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Body Mechanics
Body Mechanics is using the body in an efficient and careful way. It involves the use of good posture, balance, and the strongest and largest muscles of the body to perform work. The body's major movable parts are the head, trunk, arms and legs.

• Posture, or body alignment, is the way the body parts are aligned with one another. Good body alignment (posture) allows the body to move and function with strength and efficiency.
• Base of support is the area upon which an object rests. The feet provide the base of support for human beings. A good base of support is needed for balance.
• The strongest and largest muscle groups are located in the shoulders, upper arms, hips, and thighs. These muscles are used to lift and move heavy objects.
• Use the strong muscles of your thighs and hips by bending at the knees or squatting to lift heavy objects.
• Avoid bending over from the waist when lifting. Bending from the waist involves the small muscles of the back.
• Holding objects close to the body and base of support involves using upper arm and shoulder muscles.
• If the object is held away from the body, strain is placed on the smaller muscles of the lower arms.

The following rules will help you use good body mechanics to lift and move residents / patients and heavy objects safely and efficiently:

• Stand in good alignment and with a wide base of support (Spread your legs slightly apart).
• Use the stronger and larger muscles of your body. They are in the shoulders, upper arms, thighs, and hips.
• Keep objects close to your body when you lift, move, or carry them.
• Avoid unnecessary bending and reaching. If possible, have the height of the bed and over bed table level with your waist when giving care. Adjust the bed and table to the proper height.
• To prevent unnecessary twisting, face the area in which you are working.
• Push, slide, or pull heavy objects whenever possible rather than lift them.
• Use both hands and arms when you lift, move, or carry heavy objects.
• Turn your whole body when you change the direction of your movement.
• Work with smooth and even movements. Avoid sudden or jerky motions.
• Get help from a co-worker to move heavy objects or residents/ patients.
• Squat to lift heavy objects from the floor. Push against the strong hip and thigh muscles to raise yourself to a standing position.

You must follow the rules of body mechanics when lifting and moving residents/patients in bed. The residents/patients must be protected from injury during the move by being kept in good body alignment.

Protect the resident's/patient's skin from friction and shear. (Friction is the rubbing of one surface against another.) When the resident/patient is moved in bed, his or her skin rubs against the sheet. This can cause scratching and skin tears, especially in elderly persons.  Shear occurs when skin sticks to a surface and the bones move forward or backward within the skin. The skin is pinched between the bones and the surface. Blood supply to the skin is affected.  An infection or pressure sore can develop from friction and shear.

You can reduce friction and shear by rolling or lifting residents/patients instead of sliding them. A cotton draw sheet can be used as a lifting sheet to move the resident/ patient in bed thereby reducing friction and shear.

Other comfort and safety measures need to be considered before residents/patients are moved in bed:

• Consult the nurse for any limitations or restrictions in positioning or moving the resident / patient. These may be doctor's orders or par of the resident's/patient's care plan
• Decide how many co-workers you need to help you
• Get enough co-workers to help you before beginning the procedure
• Keep the person covered an screened to protect the right to privacy
• Protect any tubes or drainage containers connected to the resident/patient
• Use caution when moving residents / patients with severe arthritis or osteoporosis. Always ask for help when moving them to avoid causing pain or injury

You may have to raise a resident's/patient's head and shoulders to tie the back of a gown, to turn or remove a pillow, or to give care. You can raise the resident's/patient's shoulders easily and safely by locking arms with the resident/patient.

Procedure: Raising the Resident's/Patient's Head and Shoulders by Locking Arms with the Resident/Patient

1. Ask a co-worker to help if assistance is needed
2. Wash your hands
3. Identify the resident/patient. Check the ID bracelet and call the resident/patient by name.
4. Explain what you are going to do.
5. Provide for privacy.
6. Lock the bed wheels.
7. Raise the bed to the best level for good body mechanics.
8. Ask your helper to stand on the other side of the bed. Lower the side rails if they are up.
9. Ask the resident/patient to put the near arm under your near arm and behind your shoulder. His or her hand should rest on top of your shoulder. If you are standing on the right side, the resident's/patient's right hand will rest on your right shoulder. If you have assistance, have the resident/patient do the same with your co-worker. The resident's/patient's left hand will rest on your co-worker's left shoulder.
10. Put your arm near the resident/patient under his or her arm. Your hand should be on the resident's/patient's shoulder. Have your helper do the same.
11. Put your free arm under the resident's/patient's neck and shoulders. If you have assistance, ask your helper to do the same.
12. Help the resident/patient pull up to a sitting position on the count of "3".
13. Use the arm and hand that supported the resident's/patient's neck and shoulders to straighten pillow, tie the gown, etc. If you have assistance, ask your co-worker to support the resident/patient.
14. Help the resident/patient lie down. Provide support with your locked arm. Support his or her neck and shoulders with your other arm.
15. Make sure the resident/patient is comfortable and in good body alignment.
16. Place the signal light within reach.
17. Raise or lower side rails as instructed by the nurse.
18. Lower the bed to its lowest position.
19. Unscreen the resident/patient.
20. Wash your hands.

Procedure: Moving the Resident / Patient Up in Bed
When the head of the bed is raised, residents/patients often slide down toward the middle and foot of the bed. They need to be moved up in bed to maintain good body alignment.

1. Wash your hands.
2. Identify the resident/patient. Check the ID bracelet and call the resident/patient by name.
3. Explain what you are going to do.
4. Provide for privacy.
5. Lock the bed wheels.
6. Raise the bed to the best level for good body mechanics.
7. Lower the head of the bed to a level appropriate for the resident/patient. The bed should be as flat as possible.
8. Place a pillow against the headboard if the resident/patient can be without it. This prevents his or her head from hitting the headboard when being moved up.
9. Make sure the far side rail is raised. Lower the one near you if it is up.
10. Stand with your feet about 12 inches apart. Point the foot nearest the head of the bed toward the head of the bed.
11. Bend your hips and knees, and keep your back straight.
12. Place one arm under the resident's / patient's shoulders and the other under the resident's / patient's thighs.
13. Ask the resident / patient to grasp the headboard and to flex both knees.
14. Explain that you will both move on the count of "3". Ask the resident / patient to pull up with the hands and push against the bed with the feet. Explain what you will be doing.
15. Move the resident / patient to the head of the bed on the count of "3". Shift your weight from your rear leg to your front leg.
16. Put the pillow under the resident's / patient's head and shoulders. Lock arms with him or her to complete the this step.
17. Straighten linens. Make sure the resident / patient is comfortable and in good alignment.
18. Place the signal light within reach.
19. Raise or lower side rails as instructed by nurse.
20. Raise the head of the bed to a level appropriate for the resident / patient.
21. Lower the bed to its lowest position.
22. Unscreen the resident / patient.
23. Wash your hands.

