providing information on the normal growth and development of children and routine health care needs as well as by serving as a positive role model and support person. Referring families to support services when a need for assistance is identified in another way in which the nurse can help stop the cycle of abuse. These approaches have been helpful in reducing the risk of abuse. B. Elder Neglect and Abuse The problem of elder abuse and neglect and speculations about its causation has important implications for nurses working with dependent elders and caregivers of all types. As elders may suffer neglect or abuse at the hands of themselves, their peers, family members, paid helpers and organizations designed to help them, nurses have an opportunity to affect the development and consequences of elder abuse and neglect in many ways. While working with elderly individuals, whether in the hospital, nursing home, clinic or home setting, nurses should be alert for signs of abuse or neglect. Nurses often monitor patient condition and family concerns in the community setting. This is an excellent opportunity to identify family situations with high potential for abuse. Initial research points to families with a history of abusive behavior and family caregivers with multiple stressors as at high risk for elder abuse. It may be important to help the older person identify an alternative source of care so that an abuse-prone situation is avoided entirely. Page 9 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/104 O’Malley (1979) defines abuse as the willful infliction of physical pain, injury or debilitating mental anguish, unreasonable confinement, or the willful deprivation by a caretaker of services which are necessary to maintain physical and mental health. Neglect refers to an elderly person who is either living alone and not able to provide for him/herself the services, which are necessary to maintain physical and mental health or is not receiving necessary services form the responsible caretaker. See facility’s policy and procedure manual for current mandatory reporting requirements. C. References Code of Iowa. (1999). Sections 232.67-232.70. Page 10 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/105 Name: ___________________ Score: ___________________ Regional Hospitals: Mandatory Reporting Final Exam for the Certified Nursing Assistant 1. T F As a certified nursing assistant nurse you are a mandatory reporter for child abuse/neglect in all fifty states. 2. T F As a mandatory reporter suspecting child abuse/neglect, you are required to make an oral report to the Department of Human Services within 24 hours and a written report within 48 hours of the oral report. 3. T F The law protects nurses form civil suits in the case that a reported child abuse was unfounded as long as the nurse had a reasonable cause to report it. 4. T F Abuse is willful infliction of physical pain, injury or debilitating mental anguish, unreasonable confinement or the willful deprivation by a caretaker of services which are necessary to maintain physical and mental health. 5. T F Neglect refers t an elderly person who is either living alone and not able to provide for himself/herself the services which are necessary to maintain physical and mental health or is not receiving necessary services form the responsible caretaker. CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/106 Mandatory Reporting Final Exam Answer Key 1. False 2. True 3. True 4. True 5. True CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/107 Title: Regional Hospital: Pain and Comfort Study Module for the Certified Nursing Assistant Purpose: This module focuses on the Certified Nursing Assistant’s role in providing comfort Competency: Recognize essential aspects of pain and comfort. Implement measures to promote comfort Objectives: A. B. C. D. E. F. Upon completion of this module, the orientee will be able to: Recognize that comfort, rest, and sleep are needed for well-being Acknowledge age, illness, and activity affect comfort. Recognize that pain is subjective Evaluate the patients pain Identify interventions to promote comfort Content: A. B. C. D. E. F. G. H. I. J. Pain Recognition Vital Signs in assessing pain Quality of pain Severity of pain Body Responses to pain Behaviors Focus on children Focus on adults Certified Nursing Assistant measures to promote comfort and relieve pain Certified Nursing Assistant measures to promote rest and sleep Required Activities: A. Complete final exam with 85% accuracy B. Provide comfort measures to patients in pain C. Read and study Pain and Comfort Study Module Approved by: Becky Finch RN Jodi Asche CNA Mary Vold RN BSN Beverly Nelson CNA Diane Vrieze RN Page 1 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/108 Introduction: Pain is an important condition to observe and report with your patients. Pain is referred to as the fifth vital sign. It is as important to monitor pain as any other vital sign. Pain is a very difficult thing with which to cope. It can affect the patient’s daily life to the point that their ability to perform ADL’s is restricted. Pain can swiftly drain energy and hope. All caregivers are responsible for recognizing pain and taking appropriate action to provide pain management. Content: A. Pain Recognition 1. Notice individual signs of pain specific to each patient. 2. Work with family and friends who can assist with recognition of unrelieved pain 3. Monitor patients responses to pain medications 4. Report to charge nurse changes in pain level. These factors help determine an individual’s perception of pain, response to the pain, effectiveness of the pain control measures, and tendency to repeat pain. 5. Pain is whatever the patient says it is, exists whenever he/she says it does. Pain means different things to different people. An individual may have difficulty-describing pain to others because pain is a personal experience. Pain can be categorized according to its duration, quality and severity. B. Vital signs in assessing pain 1. Vital signs that often increase when a patient has pain are: a. Pulse b. Respirations c. Blood pressure 2. Other signs and symptoms that accompany pain are: a. Dizziness b. Nausea c. Vomiting d. Weakness e. Numbness f. Tingling 3. Location a. Identifying the location of the pain b. Does the pain spread? 