Tuesday, February 28, 2012

Grade-schoolers produce their own opera — with duct tape

Grade-schoolers produce their own opera — with duct tape
Musical theater • Program helps students in 160-plus schools create musical performances.
By Carol Lindsay
The Tribune

Published: February 28, 2012 10:13AM
| Special to The Tribune Fourth-graders at Knowlton Elementary in Farmington wrote and performed their own opera as part of the Utah Festival Opera & Musical Theatre’s children’s opera program. The storyline centered around a handful of Indian pranksters who sabotaged their tribe's teepees with duct tape. An opera that includes a verse about playing a prank with duct tape is not your typical opera.

And yet duct tape, sticks and yo-yos were an integral part of the opera performed by Julie Potter’s fourth-grade class at Knowlton Elementary in Farmington.

The students staged their own opera last month titled “Indian Trouble.” It was the culmination of months of work by the students as part of Utah Festival Opera & Musical Theatre’s children’s opera program.

A beaming Principal Grace Larsen introduced the production to students:

“You are in for such an amazing treat,” she said. “I have watched this opera from the very beginning and they have done an amazing job writing the music, the dance and the script.”

The topic for the opera was chosen by the children based on a unit they were studying in Utah history: American Indians. The story — written by children — revolved around a fictional tribe of Indians known as the Paka Pakas.

As the story goes, some of the tribe’s children were bored because all they did was hunt, fish and weave baskets. So a couple of them decided to play a prank by fastening tribe members’ teepees closed with duct tape. The pranksters continued their trickery until they accidentally burned down a teepee. Realizing the error of their ways, the children apologized and made amends.

Potter, along with parent Wendy McFarland, attended a nine-hour workshop during the summer to learn how to help the children piece together the production. Although the training was overwhelming, McFarland described the resulting opera as a worthwhile experience.

“It has been so much fun, so much work,” she said. “It’s been exciting to see the students come together and [discover] how much they can really do. They’ve done everything themselves. We were worried some of the parents wouldn’t understand the plot because it is 10-year-old humor, but it’s theirs.”

Pamela Gee, director of the Opera by Children program, said the process is truly educational.

“The students drive all the action, they direct their opera,” she said. “Everything is student-driven. There are no mistakes. They are empowered. They are so clever, they come up with the most creative opera. Adults would never think this way. They are magical. There is so much learning.”

Larsen couldn’t be happier to have the opera at her school.

“Research has proven the arts enhance learning,” she said. “Students have used their curriculum for this opera. Utah history and Indians are one of the first things they talk about. The curriculum is interwoven throughout the process.”

The students not only wrote and choreographed the opera, but they came up with the melodies. Using the students’ tunes, a composer with the opera company developed a musical score.

Performer Alex DeJong, 9, was excited to be in the opera.

“It was good,” she said. “Everybody did what they were supposed to. It was a lot of work and sometimes it was hard and we couldn’t figure it out.”

The Opera by Children program now works with 162 classes, which are writing operas throughout the state.

Although the productions are a ton of work, Gee said the journey is well worth the effort. Every year, teachers say they are not going to do the opera again, she mused. But after the children perform, they inevitably change their minds.


© 2012 The Salt Lake Tribune
Grade-schoolers produce their own opera — with duct tape
By Carol Lindsay

Special to The Tribune

Sunday, February 26, 2012


Honestly, we have the MOST interesting students. Roberto Castillo a current student was a AAA wrestler in Mexico for years. He was one of the top wrestlers now he says it's time to get a real job or at least one where people aren't stomping his head.

here's a video

Misterioso (wrestler)From Wikipedia, the free encyclopediaJump to: navigation, search
This article is about the original Misterioso. For his nephew, see Misterioso, Jr..
Ring name(s) Rey Misterio II
The Centipede
The Predator
Billed height 1.72 m (5 ft 7 1⁄2 in)
Billed weight 88 kg (190 lb)
Born May 26, 1966 (1966-05-26) (age 45)
Los Angeles, California, USA
Billed from Tijuana, Baja California, Mexico
Trained by Rey Misterio, Sr.
Debut 01988-03-10 March 10, 1988

Roberto Castillo (Born May 26, 1966) is a Mexican-American Luchador or professional wrestler currently working on the independent circuit in Mexico and Southern California under the ring name Misterioso. Together with Volador, Misterioso formed one of the most popular and talented teams in Mexico in the early to mid-1990s.

1 Biography
1.1 Professional wrestling career
1.1.1 Consejo Mundial de Lucha Libre
1.1.2 Asistencia Asesoría y Administración
1.2 Independent Circuit
2 In wrestling
3 Championships and accomplishments
4 Lucha de Apuesta record
5 Notes
6 References

BiographyCastillo was born in Los Angeles in 1966, son of Mexican emmigrants. Growning up he was a big fan of the Lucha libre movies starring El Santo, Blue Demon and Mil Mascaras.[1] When he was old enough he joined the Marine Corps.[1]

Professional wrestling careerAfter ending his stint in the Marines Castillo travelled to Tijuana, Baja California. While shopping for wrestling masks for a friend he met someone who created outfits for wrestlers, who in turn introduced Castillo to Rey Misterio who quickly agreed to train Castillo.[1] Castillo made his debut on MArch 10, 1988 wrestling as "Rey Misterio II", given the great honor by his mentor.[2]