Procedure: Moving the Resident / Patient Up in Bed with Assistance

1. Ask a co-worker for help.
2. Wash your hands.
3. Identify the resident / patient. Check the ID bracelet and call the person by name.
4. Explain what you are going to do.
5. Provide for privacy.
6. Lock the bed wheels.
7. Raise the bed to a level for good body mechanics.
8. Lower the head of the bed to a level appropriate for the resident / patient. The bed should be as flat as possible.
9. Place the pillow against the headboard if the resident / patient can be without it. This prevents his or her head from hitting the headboard when being moved up.
10. Stand on one side of the bed. Have your helper stand on the other.
11. Lower the side rails if they are up.
12. Stand with your feet about 12 inches apart. Point the foot near the head of the bed toward the head of the bed. Face that direction.
13. Bend your hips and knees, and keep your back straight.
14. Place one arm under the resident's / patient's shoulder and one arm under the buttocks. Your helper does the same. Grasp each other's forearms.
15. Ask the resident / patient to flex both knees.
16. Explain that you and your helper will move on the count of "3". The resident / patient, if able, should push against the bed with the feet.
17. Move the resident / patient to the head of the bed on the count of "3". Shift your body weight from your rear leg to your front leg.
18. Repeat steps 12 though 17 if necessary.
19. Put the pillow under the resident's / patient's head and shoulders. Straighten the linens. Make sure the resident / patient is comfortable and in good body alignment.
20. Place the signal light within reach.
21. Raise or lower side rails as instructed by the nurse.
22. Raise the head of the bed to a level appropriate for the resident / patient.
23. Lower the bed to its lowest position.
24. Unscreen the resident / patient.
25. Wash your hands.

Procedure: Transferring Residents / Patients
Residents / patients often need to be moved from their beds to chairs, wheelchairs, or stretchers. A transfer belt is used for transferring most residents / patients. The belt is used to hold onto the resident / patient during the transfer. Remember, if the resident / patient requires assistance to transfer, a transfer belt is required. The belt is applied around the resident's / patient's waist, and is used when walking with a resident / patient.
Applying a Transfer (Gait) Belt

1. Wash your hands.
2. Identify the resident / patient. Check the ID bracelet and call the person by name.
3. Explain what you are going to do.
4. Provide for privacy.
5. Assist the resident / patient to a sitting position.
6. Apply the belt around the waist over clothing. Do not apply it over bare skin.
7. Tighten the belt so that it is snug. It should not cause discomfort or impair breathing.
8. Make sure that a woman's breasts are not caught under the belt.
9. Place the buckle off-center in front or in the back for the resident's / patient's comfort.
10. Prepare to transfer.

Transferring the Resident / Patient to a Chair or Wheelchair

1. Explain what you are going to do.
2. Collect the following:

a. Wheelchair or armchair
b. One or two bath blankets and a lab robe
c. Clothing or robe and shoes
d. Paper or sheet for the bottom linen
e. Transfer belt if needed
f. Special cushion if used

3. Wash your hands.
4. Identify the resident / patient. Check the ID bracelet and call the person by name.
5. Provide for privacy.
6. Decide which side of the bed to use. Move furniture to provide moving space.
7. Place the chair or wheelchair at the head of the bed. The back must be even with the headboard.
8. Place the folded bath blanket or cushion on the seat.
9. Make sure the bed is in the lowest position and the bed wheels are locked.
10. Fan-fold top linens to the foot of the bed.
11. Help the resident / patient put on clothing or a robe.
12. Place the paper or sheet under the resident's / patient's feet to protect the bottom sheet. Put shoes on the resident / patient.
13. Help the resident / patient dangle. Make sure his or her feet touch the floor.
14. Apply the transfer belt.
15. Help the resident / patient stand. Do the following if a transfer belt is used.

a. Stand in front of the resident / patient
b. Have the resident / patient place his or her fist on the bed by their thighs.
c. Make sure the resident's / patient's feet are flat on the floor.
d. Have the resident / patient lean forward
e. Grasp the transfer belt at each side
f. Brace your knees against the resident's / patient's knees and block his or her feet with your feet.
g. Ask the resident / patient to push the fists down on the bed and to stand on the count of "3". Pull the resident / patient into a standing position as you straighten your knees.

16. Use this method if a transfer belt is not available.

a. Stand in front of the resident / patient
b. Have the resident / patient place the fists on the bed by the thighs.
c. Make sure the resident's / patient's feet are flat on the floor
d. Place your hands under his or her arms. Your hands should be around the shoulder blades.
e. Have the resident / patient lean forward
f. Brace your knees against the resident's / patient's knees, and block his or her feet with your feet.
g. Ask the resident / patient to push the fists into the bed and to stand on the count of "3". Pull the resident / patient up into a standing position as you straighten your knees.

17. Support the resident / patient in the standing position. Hold the transfer belt or the resident's / patient's shoulder blades. Continue to block the resident's / patient's feet and knees with your feet and knees. This helps prevent falling.
18. Turn the resident / patient so he or she can grasp the far arm of the chair. The legs will touch the edge of the chair. Turn the resident / patient until the other armrest is grasped.
19. Lower him or her into the chair as you bend your hips and knees. The resident / patient assists by leaning forward and bending the elbows and knees.
20. Make sure the buttocks are to the back of the seat. Position the resident / patient in good alignment.
21. Position the feet on the footrests.
22. Cover the resident's / patient's lap and legs with a lap robe or bath blanket if the resident patient is not dressed. The blanket must be off the floor and wheels.
23. Remove the transfer belt.
24. Position the chair as the resident / patient prefers.
25. Place the signal light and other necessary items within reach if the resident / patient will be at bedside. Straighten the unit.
26. Unscreen the resident / patient.
27. Wash your hands.
28. Report the following to the nurse:

a. Pulse rate if taken
b. How well the activity was tolerated
c. Complaints of lightheadedness, pain, discomfort, difficulty breathing, weakness, or fatigue
d. The amount of assistance needed to transfer the resident / patient

29. Reverse the procedure to return the resident / patient to bed.

Basic Emergency Care
Emergency situations can occur in nursing facilities, homes, public places, or on the highway. Knowing what to do may mean the difference between life or death. I would like to encourage you to take a first aid course offered by the American Red Cross and a basic life support course offered by the American Heart Association or the Red Cross. These courses will prepare you to give care in emergency situations.