4. Timing a. When did the pain start, was it sudden or gradual? b. How long did it last? c. How much does it bother you? d. What time of day does it bother you the most? e. Does it interrupt sleep? f. Does it happen before, during, or after meals? Page 2 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/109 C. Quality of pain-how does it feel, could it be described as: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Aching Burning Sore Throbbing Sharp Twisting Crushing Stabbing Cramping Squeezing Binding Cutting or dull Pins and needles Steady pain Has it changed D. Severity- a variety of pain assessment tools are available to the health care provider Visual Pain Scale: Ask patients to rate their pain Simple Descriptive Pain Distress Scale No pain 0 Unbearable pain 1 2 3 4 5 6 0-10 Numberic Pain Distress Scale Page 3 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/110 7 8 9 10 FLACC Scale: To be used if patient is unable to use visual scale Observation Face Legs Activity Cry Consol ability Value = 0 No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed Value = 1 Occasional grimace or frown, withdrawn, disinterested Uneasy, restless, tense Squirming, shifting back and forth, tense Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or “talking to,” distractible Value = 2 Frequent to constant frown, clenched jaw, quivering chin Kicking or legs drawn up Arched, rigid, or jerking Crying steadily, screams or sobs, frequent complaints Difficult to console or comfort Directions: Observe the behavior in each category. Add up the five “scores” to obtain a number on a scale of 0-10. Pain Thermometer: Place a check on the thermometer to indicate the amount of pain you are experiencing Page 3 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/111 Signs and Symptoms of Pain A. Body Responses to Pain 2. 3. 4. 5. 6. B. Behaviors 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. C. Crying Gasping Grimacing Groaning Grunting Holding the body part (splinting) Irritability Maintaining one position; refusing to move Moaning Quietness Restlessness Rubbing Screaming Focus on Children 1. 2. 3. 4. 5. D. Increased pulse, respirations and blood pressure Sweating (diaphoresis) Nausea Vomiting Pale skin (pallor) Children may not understand pain Children have fewer ways of dealing with pain Children rely on adults for help Infants, toddlers, and pre-school age children have difficulty alerting adults to pain Adults must be alert for behavior and situations that signal pain Focus on Adults 1. 2. 3. 4. 5. 6. 7. Older patients may have decreased pain sensations Some older patients may have health problems that cause pain Adults and older patients often deny or ignore pain because of what it may mean (denial) Thinking and reasoning are affected in some older patients Some adults cannot verbally communicate pain Changes in usual behavior may indicate pain Always report any changes in behavior to the charge nurse Page 4 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/112 Comfort Measures A. Certified Nursing Assistant Measures to Promote Comfort and Relieve Pain 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. B. Position the patient using good body alignment; use pillows for support Keep bed linens tight and wrinkle free Make sure the patient is not lying on drainage tubes Assist the patient to the bathroom/commode, or offer the bedpan or urinal Provide blanket for warmth and prevent chilling Use correct lifting, moving, and turning procedures Wait until pain medicine is effective before performing procedures (30 min. – 1 hour) Give back massage Provide soft music to distract the patient Use tough to provide comfort Allow family members and friends at the bedside as requested/tolerated by the patient Avoid sudden or jarring movements of the bed Handle the patient gently Offer a warm bath or shower Encourage slow, deep breathing Always be patient, caring and sympathetic Certified Nursing Assistant Measures to Promote Sleep Rest means being calm, at ease, and relaxed, free of anxiety and stress. Sleep is a state of unconsciousness, reduced voluntary muscle activity, and lowered metabolism. Sleep is a basic need. It lets the body and mind rest. During sleep the body saves energy. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Organize care to allow for uninterrupted rest Avoid physical activity before bedtime Encourage the patient to avoid tending to stressing matters before bedtime Allow a flexible bedtime. Bedtime is when the patient is tired and fatigued. Not a certain time. Provide a comfortable room temperature Allow the patient to take a warm bath or shower Provide a bedtime snack Avoid caffeine, (coffee, tea, colas, or chocolate) Have the patient void before going to bed Make sure incontinent patients are clean and dry- (change a baby’s diaper) Follow bedtime rituals Make sure the patient wears loose-fitting nightwear Provide adequate warmth, (blanket, socks), offer extra pillows Reduce noise Darken the room by closing shades, blinds, and the privacy curtain. Shut off or dim lights Dim lights in hallways and the nursing unit. Ensure staff activities and conversation aren’t disturbing sleep Make sure linens are clean, dry, and wrinkle free Make sure the patient is in a comfortable position and in good alignment Support the body parts, elevate/splint extremities as ordered Give a back massage Implement measures to relieve pain Allow the person to read or the Certified Nursing Assistant can read to small children Allow the person to listen to music/TV Assist with relaxation exercises as ordered Page 5 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/113 25. Sit and talk with the person-provide emotional support and socialization 26. Practice safety measures if the patient is receiving strong pain medication or sedatives a. Keep the bed in low position b. Raise bed rails as directed (Follow the care plan) c. Check on the patient every 10-15 minutes d. Provide assistance when the person is up e. Apply heat or cold applications as directed by the nurse f. Provide a calm, quiet, darkened environment g. Bed alarm system activated Summary: It is important for the caregiver to evaluate the pain management plan and its effectiveness towards relieving the patient’s pain and suffering 1. 