Consejo Mundial de Lucha LibreIn Mid-1990 Castillo travelled to Mexico City and began working for Consejo Mundial de Lucha Libre (CMLL). In CMLL he was repackaged as "Misterioso" ("the mysterious one") modifying the "Rey Misterio II" character since the original Misterio did not work for CMLL. Castillo wore a very colorful, creative mask unlike what was generally used at the time, helping usher in some of the more elaborate masks used in Lucha Libre today.[2] His career was put on hold as he was recalled to the Marines, serving for three months before returning to CMLL.[1] On December 8, 1991 defeated Fuerza Guerrera, in what was described as a surprise, to win the NWA World Welterweight Championship[3] In 1992 Misterioso began training together with Volador. CMLL booker Antonio Peña noticed how well the two worked together and decided to make them a permanent tag team. The team immediately started began working a storyline feud with Los Destructores (the brother team of Tony Arce and Vulcano). On March 8, 1992 Misterioso and Volador defeated Los Destructores to win the Mexican National Tag Team Championship.[4]

Asistencia Asesoría y AdministraciónIn mid-1992 EMLL booker Antonio Peña decided to break away from EMLL and form his own promotion Asistencia Asesoría y Administración (AAA) and took a number of EMLL wrestlers with him. Misteriosos and Volador were among the wrestlers who were loyal to Peña and left with him, taking the Mexican National Tag Team titles with them to AAA[Note 1][4] The team held the belts until August 28, 1992 where they lost them to Los Destructores as part of a rivalry that had carried over from CMLL to AAA. Volador and Misterioso would regain the titles, but ultimately lost the belts on February 12, 1993.[4] In AAA Misterioso and Volador began teaming up with Rey Misterio, Jr. (nephew of Rey Misterio) to form a team called La Tercia del Aire ("The Trio of the Air"). The team took on and defeated Los Destructores, now a trio with Rocco Valente making up the third member, at AAA's first ever TripleMania event.[5] On August 29, 1993 Misterioso defeated Huichol to become the first ever IWC World Middleweight Championship.[6]

In March, 1994 Misterioso turned on Volador during a trios match, turning Rudo (Bad guy) for the first time in his career.[1] Misterioso formed a unit with Fuerza and Juventud Guerrera taking on Volador with various partners. At TripleMania II-A Misterioso and the Guerreras defeated Volador, Latin Lover and El Mexicano.[7] TripleMania II-B saw the trio defeat Volador, Rey Misterio, Jr. and Rey Misterio.[8] and finally at TripleMania II-C Volador teamed with Tinieblas, Jr. and Lizmark, Jr. to finally gain a victory over Misterioso as he teamed up with Love Machine and Miguel Pérez, Jr..[9] During this time Misterioso became a part of Los Gringos Locos, filling in when members wrestled in Japan. On November 27, 1994 Misterioso lost the IWC Middleweight title to Rey Misterio, Jr.[6] By late 1994 Misterioso's knees were in such bad shape he could no longer wrestle the style he used to and turned to hardcore wrestling instead. One of his trademarks was the use of a dinner fork, earning him the nickname El Rey del Tenedor, King of the Fork.[10] The storyline between Misterioso and Volador played out over a long period of time, cluminating in a Lucha de Apuesta match on July 15, 1995 where both men put their masks on the line. The event drew a crowd of 16,000 people to El Torero de Tijuana for a very profitable show. During the match Misterioso's cornerman Blue Panther attempted to injure Volador (in storyline terms) with a Martinete (piledriver). Misterioso came to the aid of his former friend, saving him from Blue Panther but ended up knocked out by a chair shot to the head. Out of respect for his former partner and in appreciation of what he had just done Volador dragged the unconscious Misterioso on top of himself and allowed the referee to count to three. Following the match Misteriosos pleaded with Volador not to remove the mask but Volador was a man of his word and unmasked.[2][11] Following the mask loss Misterioso and Volador reunited, wrestling as a team until 1997 when both wrestlers left AAA.

Independent CircuitFollowing his stint in AAA Misterioso began working on the Southern California independent circuit, wrestling for companies such as Revolution Pro, Alternate Wrestling Show and Lucha VaVoom. At one point he was in talks to work for World Championship Wrestling but nothing came of it in the end.[1] On July 4, 2009 Misterioso and Volador reunited for the Luchas 2000 Magazine 9th anniversary show, losing to Brazo de Oro and Brazo de Platino.[12]

In wrestlingFinishing moves
Signature moves
Springboard Arm drag
Tope Suicida
Championships and accomplishmentsAlternative Wrestling Show
AWS Tag Team Championship (1 time) – with Super Boy
Asistencia Asesoría y Administración
IWC World Middleweight Championship (1 time)[6]
Mexican National Tag Team Championship (2 times) – with Volador[Note 2]
Empresa Mexicana de Lucha Libre
NWA World Welterweight Championship (1 time)[3]
Mexican National Tag Team Championship (2 times) – with Volador[4]
Local promotions
Baja California Tag Team Championship (1 time) – With Rey Misterio









Saturday, February 25, 2012

An Old Woman

(Note: This poem was found in the bedside table of an elderly woman living in an extended care facility upon her death.)