General Rules of Emergency Care
First aid is the emergency care given to an ill or injured person before medical help arrives. The goals of first aid are to prevent death and to prevent injuries from becoming worse. When an emergency occurs, the local Emergency Service (EMS) system is activated. The system involves emergency personnel (paramedics, emergency medical technicians) who have had education and training in emergency care. They have learned how to treat, stabilize, and transport persons who are experiencing life-threatening conditions.
In many areas the EMS system can be activated by dialing 911, or by calling the local fire or police department or the telephone operator. In nursing facilities a nurse decides when to activate the EMS system. The nurse will tell you what to do to help in the situation. If a resident/patient has stopped breathing or is having cardiac arrest, the nurse may start cardiopulmonary resuscitation (CPR). Policies vary about nursing assistants starting CPR.

Each emergency is different. However, the following rules apply to any emergency:

• Know your limitations. Do not try to do more than you are able. Do not perform a procedure with which you are not familiar. Do what you can under the circumstances.
• Stay calm. Calm and efficient functioning will help the victim feel more secure.
• Make quick observations for life-threatening problems. Check for breathing, pulse, and bleeding.
• Keep the victim lying down or in the position in which he or she was found. You could make an injury worse by moving the victim.
• Perform necessary emergency measures.
• Call for help or have someone activate the EMS system. An operator will send emergency vehicles and personnel to the scene. Do not hang up until the operator has hung up. Give the operator the following information:
  • Your location - include the street address and the city or town you live in. Give names of cross streets or roads and landmarks if possible. Also give the telephone number you are calling from.
  • What has happened - (heart attack, accident, etc.) police, fire equipment, and ambulances may be needed.
  • How many people need help.
  • The condition of the victims, any obvious injuries, and if there are any life-threatening situations.
  • What aid is being given.
• Do not remove clothes unless you have to. If clothing must be removed, tear the garment along the seams.
• Keep the victim warm. Cover the victim with a blanket. Use coats and sweaters if there is no blanket.
• Reassure the conscious victim. Explain what is happening and that help has been called.
• Do not give the victim any food or fluid.
• Do not move the victim. Emergency personnel have been trained to do so.
• Keep bystanders away from the victim. They tend to stare, offer advice, and make comments about the victim's condition. The victim may think the situation is worse than it really is. Also, privacy is invaded by onlookers.

Basic Life Support
When the heart and breathing stop, the person is clinically dead. Blood and oxygen are not circulated through the body. Permanent brain damage and other organ damage occur within 4 to 6 minutes. Death may be expected. Death is expected in persons suffering from long illnesses for which there is no hope of recovery. However, the heart and breathing can stop suddenly and without warning. This is a state of cardiac arrest. Cardiac arrest is a sudden, unexpected, and dramatic event. People have had cardiac arrests while driving, shoveling snow, playing golf, watching television, eating, and sleeping. Cardiac arrest can occur anywhere and at any time.
Common causes include heart disease, drowning, electrical shock, severe injury, obstruction of the air passages, and drug overdose. The victim suffers permanent brain damage unless breathing and circulation are restored.

Respiratory arrest is when breathing stops but the heart continues to pump blood for several minutes. If breathing is not restored, cardiac arrest occurs. Causes of respiratory arrest include drowning, stroke, obstructed airway, drug overdose, electrocution, smoke inhalation, suffocation, injury from lightening, myocardial infarction, coma, and other injuries.

Basic life support involves preventing or promptly recognizing cardiac arrest or respiratory arrest. Basic life support procedures support breathing and circulation. These life-saving measures require speed, skill, and efficiency. Again, you are advised to take a course to become certified in basic life support.

Cardiopulmonary Resuscitation
There are three major signs of cardiac arrest - no pulse, no breathing, and unconsciousness. The person's skin is cool, pale, and gray. The person has no blood pressure. Cardiopulmonary resuscitation (CPR) must be started as soon as cardiac arrest occurs. CPR provides oxygen to the brain, heart, kidneys, and other organs until more advanced emergency care can be given. CPR has three basic parts (the ABC's of CPR): airway, breathing, and circulation.

Airway - The respiratory passages (airway) must be open if breathing is to be restored. The airway often is blocked or obstructed during cardiac arrest. The victim's tongue falls toward the back of the throat and blocks the airway. The head-tilt/chin-tilt maneuver is used to open the airway. One hand is placed on the victim's forehead. Pressure is applied on the forehead with the palm to tilt the head back. The fingers of the other hand are placed under the bony part of the chin. The chin is lifted forward as the head is tilted backward with the other hand.

Breathing - Oxygen is not inhaled when breathing stops. The victim must get oxygen. Otherwise permanent brain and organ damage will occur. Because the victim cannot breathe, breathing is done for the victim. This is accomplished during CPR by mouth-to-mouth resuscitation.

The airway is kept open to give mouth-to-mouth resuscitation. The victim's nostrils are pinched shut with the thumb and index finger of the hand on the forehead. Shutting the nostrils prevents air from escaping through the nose. After taking a deep breath, place your mouth tightly over the victim's mouth. Blow air into the victim's mouth as you exhale. You should see the victim's chest rise as the lungs fill with air. After you give a ventilation, remove your mouth. Then take in a quick deep breath. Mouth-to-mouth resuscitation is not always indicated or possible. The mouth-to-nose technique may be necessary. The mouth-to-nose technique is suggested when:

• You cannot ventilate the victim's mouth.
• You cannot open the mouth.
• You cannot make a tight seal for mouth-to-mouth resuscitation.
• The mouth is severely injured.