2. 3. 4. 5. The patient or caregiver is encouraged to report pain and pain relief The rating tools/scales are used to evaluate pain The family/significant other are vital reporters of pain, for patients who are unable to speak for themselves The Certified Nursing Assistant must recognize behavioral and physical clues to evaluate pain relief The Certified Nursing Assistant will report the patient’s rating of pain, and pain relief Page 6 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/114 Name: _____________________ Score: _____________________ Regional Hospitals: Pain Control Final Exam 1. List 3 interventions the Certified Nursing Assistant can do to promote comfort 1. _____________________________________________________________________ 2. _____________________________________________________________________ 3. _____________________________________________________________________ 2. List 3 interventions the Certified Nursing Assistant can do to promote rest and sleep 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 3. List 5 signs of pain 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________ 5. __________________________ 4. List one tool to assess pain 1. __________________________ True or False: 5. True or False Nurses are responsible for recognizing pain and taking appropriate action 6. True or False Change in behavior could be an indication of pain CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/115 Regional Hospitals: Pain Control Final Exam for the Certified Nursing Assistant 7. True or False Asking the patient questions about the location, timing and quality of pain will help the patient describe their pain experience 8. True or False Using the pain scale of 1-10 is the only way to evaluate pain Multiple Choice: 9. Factors that effect comfort are: A. Age B. Illness C. Activity D. All of the above 10. The pain experience is A. Subjective B. Objective C. Rejective D. None of the above 11. The pain experience for the child and the adult is A. The same B. Different C. None of the above 12. Comfort measures that may assist with pain A. Provide a blanket B. Provide soft music C. Give back massage D. All of the above CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/116 Answer Key: Pain Control Final Exam 1. Comfort Measures A. Certified Nursing Assistant Measures to Promote Comfort and Relieve Pain 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Position the patient using good body alignment; use pillows for support Keep bed linens tight and wrinkle free Make sure the patient is not lying on drainage tubes Assist the patient to the bathroom/commode, or offer the bedpan or urinal Provide blanket for warmth and prevent chilling Use correct lifting, moving, and turning procedures Wait until pain medicine is effective before performing procedures (30 min. – 1 hour) Give back massage Provide soft music to distract the patient Use tough to provide comfort Allow family members and friends at the bedside as requested/tolerated by the patient Avoid sudden or jarring movements of the bed Handle the patient gently Offer a warm bath or shower Encourage slow, deep breathing Always be patient, caring and sympathetic 2. Certified Nursing Assistant Measures to Promote Sleep Rest means being calm, at ease, and relaxed, free of anxiety and stress. Sleep is a state of unconsciousness, reduced voluntary muscle activity, and lowered metabolism. Sleep is a basic need. It lets the body and mind rest. During sleep the body saves energy. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Organize care to allow for uninterrupted rest Avoid physical activity before bedtime Encourage the patient to avoid tending to stressing matters before bedtime Allow a flexible bedtime. Bedtime is when the patient is tired and fatigued. Not a certain time. Provide a comfortable room temperature Allow the patient to take a warm bath or shower Provide a bedtime snack Avoid caffeine, (coffee, tea, colas, or chocolate) Have the patient void before going to bed Make sure incontinent patients are clean and dry- (change a baby’s diaper) Follow bedtime rituals Make sure the patient wears loose-fitting nightwear Provide adequate warmth, (blanket, socks), offer extra pillows Reduce noise Darken the room by closing shades, blinds, and the privacy curtain. Shut off or dim lights Dim lights in hallways and the nursing unit. Ensure staff activities and conversation aren’t disturbing sleep Make sure linens are clean, dry, and wrinkle free Make sure the patient is in a comfortable position and in good alignment Support the body parts, elevate/splint extremities as ordered Give a back massage Implement measures to relieve pain CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/117 3. Signs and Symptoms of Pain A. Body Responses to Pain 1. 2. 3. 4. 5. B. Behaviors 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 4. Increased pulse, respirations and blood pressure Sweating (diaphoresis) Nausea Vomiting Pale skin (pallor) Crying Gasping Grimacing Groaning Grunting Holding the body part (splinting) Irritability Maintaining one position; refusing to move Moaning Quietness Restlessness Rubbing Screaming Face scale Thermometer scale Word scale Number scale 5. F 6. T 7. T 8. F 9. D 10. A 11. B 12. D CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/118 CBO/NURSE ASSIST/HCMH/8/13/2004/VOLD/119