What do you see nurses,
What do you see?
Are you thinking,
When you look at me;
A crabbit old woman,
Not very wise
Uncertain of habit,
With far away eyes,
Who dribbles her food,
And makes no reply
When you say in a loud voice
'I do wish you'd try',
Who seems not to notice
The things that you do,
And forever is losing
A stocking or shoe,
Who, unresisting or not,
Lets you do as you will,
With bathing and feeding,
The long day to fill,
Is that what you're thinking,
Is that what you see?
Then open your eyes nurse.
You're not looking at me.
As I'll tell you who I am,
As I sit here so still,
As I rise at your bidding,
As I eat at your will.
I'm a small child of ten
With a mother and father
Brothers and sisters,
Who love one another,
A young girl of sixteen,
With wings on her feet,
Dreaming that soon now
A lover she'll meet;
A bride soon at twenty;
My heart gives a leap,
Remembering the vows
That I promised to keep;
At twenty-five now
I have young of my own,
Who need me to build
A secure, happy home.
A young woman of thirty,
My young now grow fast,
Bound to each other
With ties that should last;
At forty, my young ones,
Now grown, will soon be gone,
But my man stays beside me,
To see I don't mourn.
At fifty once more,
babies play round my knee.
Again we know children,
My loved one and me.
Dark days are upon me,
My husband is dead,
I look at the future,
I shudder with dread,
For my young are all busy,
Rearing young of their own,
And I thin of the years
And the love I have known.
I'm an old woman now,
And nature is cruel.
'tis her jest to make old age
To look like a fool.
The body is crumbled,
Grace and vigor depart.
There is now a stone
Where I once had a heart.
But inside this old carcass,
A young girl still dwells,
And now and again
My battered heart swells.
I remember the joys,
I remember the pain,
And I'm loving and living
Life over again.
I think of the years,
All too few,
Gone to fast,
And accept the stark fact
that nothing can last.
So open your eyes, nurses,
Open and see,
Not a crabbit old woman;
Look closer ... see ME.

Look Closer - A Nurse's Reply

Liz Hogben
This was sent in by Mrs B Boyle.
I came across this poem, when my mother was in the nursing home it was place in the rooms there,
believe it's a reply to the poem, "A Young Girl Still Dwells"

What do we, you ask, what do we see ?
Yes, we are thinking when looking at thee!
We may seem to be hard when we hurry and fuss,
But there's many of you and too few of us.
We would like far more time to sit by you and talk,
To bath you and feed you and help you to walk,
To hear of your lives and the things you have done;
Your childhood, your husband, your daughter, your son,
But time is against us, there's too much to do-
Patients too many and nurses too few.
We grieve when we see you so sad and alone,
With nobody near you, no friends of your own.
We feel all your pain, and know of your fear
That nobody cares now your end is so near.

But nurses are people with feelings as well,
And when we're together, you'll often hear tell
Of the dearest old Gran in the very end bed,
And the lovely old Dad, and the things that he said,
We speak with compassion and love, and feel sad
When we think of yours and the joy that you've had.
When the time has arrived for you to depart,
You leave us behind with an ache in our heart.

When you sleep the long sleep, no more worry or care,
There are other old people, and we mist be there.
So please understand if we hurry and fuss--
There are many of you and too few of us.


By Kim Jordan RN

I have nine patients, you are but one
I will walk five miles before I am done
Tiptoeing in and out of the rooms
Darkened and quiet like silent tombs
I try not to wake you, for there is no time
When trying to divide eight hours by nine.



Thursday, February 23, 2012

Seeing double: Clinton grade school has 15 sets of twins

Seeing double: Clinton grade school has 15 sets of twins
Twins • However, the numbers are fairly close to the national birth rate for twins.
By Carol Lindsay

Special to The Tribune

Published: February 22, 2012 01:38PM

Paul Fraughton | The Salt Lake Tribune. West Clinton Elementary School has 15 sets of twins. Front row left to right: Mason and Averie, Jaxson and Reese, Manuel and Juan, Jacob and Joseph. Second row: Darius and Chris, Chase and Nick, Connor and Trevor, Maren and Brock, Jane and Kate.Third row: Gage and Chance, Damion and Hannah, Marissa and David. Top row: McKenzie and Madison , Makayla and Makenzie. Students have been enrolling at West Clinton Elementary in pairs.

Granted, it is a big school with a population of nearly 1,000 children. But still, 15 sets of twins under the same roof is something to talk about.

The school has only two sets of identical twins. The rest are fraternal twins, which simply populate the rolls with identical last names.

Principal Steve Hammer described it as the biggest population of twins he has ever heard of in a school. But it hasn’t caused him many problems as a principal, aside from occasionally mixing up twins when talking to a parent.

“We had one rambunctious set,” Hammer recalled. “When one would get in a fight, the other would join in.”

So do the twin attend the same classes? Sometimes. Other times they are separated. It all depends on what the parents decide. West Clinton allows parents to request a particular class for their child.

Fifth-grade twins David and Marissa Bowles have spent their grade-school years in the same classes.

“They’ve tried to separate us,” David said, “but our mom doesn’t want to deal with two different sets of homework.”

But the two don’t seem to mind.

“We pretty much ignore each other unless we are talking about something from home,” David said.

Salt Lake City obstetrician Stephen Lash’s first reaction to 15 sets of twins in one school was this: “We need to see what’s in the drinking water out there.”

Then, on a more serious note: “Twins have been increasing awhile because of assisted reproductive technology and more older women having babies” Lash said.