The mouth must be closed for mouth-to-nose resuscitation. The head-tilt/chin-tilt method is used to open the airway. Pressure is placed on the chin to close the mouth. To give the ventilation, place your mouth over the victim's nose and blow air into the nose.

Some people breathe through openings (stomas) in their necks. They need mouth-to-stoma ventilation during cardiac or respiratory arrest. You will seal your mouth around the stoma and blow air into the stoma. To see if the person is a "neck-breather," check for an opening at the front of the neck.

You will have contact with the victim's body fluids or body substances when giving artificial ventilation. If available, a pocket mask with a one-way valve is used for mouth-to-mouth resuscitation. This provides a barrier between you and the victim's fluids or body substances.

Circulation - Blood flow to the brain and other organs must be maintained. Otherwise permanent damage results. In cardiac arrest, the heart stops beating. Therefore blood must be pumped through the body some other way. Artificial circulation is accomplished by external chest compression. This is also called external cardiac massage. Each chest compression forces blood through the circulatory system.

The heart lies between the sternum (breastbone) and the spinal column. When pressure is applied to the sternum, the sternum is depressed. This compresses the heart between the sternum and the spinal column. For effective chest compressions, the victim must be supine and on a hard, flat surface.

Proper hand position is important for external chest compressions. Use this process for locating hand position for adults:

• Use your index and middle fingers to locate the lower part of the victim's rib cage on the side nearest you.
• Then run your fingers up along the rib cage to the notch at the center of the chest. The notch is where the ribs and the sternum meet.
• Use your middle finger to mark the notch.
• Place your index finger next to your middle finger on the lower end of the sternum.
• Place the heel of your other hand on the lower half of the sternum next to your index finger.
• Remove your index finger and middle finger from the notch.
• Place that hand on the hand already on the sternum.
• Extend or interlace your fingers to keep them off the chest.

You must be positioned properly for chest compressions. Your elbow must be straight. Your shoulders must be directly over the victim's chest. Firm downward pressure is exerted to depress the sternum about 1 1/2 to 2 inches. Then the pressure is released without removing your hands from the chest. Compressions are given in a regular, rhythmic fashion.

Performing CPR - CPR is performed only for cardiac arrest. You must determine if cardiac arrest or fainting has occurred. CPR is done when there is unresponsiveness, breathlessness, and lack of pulse.

Determine unresponsiveness by tapping or gently shaking the victim and shouting "Are you OK!" If there is no response, the victim is unconscious.

Establishing breathlessness involves three steps:

• Look at the victim's chest to see if it rises and falls.
• Listen for the escape of air during expiration. Place your ear near the victim's nose and mouth to listen for the escape air.
• Feel for the flow of air. To feel for the flow of air, place your cheek near the victim's nose.

The carotid artery is used to check for a lack of pulse.
To find the carotid pulse, place the tips of your index and middle fingers on the victim's trachea (windpipe). Then slide your fingertips down off the trachea to the groove of the neck on the side near you.

Procedure - Adult CPR - One Rescuer

1. Check for unresponsiveness.
2. Call for help. Activate the EMS system.
3. Position the victim supine. Logroll the victim so there is no twisting of the spine. The victim must be on a hard, flat surface. Place the victim's arms alongside the body.
4. Open the airway. Use the head-tilt/chin-tilt maneuver.
5. Check for breathlessness.
6. Give two ventilations. Each should be 1 1/2 seconds long. Let the victim's chest deflate between ventilations.
7. Check for a lack of pulse. Check the pulse for 5 to 10 seconds. Use your other hand to keep the airway open with the head-tilt maneuver.
8. Give chest compressions at a rate of 80 to 100 per minute. Give 15 compressions and then 2 ventilations.
9. Establish a rhythm and count out loud (try: "1 and, 2 and, 3 and, 4 and, 5 and, 6 and, 7 and, 8 and, 9 and, 10 and, 11 and, 12 and, 13 and, 14 and, 15").
10. Open the airway and give 2 ventilations. - Repeat this step until 4 cycles of 15 compressions and 2 ventilations have been given.
11. Check for a carotid pulse (5 seconds).
12. Resume cycle of 15 compressions and 2 ventilations.
13. Repeat step 8. Check for a pulse every 4 to 5 minutes. Do not interrupt CPR for more than 7 seconds.

Procedure - Adult CPR - Two Rescuers

1. Perform one-person CPR until a helper arrives.
2. Continue chest compressions. The helper says, "I know CPR. Can I help?"
3. Indicate that you want help. Ask that the EMS system be activated, if not already done.
4. Do not stop chest compressions. The helper kneels on the other side of the victim. The two-rescuer procedure begins after you complete a cycle of 15 compressions and 2 ventilations.
5. Stop compressions for 5 seconds. The helper checks for a carotid pulse. The helper states "No pulse."
6. Perform two-person CPR as follows:
   1. The helper gives 2 ventilations.
   2. Give chest compressions at a rate of 80 to 100 per minute. Count out loud in a rhythm (try: "1 and, 2 and, 3 and, 4 and, 5").
   3. The helper gives a ventilation immediately after the fifth compression. Pause 1 to 1 1/2 seconds for the ventilation. Continue chest compressions after the ventilation.
   4. A ventilation is given after every fifth compression. Your helper checks for pulse during the compressions.
   5. Stop compressions after 1 minute. Your helper checks for breathing and a pulse. After the first minute, compressions are stopped every few minutes to check for breathing and circulation. Compressions are stopped for only 5 seconds.
7. Call for a switch in positions when you are tired.
8. Change positions quickly.
9. Give 1 ventilation after every fifth compression.
10. Switch positions when the person giving the compressions is tired. Check for pulse and breathing at every position change.

Obstructed Airway - Airway obstruction (choking) can lead to cardiac arrest.
Air cannot pass through the air passages to the lungs. The entire body is deprived of oxygen. Airway obstruction often occurs during eating. Meat is the most common food to cause airway obstruction. Choking often occurs on large, poorly chewed pieces of meat. Laughing and talking while eating also are common causes.

Airway obstruction can occur in the unconscious person. Common causes are aspiration of vomitus and the tongue falling back into the airway.

When airway obstruction occurs, the conscious person will usually clutch at the throat. The person cannot breathe, speak, or cough and appears pale and cyanotic. The victim will be very apprehensive. The obstruction must be removed immediately before cardiac arrest occurs.

The Heimlich maneuver is used to relieve an obstructed airway. It involves abdominal thrusts. The maneuver can be performed with the victim standing, sitting, or lying.

The finger sweep is another maneuver used when an adult victim is unconscious.

Call for help when a victim has an obstructed airway. Have someone activate the EMS system.

The Heimlich maneuver is not effective in extremely obese persons or pregnant women. Chest thrusts are used.

They are performed as follows

• Ask your conscious victim if they are choking and determine if they are able to cough or speak.
  • The victim is sitting or standing:
  • Stand behind the victim.
  • Place your arms under the victim's arms. Wrap your arms around the victim's chest.
  • Make a fist. Place the thumb side of the fist on the middle of the sternum.
  • Grasp the fist with your other hand.
  • Give backward chest thrusts until the object is expelled or the victim becomes unconscious.

The victim is lying down or unconscious:

1. Check for unresponsiveness.
2. Call for help.
3. Logroll the victim to the supine position with his or her face up. The victim's arms should be at the sides.
4. Open the airway. Use the head-tilt/chin-lift maneuver.
5. Check for breathlessness.
6. Give 1 ventilation. Reposition the victim's head, and open the airway if you could not ventilate. Give 1 ventilation.
7. Have someone activate the EMS system.
8. Do the Heimlich maneuver.
   1. Kneel next to the victim's thighs.
   2. Place the heel of one hand against the middle of the victim's abdomen. It should be in the middle of the abdomen between the lower end of the sternum and the navel.
   3. Place your other hand on top of the hand on the victim's abdomen.
   4. Give an abdominal thrust. Press inward and upward.
   5. Give 5 abdominal thrusts.
9. Do the finger sweep maneuver to check for a foreign object.
   1. Open the victim's mouth. Use the tongue-jaw lift maneuver:
   2. Grasp the tongue and lower jaw with your thumb and fingers.
   3. Lift the lower jaw upward.
   4. Insert your other index finger into the mouth along the side of the cheek and deep into the throat. Your finger should be at the base of the tongue.
   5. Form a hook with your index finger.
   6. Try to dislodge and remove the foreign object. Do not push it deeper into the throat.
   7. Grasp and remove the object if it is within reach.
10. Open the airway with the head-tilt/chin-lift method.
11. Give 1 ventilation. Repeat steps 8 through 10, and give 1 ventilation.
12. Repeat steps 8 through 11 for as long as necessary.

Hemorrhage
Life and body functions require an adequate blood supply. Circulation of blood through the body also is required. If a blood vessel is torn or cut, bleeding and blood loss occur. The larger the blood vessel, the greater the bleeding and blood loss. Hemorrhage is the excessive loss of blood from a blood vessel. If bleeding is not stopped, death will result. Hemorrhage may be internal or external.
Internal hemorrhage cannot be seen. Bleeding occurs inside the body into tissues and body cavities.

Pain, shock, vomiting blood, coughing up blood, and loss of consciousness are signs of internal hemorrhage. There is little you can do for internal bleeding. Keep the person warm, flat, and quiet until medical help arrives. Fluids are not given.

External bleeding usually is seen. However, it may be hidden by clothing. Bleeding may be from an injured artery or a vein. Bleeding from an artery is bright red and occurs in spurts. There is a steady flow of blood when bleeding is from a vein. Basic emergency care for external hemorrhage involves stopping the bleeding. The treatment of choice is to apply direct pressure to the bleeding site. If direct pressure does not control bleeding, pressure is applied to the artery above the bleeding site. You can use the following to control external hemorrhage:

1. Call for help. Have someone activate the EMS system if possible.
2. Use universal precautions and follow the bloodborne pathogen standard. Wear gloves if possible.
3. Place a sterile dressing over the wound. Any clean material (handkerchief, towel, cloth, or sanitary napkin) can be used if there is no sterile dressing.
4. Apply pressure with your hand directly over the bleeding site. Do not release the pressure until the bleeding is controlled.
5. If direct pressure does not control the bleeding, apply pressure over the artery above the bleeding site. Use your first three fingers. For example, if bleeding from the lower arm, apply pressure over the brachial artery. The brachial artery supplies blood to the lower arm.

Shock
Shock occurs when there is an inadequate blood supply to organs and tissues. Blood loss, heart disease, and severe infection can cause shock. Signs and symptoms include low or falling blood pressure; a rapid and weak pulse; cold, moist, and pale skin; rapid respirations; thirst; and restlessness. Confusion and loss of consciousness occur as shock becomes worse. Shock is possible in any person who is acutely ill or injured. Do the following to prevent or to treat shock:

• Keep the victim lying down.
• Control hemorrhage.
• Keep the victim warm. Place a blanket over and under the victim if possible.
• Reassure the victim.
• Summon medical assistance.

Seizures
Seizures (convulsions) are violent and sudden contractions or tremors of muscles. They are due to an abnormality within the brain. The abnormality may be caused by head injury during birth, high fever, brain tumors, poisoning, or central nervous system infections.
Head trauma and lack of blood flow to the brain also can cause seizures. There are many types of seizures. You need to be aware of two types.

The tonic-clonic type (grand mal seizure) has two phases.

• The tonic phase is the first. The person loses consciousness. The person, if standing or sitting, falls to the floor. The body is rigid. This occurs because all muscles contract at once.
• The clonic phase is the next. Muscle groups contract and relax. This causes jerking and twitching movements of the body. Urinary and fecal incontinence may occur during this phase.
• After the seizure the person usually falls into a deep sleep. On awakening, the person may experience confusion and headache.

The generalized absence type (petit mal seizure) usually lasts 5 to 15 seconds. There is loss of consciousness, twitching of arm and face muscles, and rolling of the eyes. The person appears to be staring.

The person must be protected from injury during a seizure. The following measures are performed:

• Call for help.
• Lower the person to the floor.
• Place a folded bath blanket or towel under the person's head. Or cradle the person's head in your lap or on a pillow. This prevents the person's head from striking the floor.
• Turn the head to one side.
• Loosen tight clothing.
• Move furniture and equipment away from the person. The person may strike these objects during the uncontrolled body movement.
• Do not try to restrain body movement during the seizure.
• Position the person on one side if possible.
• Summons medical help. Do not leave the person during the seizure.