The Centers for Disease Control estimate that 20 percent of twin births are to women 45 and older. Less than 2 percent are to teen mothers.

Kindergarten twins Jane and Kate Fletcher are identical — with blonde hair and freckles. They talk at the same time and finish each other’s sentences.

“We share a room at home,” said Jane, the older of the two. “We sleep in the same bed. We don’t ever want to have our own rooms.”

However, Jane and Kate have decided not to dress alike. Why? Because they don’t like people mixing them up.

“We like to be called our same name and not the different name,” Kate said.

But that doesn’t mean they don’t like being twins.

“We are special because we are twins,” the two remarked in surprising unison. “We like being the same, and we are friends. Its fun being twins. We are never alone.”

Kristine Hatch, Jane and Kate’s teacher, has had twins in her class during five of the past eight years.

“They are really good to tell me who they are,” she said. “They don’t like to be mixed up. I keep telling them they can trick me, but they don’t.”

The explanation for all these West Clinton twins? The Centers for Disease Control reports that the twin birth rate reached 33.2 per 1,000 births in 2009. So with 30 twins in a student population of 971 students, West Clinton is actually right on target a perfect representation of twins.


By the numbers •

West  Clinton  twins

18 • Boys 12 • Girls

4 • Sets of twins in first grade

3 • Sets of twins in kindergarten

3 • Sets of twins in second grade

2 • Sets of twins in fifth grade

1 • Set of twins in third, fourth and sixth grades, respectively

© 2012 The Salt Lake Tribune
Seeing double: Clinton grade school has 15 sets of twins
By Carol Lindsay

Special to The Tribune

Facebook Might Be Tough on Users With Low Self-Esteem

Inundating friends with negative life details makes 'poster' less likeable, study finds

TUESDAY, Feb. 7 (HealthDay News) -- Using Facebook can be bad for people with low self-esteem, a new study suggests.

Canadian researchers found people with low self-esteem deluge their Facebook friends with negative details about their lives, which makes them less likeable.

The findings, published online Feb. 7 in the journal Psychological Science, were unexpected, according to the researchers.

Many people with low self-esteem are uncomfortable sharing their thoughts and feelings face-to-face, but Facebook enables them to do this remotely, explained study author Amanda Forest, a graduate student at the University of Waterloo, in Ontario.

"We had this idea that Facebook could be a really fantastic place for people to strengthen their relationships," Forest said in a journal news release.

However, while people with low self-esteem may feel safer making personal disclosures on Facebook, doing so may actually cause them social harm.

"If you're talking to somebody in person and you say something, you might get some indication that they don't like it, that they're sick of hearing your negativity," Forest said.

But when people have a negative reaction to a post on Facebook, they tend to keep it to themselves.

"On Facebook, you don't see most of the reactions," Forest said.

Friday, February 17, 2012

UtahsRight: Food inspections in health care facilities

By Jessica Miller

The Salt Lake Tribune

Published: February 17, 2012 12:05PM

In their most recent food inspections, Salt Lake County care facilities received an average of five violations each.

Of the 122 facilities, which include nursing homes, care centers and hospitals, inspectors with the Salt Lake Valley Health Department observed 598 food-related violations.

Taylorsville had the highest average in the county, with 11 violations. Two facilities reside in city limits; one received 12 violations and the other 10.

Midvale had the second-highest average, with eight violations. It also had just two facilities within the city, with one facility receiving 13 dings on its latest inspection, and the other only three.

The most recent health inspections of the care centers ranged from 2009 to 2012. Sixteen cities were included in the analysis, as well as care facilities that were classified by the health department as within the unincorporated county.

The data was compiled by UtahsRight.com for a weekly series in The Salt Lake Tribune’s neighborhood section highlighting information gleaned from public databases. The purpose is not to provide analysis of the data, but rather provide the raw information in public databases so the public can analyze the data for their own purposes. See more food inspections at http://www.utahsright.com/h_inspections.php.

The care center with the largest number of food-related violations in the county was Murray’s Intermountain Medical Center. It received 22 violations in a January inspection, five of which were considered critical. The inspector observed raw beef being stored above ready-to-eat ham in the cooler, dented cans not segregated from usable food products, employee beverages not separated from food preparation areas, and a hand sink that did not reach optimal temperature in 30 seconds. They were also dinged for pasta that had been cooling in covered containers that had a temperature of 95 to 103 degrees.

One other Intermountain Healthcare hospital was a top offender in its city. The Intermountain Riverton Hospital received 12 violations in a December inspection, three considered critical. Those offenses mostly concerned cleanliness of the facility, with the hospital receiving violations for a dirty floor, dusty cooling vents, unclean microwave interiors and a mop sink chemical dispenser that did not have an approved backflow prevention device.

Salt Lake County’s Chateau Brickyard was also a top violator. The care facility received 17 violations, five of which were critical. The offenses observed in its 2011 inspection included not date-marking food, a dirty juice gun, a blocked hand sink and lack of temperature control. The inspector also observed soft cheese that had been kept on the counter and reached a temperature of 67 degrees.

Salt Lake City’s John Taylor House also had 17 violations, five considered critical. In its November inspection, the health department official observed raw eggs stored above ready-to-eat food, single-use items being re-used, an unclean hand sink, and employee medicines that were not stored to prevent their contamination into food, equipment or utensils.