Fainting
Fainting is the sudden loss of consciousness as a result of an inadequate blood supply to the brain. Hunger, fatigue, fear, and pain are common causes. Some people faint at the sight of blood or injury. Fainting also can be caused by standing in one position for a long time or being in a warm, crowded room. Dizziness, perspiration, and blackness before the eyes may occur before the person faints. The person looks pale. The pulse is weak. Respirations are shallow if the person loses consciousness. Emergency care for fainting includes the following:

• Have the person sit or lie down before fainting occurs.
  • If the person is in the sitting position, have him or her bend forward and place the head between the knees if this position is possible.
  • If the person is lying down, elevate his or her legs.
• Loosen tight clothing.
• Keep the person lying down if fainting has occurred.
• Do not let the person get up until symptoms have subsided for about 5 minutes.
• Help the person to a sitting position after recovery from fainting. Observe for symptoms of fainting.

Stroke
A stroke occurs when the brain is suddenly deprived of its blood supply. Usually only part of the brain is affected. A stroke may be caused by thrombus, an embolus, or cerebral hemorrhage. Cerebral hemorrhage is due to the rupture of a blood vessel in the brain.
The signs of stroke vary. They depend on the size and location of brain injury. Loss of consciousness or semiconsciousness, rapid pulse, labored respirations, elevated blood pressure, vomiting, and hemiplegia are signs of stroke. The person may have aphasia (the inability to speak). Seizures may occur. Emergency care includes the following:

• Turn the person onto the affected side. The affected side is limp and the cheek appears puffy.
• Elevate the head without flexing the neck.
• Loosen tight clothing.
• Keep the person quiet and warm.
• Reassure the person.
• Summon medical help.

Vomiting
Vomiting is the act of expelling stomach contents through the mouth. Although not a true emergency, vomiting is a sign of illness or injury, it can be life-threatening. The vomitus (material vomited) can be aspirated and obstruct the airway. Shock can also occur if large amounts of blood are vomited. The following measures will help the vomiting person:

• Use universal precautions. Wear gloves if possible. Also follow the bloodborne pathogen standard.
• Turn the person's head well to one side. This prevents aspiration.
• Place an emesis basin under the person's chin.
• Remove the vomitus from the person's immediate environment.
• Let the person use mouthwash and perform oral hygiene. This helps eliminate the taste of vomitus.
• Eliminate odors.
• Change linens as necessary.

Observe the vomitus for color, odor, and undigested food. Vomitus that looks like coffee grounds contains digested blood. This indicates bleeding. The amount of vomitus is measured. The amount is reported to the nurse and recorded on the I&O record, if one is being used. A specimen may be saved for laboratory study. Do not discard vomitus until it has been observed by the nurse.

The Dying Person
Health care workers see death often. Many, however are unsure of their feelings about death. They are uncomfortable with dying people and the subject of death. Dying persons remind them of their own eventual death or the death of loved ones. Dying persons represent helplessness and the failure to cure.

You must examine your own feelings about death. Your attitude about death and dying affects the care you give. Your role is to help meet the person's physical, psychological, social, and spiritual needs. To do so, you need to understand the dying process. Then you can approach the dying resident/patient with caring kindness, and respect.

Terminal Illness
Many illnesses and diseases can be cured or controlled. Others have no cure. Many injuries can be repaired. Others are so serious that the body cannot continue to function. Recovery is not expected. The disease or injury will result in death.

An illness or injury for which there is no reasonable expectation of recovery is a terminal illness.

Doctors cannot tell exactly when a terminal illness will result in death. A person can be given days, month, weeks, or years to live. Predictions can be wrong.

Modern medicine has brought cures or has prolonged life in many cases. Future research is likely to bring new cures. Living and dying, however, are influenced by two very powerful psychological forces - hope and the will to live.

Attitudes About Death
Experiences, culture, religion, and age influence a person's attitude about death. Many people fear death. Others refuse to believe they will die. Some look forward to and accept death. Attitudes and beliefs about death often change as a person grows older. They also are affected by changing circumstances.

Attitudes about death are closely related to religion. Some persons believe that life after death is free of suffering and hardship. They believe there will be a reunion with family and loved ones. Some believe there is punishment and suffering for sins and misdeeds in the afterlife. Others do not believe in an afterlife. They believe that death is the end of life. There also are religious beliefs about the form of the body after death. Some believe the body keeps its physical form. Others believe that only the spirit or soul is present in the afterlife. Still others believe in reincarnation. Reincarnation is the belief that the spirit or soul is reborn into another human body or into another form of life.

Children between the ages of 3 and 5 years start to be curious and have ideas about death. They recognize deaths of family members or pets and notice dead birds or bugs. They view death as temporary. Children often blame themselves when someone or something dies. They see the event as punishment for being bad. When children ask questions about death, answers from adults often cause fear or confusion. Children who are told "He is sleeping" may be afraid to go to sleep.

Between the ages of 5 and 7 years, children view death as final. They do not see death in relation to themselves. Death is something that happens to other people. They also think death can be avoided. Children associate death with punishment and mutilation of the body. It also is associated with witches, ghosts, goblins, and monsters.

Adults have more fears about death than do children. They fear pain and suffering, dying alone, and invasion of privacy. They also fear loneliness and being separated from family and loved ones. They worry about who will care for and support loved ones left behind. Adults often resent death.

Elderly persons usually have fewer fears about death. They are more accepting that death will occur. They have had more experiences with dying and death. Many have lost family members and friends. Some welcome death as freedom from pain, suffering, and disability. However, elderly persons often fear dying alone.

The Stages Of Dying
The five stages of death have been identified as denial, anger, bargaining, depression, and acceptance.

The first stage is denial. During denial, persons refuse to believe they are dying. "No, not me" is a common response. The person believes a mistake has been made. Information about the illness or injury is not heard. The person cannot deal with any problem or decision related to the illness or injury. This stage can last a few hours, days, or much longer. Some people are still in the stage of denial at the time of death.

The second stage is anger. The person thinks "Why me?" People behave with anger and rage. They envy and resent those who have life and health. Family, friends, and the health care team usually are the targets of their anger. They blame others. They find fault with those who are loved and needed the most. Anger is a normal and healthy reaction. Do not take a person's anger personally.

The third stage is bargaining. The person now says, "Yes me, but ...." There is bargaining with God for more time. Promises are made in exchange for more time. They may want to see a child marry, see a grandchild, have one more Christmas, or live to see an important event. Usually more promises are made as they make "just one more" request. This stage may not be obvious. Bargaining usually is private and on a spiritual level.

The fourth stage is depression. The person thinks, "Yes, me." The person is very sad. There is mourning over things that have been lost and the loss of future life. The person may cry or say little. Sometimes, the person talks about people and things that will be left behind.

The fifth and final stage of dying is acceptance of death. The person is calm and at peace. The person has said what needs to be said. Unfinished business is completed. The person is ready to accept death. A person may be in this stage for many months or years. Reaching acceptance does not mean death is near.

Dying persons do not always go through all five stages. A person may never get beyond a certain stage. Some move back and forth between stages. Some people are in one stage until death.


Psychological, Social, and Spiritual Needs
Dying persons continue to have psychological, social, and spiritual need. They may want family and friends present. They may want to talk about the fears, worries, and anxieties of dying. Some want to be alone. Often they want to talk to the members of the health care team.

There are two very important aspects of communication in dealing with the dying person. These are listening and touch. The person needs to talk, express feelings, and share worries and concerns. Let the person express feelings and emotions in his or her own way. Just being there and listening helps meet the person's psychological and social needs. Don't worry about saying the wrong thing. Do not worry about finding the right words to comfort the person. Nothing really must be said. Do not feel that you need to talk. Silence, along with touch, is a very powerful and meaningful way to communicate.

Spiritual needs are important. The person may wish to see a priest, rabbi, or minister. The person may also want to take part in religious practices. Privacy is provided during spiritual moments. Courtesy is given to the clergy. The resident/patient has the right to have religious objects nearby (medals, pictures, statues, or Bibles). Handle these items like any other valuable.


Physical Needs
Dying may take a few minutes, hours, days, or weeks. There is a general slowing of body processes, weakness, and changes in the level of consciousness. The person is given as much independence as possible. As the person weakens, the nursing team helps meet basic needs. The person may totally depend on others for basic needs and activities of daily living. Every effort is made to promote physical and psychological comfort. The person is allowed to die in peace and dignity.

Vision, Hearing, and Speech

• Vision becomes blurred and gradually fails during the dying process. The person naturally turns toward light. A darkened room may be frightening. The eyes may be half open. Secretions may collect in the corners of the eyes.
• Because of failing vision, you need to explain what is being done to the person or in the room. The room should be well lit. Bright lights and glares, however, should be avoided.
• Good eye care is essential. If the eyes stay open, a nurse may apply a protective ointment. Then the eyes are covered with a moistened pad to protect them from injury.
• Speech becomes difficult and may be hard to understand. Sometimes the person cannot speak. The nursing team needs to anticipate the resident's/patient's needs.
• You should not ask questions that need long answers. "Yes" or "No" questions can be asked but should be kept to a minimum.
• Although speech may be difficult or impossible for the person, you must still talk to him or her.
• Hearing is one of the last functions to be lost during the dying process. Many people hear until the moment of death. Even if unconscious, the person may hear.
• Always assume that the dying, or any unconscious person, can hear. Speak in a normal voice, and provide reassurance and explanations about care. Offer words of comfort.
• Topics that could upset the resident/patient are avoided.

Mouth, Nose, and Skin

• Oral hygiene is very important for comfort.
• Routine mouth care usually is enough if the resident/patient can eat and drink. Frequent oral care is given as death nears and when the person has difficulty taking oral fluids. Oral hygiene also is important if mucus collects in the mouth and the person cannot swallow.
• Crusting and irritation of the nostrils can occur.
• Common causes are increased nasal secretions, an oxygen cannula, or an NG tube. Careful cleansing of the nose is important. The nurses may have you apply a lubricant to the nostrils.
• Circulation fails and body temperature rises as death approaches. The skin is cool and pale. Perspiration increases.
• Good skin care, bathing, and the prevention of pressure sores are necessary. Linens and gowns are changes whenever needed because of perspiration. Although the skin feels cool, only light bed coverings may be needed. Blankets may make the person feel warm and cause restlessness.

Elimination

• Dying persons may have urinary and anal incontinence.
• Bed protectors are used. Perineal care is given as necessary. Some residents/patients have constipation and urinary retention. Doctors may order enemas. Foley catheters may be ordered. You may be asked to give enemas and perform catheter care.

Comfort and Positioning

• Measures are taken to promote comfort. Good skin care, personal hygiene, back massages, and oral hygiene help to increase comfort.
• Some people have severe pain. They need strong pain medications, which are given by nurses.
• You can promote comfort by frequent position changes. Good alignment and supportive devices also promote comfort. Take care when turning the person. You may need help to turn the person slowly and gently.
• Persons with breathing difficulties usually prefer the Fowler's position.

The Resident's/Patient's Family
The family is going through a hard time. It may be very hard to find words to comfort them. You can show your feelings to the family by being available, courteous, and considerate. Use touch to show your concerns.

The family usually is allowed to spend a lot of time with their loved one. Normal visiting hours usually do not apply if the resident/patient is dying. You must respect the resident's/patient's and family's right to privacy. They need as much time together as possible. The resident's/patient's care, however, cannot be neglected just because family is present. Let family members help give care if they wish. If they do not want to help, you can suggest that they take a break. They can use the time to have a beverage or meal.

The family may be very tired, sad, and tearful. They need support and understanding. Watching a loved one die is very painful. So is dealing with the eventual loss of that person. In their grief the family goes through stages like the dying person. They may be very angry. Do not take this anger personally. Try to be understanding. Treat the family with courtesy and respect. Visiting with a member of the clergy may be comforting to the family. You need to communicate this request to the nurse immediately.

Hospice Care
Many residents/patients seek hospice care when they are dying. Hospices focus on the physical, emotional, social, and spiritual needs of the dying person and their families. Hospices are not concerned with cure or life-saving procedures. They emphasize pain relief and comfort measures. Care is designed to improve the dying person's quality of life. A hospice may be a part of the health care facility or a separate facility. Many hospices offer home care. Follow-up care and support groups for survivors also are part of hospice services.