West Valley City had some of the cleanest facilities in the county, with each of the three care facilities receiving two violations on their last health inspections. Behind them, West Jordan and Cottonwood Heights had its top offenders dinged for three violations each.

UtahsRight.com, the data website for The Salt Lake Tribune, conducts an ongoing statewide quest for restaurant inspections and other public information, using public records requests made under the states’ Government Records Access and Management Act, also known as GRAMA.

CNA training playing with Hoyer lift

Still more fun with they Hoyer lift at ccCNA




Improving End-Of-Life Options For Residents


Karen Everett Watson

Karen Everett Watson is a gerontologist, blogger, and journalist based in Sacramento, Calif.
Page Content
​Everyone knows that death is inevitable, but for those with terminal illnesses, that knowledge brings urgency to be remembered beyond life and for those left behind, there’s a deep desire and need to connect with that departed loved one. David Levey saw that need embodied in a small child just after her mother had been buried.

“This little girl was crying uncontrollably that she wanted her mum,” said Levey of the United Kingdom. “Her dad, also devastated, had to tell her she couldn’t because her mum was dead.”
A Place To Post Their Words
Levey said this was a life-changing experience for him and the seed for a website known as Immortum—A Memory Box Like None Before that he and business partner, Pankaj Goel, created on a joint venture basis.

Levey credits Goel for the technical success of the site and said his partner “is a man of great insight with profound technical abilities that were essential to this project.”

Goel’s background is in the corporate banking sector, but after the financial collapse, he questioned if he was in the right business, doing the right work. “I felt had skills that could help make an impact to the lives of millions of people around the world,” he said. “(Then) David approached me with the story of a little girl who would grow up without ever getting a ‘Happy Birthday’ message from her mother, I knew that I had found a direction. I wanted to do something to put a smile back on the faces of millions of children like that little girl. I wanted to help people cope with the most difficult times of their lives. It was then that Immortum came to be.”

Immortum is dedicated to patients who have terminal illnesses as a place where they can post their words, both private and public. The site is fully integrated with Facebook, and the users can choose when their messages will be sent to their intended recipients.

Public posts will appear on the Facebook pages of the users, as well as in their own journals. Unlike Facebook alone, their posts will not disappear into cyberspace but remain visible, perpetually; they are also searchable.

Joining Immortum is free for anyone wishing to use it, and there is no limitation of its use. Both Levey and Goel are adamant that there will never be a charge. “It’s not fair that only the rich and famous have their words immortalized,” Levey said. “Everyone should have that right.”
Forum For End-of-Life Issues
Levey said the website also has a forum for discussing end-of-life issues, a place for a Life Journal and one for delivering messages after death (Postlife Journal). All entries created in the Life Journal are automatically private and pre-populate into a user’s blog. The users decide who sees each of their entries by deciding which message they wish published and when.

The Postlife Journal works this way:
1. The user selects a minimum of two trustees—from their Facebook friends.
2. They can write and select dates in the future when they wish a person (or persons) to receive the messages.
3. When the user passes on, it is the role of the chosen trustees to activate the account.

Levey notes that every active user needs two others to assist.
Brings Awareness To Advance Directives
Nathan Kottkamp, a health care attorney and founder of the U.S. National Healthcare Decision Day (NHDD), said the forum capabilities of Immortum will be a valuable tool. NHDD is dedicated to making Americans more aware of their need for advance directives for their health care preferences, as well as other life issues.

“I serve on several hospital ethics committee where, on almost a weekly basis, we have to deal with the issue of having to make choices about health care for patients who never had a conversation with their loved ones about their wishes, much less provided any written documentation,” said Kottkamp.

“Immortum is yet another tool that will enable people to convey their wishes to loved ones, whether it is through written messages, video, or otherwise. It’s a great concept to harness social media for this much-needed activity that far too many people fail to do—often with terrible consequences.”

Kottkamp believes that Immortum’s global appeal will be a powerful way to spread information on issues concerning death and medical directives.
Leaving A Legacy
The therapeutic effects of memory boxes and life stories have long been recognized by palliative care experts. It gives people who are dying a tool to express their emotions and a way to be remembered by their loved ones.

According to Levey and Goel, this can be especially important to those leaving young children behind. They want to know that their children will know who they were.

“The parent can leave their children advice for living and even their views on life,” said Levey. “It’s a way to leave a living legacy.”

Levey said one woman has left a letter to be delivered to her daughter after she is married. A father left clues to be sent to his now young son when he is older. These clues will lead him to a buried “treasure box” that the father hopes will be both meaningful and fun to the son when he is grown.

Goel hopes to enhance the site with input from users, as the needs are made known. “The site is in its infancy right now,” he said. “There are major releases planned that would provide new social media-enabled tools to charities or professionals working in palliative care industry to support people near end of life. We are seeking such organizations at this moment so that we can give away solutions to help make them more efficient without any cost to them.”

“If Immortum can relieve any stress to those suffering from terminal illnesses and provide insight to their friends and family, on any level, it will be a huge success,” Levey said.

Go to the website at: www.immortum.com. To follow the site on Twitter, go to: www.twitter.com/@immortum1.

Karen Everett Watson is a gerontologist, blogger, and journalist based on Sacramento, Calif. She can be reached at Watson@softcom.net.