"Do Not Resuscitate" Orders
When death is sudden and unexpected, every effort is made to save the person's life. CPR is started. Nurses, doctors, and other emergency staff members rush to the person's bedside. They bring emergency and life-saving equipment. CPR and other life support measures are continued until the person is resuscitated or until declared dead by the doctor. Doctors often write "do not resuscitate" (DNR) orders for terminally ill residents/patients. This means that no attempts will be made to resuscitate the person. The person will be allowed to die with peace and dignity. The orders are written after consulting with the resident's/patient's family. The family makes the decision if the resident/patient is not mentally able.

Living Wills
Some persons, especially terminally ill or elderly, choose not to be resuscitated. They have the right to refuse treatment. Some have written instructions about acceptable treatments and life-prolonging measures. These are called "living wills."

A living will states that the person does not want life prolonged by extraordinary means if there is no reasonable expectation of recovery. As of 1994, 41 states allow living wills. State laws vary. Most require that the person making the will be 18 years of age or older. Some states require new living wills every 5 or 7 years. Living wills have been a focus of financial abuse of elderly persons. Some have been charged excessive legal fees, as much as $7,000. Be aware that living wills can be drawn up free or for a very small charge. A local Legal Aid office will give you assistance in making living wills.

You may not agree with the decisions made about treatment and resuscitation. However, you must follow the resident's/patient's or family's wishes and the doctor's orders. These may be against your personal, religious, and cultural values. If so, discuss the situation with the nurse. It may be necessary to change your assignment.

Signs Of Death
You need to know the signs of approaching death. The following signs may occur rapidly or gradually:

1. Movement, muscle tone, and sensation are lost. This usually begins in the feet and legs and eventually spreads to the rest of the body. When mouth muscles relax, the jaw drops. The mouth may stay open. There is often a peaceful facial expression.
2. Peristalsis and other gastrointestinal functions slow down. There may be abdominal distention, anal incontinence, fecal impaction, nausea, and vomiting.
3. Circulation fails and body temperature rises. The person feels cool or cold, looks pale, and perspires heavily. The pulse is fast, weak, and irregular. Blood pressure begins to fall.
4. The respiratory system fails. Cheyne-Stokes, slow or rapid and shallow respirations may be observed. Mucus collects in the respiratory tract. This causes the "death rattle" to be heard.
5. Pain decreases as the person loses consciousness. Some persons, however, are conscious until the moment of death.

The signs of death include the absence of pulse, respirations, and blood pressure. The pupils are fixed and dilated. A doctor determines that death has occurred and pronounces the person dead.

Care Of The Body After Death
Care of the body after (post) death (mortem) is called postmortem care.

A nurse is responsible for postmortem care. You may be asked to assist. Care begins as soon as the doctor pronounces the person dead. Universal precautions and the bloodborne pathogen standard are followed. You may have contact with infected body fluids or body substances.

Postmortem care is done to maintain good appearance of the body. Discoloration and skin damage are prevented. Postmortem care also includes gathering valuables and personal items for the family. The right to privacy and the right to be treated with dignity and respect apply.

Within 2 to 4 hours after death, rigor mortis develops. Rigor mortis is the stiffness or rigidity (rigor) of skeletal muscles that occurs after death (mortis). Postmortem care involves positioning the body in normal alignment before rigor mortis sets in.

The family may wish to view the body before it is taken to the funeral home. The body should appear in a comfortable and natural position for viewing by the family.

In some facilities, the body is prepared only for viewing. Postmortem care is completed later by the funeral director.


(Procedure) Assisting With Postmortem Care

1. Wash your hands.
2. Collect the following:

a. Postmortem kit if used in your facility (shroud, gown, two tags, gauze squares, and safety pins)
b. Valuables list
c. Waterproof bed protectors
d. Wash basin
e. Bath towels
f. Washcloth
g. Tape
h. Dressing
i. Disposable gloves

3. Provide for privacy.
4. Raise the bed to the best level for good body mechanics.
5. Make sure the body is flat.
6. Put on gloves.
7. Position the body supine. Arms and legs are straight. Place a pillow under the head and shoulders.
8. Close the eyes. Gently pull the eyelids over the yes. Apply moistened cotton balls gently over the eyelids if the eyes will not stay closed.
9. Insert dentures if it is facility policy. If not, put them in a labeled denture container.
10. Close the mouth. Place a rolled towel under the chin to support the mouth in the closed position if necessary.
11. Remove all jewelry except for wedding rings. List jewelry that has been removed. Place the jewelry and the list in an envelope to be given to the family.
12. Place a cotton ball over the ring and secure it in place with tape.
13. Remove drainage bottles, bags, and containers. Leave tubes and catheters in place if an autopsy is to be performed. Ask the nurse about the removal of tubes.
14. Bathe soiled areas with plain water. Dry thoroughly.
15. Place a bed protector under the buttocks.
16. Remove soiled dressings and replace them with clean ones.
17. Put a clean gown on the body. Make sure the body is positioned as in Step 7.
18. Brush and comb the hair if necessary.
19. Fill out the ID tags. Tie one to an ankle or to the right big toe.
20. Cover the body to the shoulders with a sheet if the family is to view the body.
21. Collect the person's belongings. Put them in a bag marked with the person's name.
22. Remove all used supplies, equipment, and linens except the shroud and the other ID tag. Make sure the room is neat. Adjust the lighting so it is soft.
23. Let the family view the body. Provide for privacy. Give the person's belongings to the family.
24. Place the body on the shroud or cover the body with a sheet after the family has left the room. Apply the shroud:

a. Bring the top down over the head.
b. Fold the bottom up over the feet.
c. Fold the sides over the body.

25. Secure the shroud in place with safety pins or tape.
26. Attach the second ID tag to the shroud.
27. Leave the body on the bed for the funeral director. Leave the denture cup with the body.
28. Remove the gloves.
29. Strip the resident's/patient's unit after the body has been removed. Wear gloves for this step.
30. Wash your hands.
31. Report the following to the nurse:

a. The time the body was taken by the funeral director.
b. What was done with jewelry and personal belongings.
c. What was done with dentures.