Physicians Moving In

Life Care Centers of America hires full-time, facility-based physicians to reduce rehospitalizations.
February 2012

Kathleen Lourde

Page Content
The health care industry is buzzing about Life Care Centers of America’s (LCCA’s) success in reducing rehospitalizations from 40 percent to 15 percent in one year among facilities participating in their latest effort to improve quality care, says Beecher Hunter, LCCA president.

Rehospitalization reduction efforts are taking center stage as hospitals will start to be penalized, beginning this year, if one of their Medicare patients returns to the hospital within 30 days.

LCCA’s size is part of what has made its new initiative—to place a full-time doctor in every nursing facility—possible. LCCA has 225 skilled nursing facilities in 28 states and employs more than 35,000 people.
Assessing Benefits
This program goes far beyond what most long term care facilities are able to do on their own, and, if Hunter and Kenneth Scott, DO, LCCA’s chief medical officer and corporate medical director, have anything to say about it, the move will dramatically improve the quality of care and quality of life for thousands of LCCA residents across the country. The initiative is changing the clinical operations of LCCA nursing facilities in many ways, from measures that reduce antipsychotic use to those that improve cardiac care, but it is also changing the resident makeup in the facilities as hospitals turn to them with greater certainty that their more critically ill patients will be well taken care of and won’t wind up back in the hospital within a month, incurring penalties for the hospital.

Further benefits LCCA has noted since the program’s inception in September 2010 include reduced staff turnover, greater resident and family satisfaction, and improved clinical outcomes.
Steps For The Future
The increasing focus by health care policymakers on ways to reduce rehospitalizations may have consequences for the vast majority of nursing facilities, and while not all facilities have the wherewithal to hire full-time physicians, other studies laud the beneficial effect of having a nurse practitioner or physician’s assistant on staff.

And, of course, nursing facilities across the nation—including LCCA—are embracing the well-known INTERACT II program, which provides care paths, communication tools, and advance care planning tools with the goal of reducing hospitalizations by improving the identification, evaluations, and communication about changes in resident status.

Whatever approach is taken, nursing facilities will increasingly confront the need to care for even sicker patients with a team of staff who will require a higher level of training to care for them, catch conditions early, and intervene promptly.

Just The Facts
The rate of Medicare rehospitalization industry-wide has significantly increased over the past three decades (see graph).

But the government is taking the issue on. This year, hospitals with high readmission rates will have to absorb a 1 percent penalty under the Hospital Readmissions Reduction Program, which places emphasis on three readmission-prone conditions: acute myocardial infarction, heart failure, and pneumonia. In the following two years, that penalty will go up to 2 percent and then 3 percent.

One out of every five Medicare beneficiaries discharged from the hospital is readmitted within 30 days at a cost to Medicare of over $17 billion annually, according to MedPAC, which also estimated that as many as 75 percent of readmissions are preventable.

According to a 2010 study, if potentially preventable rehospitalizations dropped by only 25 percent, Medicare could save more than $25 billion per year—a tidbit unlikely to escape the notice of federal budget slashers.

About 40 percent of hospitalized Medicare beneficiaries are discharged to a post-acute setting like a nursing facility, Alliance for Quality Nursing Home Care President Alan Rosenbloom said in a statement late last year. Information about the patient’s care lost during the transfer from hospital to nursing facility puts the patient at significantly higher risk for readmission, he added.

The New England Journal of Medicine published an influential study in 2009 that analyzed rehospitalization data from almost 12 million fee-for-service Medicare beneficiaries. Nearly 20 percent of those discharged from a hospital were rehospitalized within 30 days, 34 percent within 90 days, and 54 percent within a year. Of those who were discharged with a medical condition, 69 percent were readmitted or died within a year. If the beneficiary had surgery, the rate of readmission was 53 percent.
Motives Are Unselfish
Even though reducing rehospitalizations may not save nursing facilities any money—in fact, it may cost more—long term care providers are increasingly pursuing that goal anyway, some believing that higher quality care will bring its own rewards, like increased referrals.

That seems to prove true, judging by anecdotal evidence, but because those referrals will likely be of sicker residents, facilities may well be forced to staff up to meet those residents’ needs.

Rather, long term care providers are increasingly focused on reducing rehospitalizations not for financial gain but to improve the quality of life and quality of care for their residents by removing as much of the turmoil and discomfort of repeated hospital visits as they can, providers almost universally say.

To help manage this potentially dramatic change, as well as address the most pressing quality issues of the day, the American Health Care Association (AHCA) will unveil a new quality initiative near the end of this month. One of the “prongs” of that initiative will be reducing rehospitalizations.

AHCA will launch the new quality improvement initiative at its Quality Symposium in Houston Feb. 23 and 24. (For more information on the symposium or to register, visit www.ahcancal.org and click on Events.)

The initiative builds on the past decade or more of AHCA efforts, from Quality First to Advancing Excellence, says David Gifford, AHCA’s senior vice president of quality and regulatory

Gifford expects a positive reaction from members, once the initiative is made public. “AHCA and its members have said loud and clear that they really want to improve quality,” he says, “and we want to do it in a systematic way that really has an impact on organizations as a whole.”
Rehospitalization Triggers
The New England Journal of Medicine study found that five medical conditions were the most frequent causes of rehospitalizations: heart failure (27 percent return to the hospital within one month), pneumonia (21 percent), chronic obstructive pulmonary disease (23 percent), psychoses (25 percent), and gastrointestinal problems (19 percent).

In a study of more than 10,000 hospital admissions published in the Journal of Hospital Medicine, unplanned readmission within 30 days was 24 percent to 33 percent more likely for people on high-risk medications such as narcotics or steroids.

A second, smaller study published in the same journal found that depression predicted a threefold risk of multiple readmissions, while being underweight raised the risk more than 12-fold.

A study published last year in the Journal of the American Medical Directors Association analyzed more than 10,000 hospital discharges of people aged 75 and over. The researchers found that patients with genitourinary disorders had the highest rate of readmission within seven days of initial discharge (30 percent).

The seven-day readmission rates for cardiovascular disorders (25 percent), urinary tract infection (28 percent), renal failure (27 percent), and infection (36 percent) were also high.

Other risk factors identified by various studies include cancer with metastasis and heart attack.
With so many risk factors, how does one design or choose a rehospitalization reduction program?
How To Develop A Program
The conditions that most frequently account for rehospitalizations vary from one facility to another, so any reduction program must be tailored, says Beecher.

The first step is to determine the facility’s rehospitalization rate. To do this:
■ Specify a time period, like 30 days;
■ Count the number of rehospitalizations during that period;
■ Divide that number by the facility’s average census during the 30-day period; and
■ Multiply by 100.

Not all of these rehospitalizations will be avoidable, of course; the director of nursing (DON) or administrator will need to review each rehospitalization to identify those that were potentially avoidable and flag any conditions that crop up again and again as good prospects for initial efforts.

Next, set up a task force to develop the rehospitalization prevention program, involving the DON, nurse supervisors and leaders, and certified nurse assistants (CNAs) from all three shifts. This team assesses facility resources to identify which resident conditions can be managed at the facility and which need an acute care setting.

The team develops or acquires systems, protocols, and clinical pathways to assist nursing staff with clinical decision making (check out the INTERACT II tools or “How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations,” available from the Institute for Healthcare Improvement, based in Cambridge, Mass., and free on its website, www.ihi.org).

An emphasis on improved communication between nursing facility and hospital, especially through the transfer process, is crucial. Also, don’t forget to address advance planning. Without it, residents will be sent to the hospital even if their preference would be for less invasive care at the end of life.

After that, the team will be able to determine what training, supplies, or other tools will be necessary to make the program work.

Finally, set up a system for measuring the program’s success rate. Consider having debriefing sessions following each rehospitalization to identify glitches, potential problems, or ways to make the process flow more smoothly.

And, if the company is able, it can do all of the above plus hire a full-time physician for each facility.

How The LCCA Idea Originated
The events setting in motion what would one day be the buzz of the health care industry started long ago when Forrest Preston, LCCA’s founder and chief executive officer, met Scott, then a hospitalist caring for a member of Preston’s family, who came to the hospital with atrial fibrillation.

As Scott worked to stabilize his patient, the two men discussed her care, of course, but also Scott’s 16 years as a hospitalist and his success in building new hospitalist programs while carrying a full case load.

By the time the patient was ready to leave the hospital, Scott had made an enduring impression on Preston. He remembered Scott when he needed a corporate medical director who knew how to design and implement programs to improve quality of care.

“Life Care had been planning this approach” for some time, says Hunter.

But efforts to bring DONs and medical directors into gatherings where they could both earn continuing education credits and talk shop with their peers to get ideas on how to handle various clinical issues back at the facility still weren’t enough to get the outstanding results Preston was looking for.

Four or five years ago, Preston started talking with greater determination about finding new ways to improve clinical outcomes, says Beecher.

In 2009, “Preston approached me about the whole concept of having a larger physician presence in the [facilities] and having full-time physicians for each nursing home,” says Scott. “When we began, the whole thrust was simply to improve the quality of care.”

“During the formative process of trying to figure out how we were going to do this,” Scott says, he and Hunter were influenced by the New England Journal of Medicine study that reported a 20 percent rehospitalization rate for Medicare patients across the nation, “and that the cost of those rehospitalized within 30 days was exorbitant.”

“I brought it to Forrest and Beecher, [saying] ‘if we put a doctor in each nursing home [rehospitalizations are] something we could impact,’” says Scott.

For the past 15 months, Scott has been hunting down the best doctors possible who have what it takes to be a long term care physician, placing them in LCCA facilities, and watching the rehospitalization rates plummet.Common Conditions
Nearly 6 million Americans live with congestive heart failure, according to the American Heart Association. It’s the fasted growing cardiac disease in the United States. More than half a million new cases of congestive heart failure are diagnosed and 300,000 people die from the condition each year.

“If you look at some of the data just on congestive heart failure, the return to hospital from a nursing facility is about 32 percent across the nation,” says Scott.

Ten years ago, a patient with congestive heart failure stayed in the hospital an average of eight days, says Scott. Today that average is four days, “and the way we [treat] congestive heart failure hasn’t changed that much” over the past decade, he says. So patients with congestive heart failure are being transferred to a nursing facility when the patient is sicker and more frail than in the past.

A hospital can stabilize an acute congestive heart failure patient in four days. Based on the DRG that Medicare pays, it is difficult financially for a hospital to keep a patient with congestive heart failure much longer than four days. The thing is, what hospitals in the recent past did for the patient on those next four days was adjust medications so that all the dosages were working at peak efficiency.

Because these patients are being transferred to nursing facilities before dosages are worked out to their best benefit, problems can arise, often due to incomplete information received from the hospital during the transfer.

For example, if a patient is on a diuretic but the dosage is too high, he or she may dehydrate and get dizzy, fall, and come back to the hospital with a broken hip. If a doctor were on staff who had been treating that patient, he or she may have known from past experience that this patient has a strong reaction to a diuretic, or at the very least would be able to monitor the patient’s reaction to dosages closely and adjust them accordingly—and quickly.

Another illustrative issue with congestive heart failure patients who are transferred early to a nursing facility is that the facility’s direct care staff are responsible for picking up on any indications of returning congestive heart failure. But that’s a complicated thing to diagnose, says Scott.

“If it were as simple as monitoring weight,” that would be one thing, he says, “but it’s more complicated than that in many patients. So the very fact that we have our on-site, full-time physician to monitor these patients means more symptoms will be caught early enough for the nursing facility to manage the patient without a rehospitalization in many cases,” Scott says.

At one LCCA facility, rehospitalization rates overall have dropped from about 40 percent to a startling 8 percent within four months of hiring a full-time doctor, and that rate has been sustained at between 8 and 10 percent for several months.
Other Benefits
Having a full-time doctor on site also eliminates the rehospitalizations that occur because the regular on-call physician isn’t available.

Say a patient presents with fever, and the medical director, before going off-call, ordered a bunch of laboratory tests. The labs, arriving after the doctor is no longer available, indicate to the nurse that the resident has a urinary tract infection (UTI). She calls the doctor, but since he’s not available, she calls the doctor who’s filling in. That fill-in doctor has no relationship with the resident, hasn’t seen the resident, and doesn’t know the nurse or how accurate her reading of the labs is.

Worried about both the patient and his own legal risk, the doctor instructs the nurse to send the patient to the emergency room. An on-staff physician, on the other hand, is familiar with the nurse, the facility’s capabilities, and the resident’s medical history and is more likely to instruct the nurse on how to manage the UTI at the facility.

Another benefit of the on-site doctor is that he or she can improve many other aspects of nursing facility care. They lift the quality of care for all patients, of course, but they also provide superior education to nurses and CNAs, and, anecdotally, their mere presence results in higher satisfaction rates with patients, families, and staff.

“We’re hearing how excited [families] are that they can walk into the building on a given day of the week, and talk to the doctor about their loved one,” says Scott. LCCA is about to launch a customer satisfaction survey to quantify the effect that on-site doctors are having on satisfaction.

Effects On Staff
Staff turnover also appears to be dropping in facilities that employ a physician, says Scott. The information is purely anecdotal at this point, but some LCCA facility administrators have told Scott that they’re seeing greater retention of nurses and CNAs and reduced overtime.

Another big benefit is the speed with which a decision on whether the resident should go to the hospital can be reached. In a nursing facility without a doctor, the nurse, in the event of a potentially serious condition with a patient, will call the on-call doctor, leave a message, and wait hours for a response.

“By the time the doctor gets back [to them] and they finish their paperwork, they’re late in leaving,” says Scott. “Now, with a doctor on site full-time, they’re [not only] getting their orders on time and finishing their paperwork on time,” but have the satisfaction of seeing that the residents they’re concerned about are getting immediate attention. That improves their job satisfaction.

“It’s an extra level of motivation for all of us: having an impact on residents’ personal and physical lives,” says Hunter.

Another reason staff satisfaction appears to be improving is just the mere fact that the doctor is working with them. “Part of the problem over the years with nursing home work is the lack of respect for what we do from the rest of the health care industry,” says Scott. Once a doctor is on staff full-time, direct-care staff seem to feel that if the work is important enough for a doctor to be there with them all day because patients are coming in sicker, their own work must be getting more important, too. Plus, the doctor can come up to a CNA and say, “Great job!” and that means all the world to them, Scott says.

“The other aspect that I’m seeing glimpses of, and it will take a little longer to produce the data, but one of the big concerns with the state Medicaid programs is the cost of long term care patients in a nursing home. And the bottom line is that with a full-time doctor, the long term care census is starting to go down.

Patients come in and either get better and go home or get worse and go back to the hospital or don’t progress and stay on the long term care side.

“With the doctor there, more are getting better and going home. Before the intervention, every time a resident came back from a hospital he or she was weaker and worse off. Now they’re continuing to get better and reentering society. So, it’s reducing the cost of the Medicaid as well as Medicare program.”

Having full-time doctors has also resulted in reduced use of antipsychotics, says Scott. LCCA is still in the midst of collecting further data about the rehospitalization rates by a number of factors, but anecdotally the doctors appear to be making a huge difference.
Finding The Right Doctor
Finding a physician just to make rounds at the facility periodically can be difficult because Medicare reimbursement rates for seeing a patient in the nursing facility is lower than treating that same patient in his or her office. Outpatient reimbursement is much better. Even doctors who do visit nursing facilities must have a high enough volume to cover costs, and so they don’t spend all their time in one building but visit several. It’s great that the residents get to see a doctor periodically, but it doesn’t compare to having a doctor right there the moment something goes south.

Just getting a doctor into all of LCCA’s 225 buildings appropriate for the intervention is consuming most of Scott’s time right now. He must not only locate doctors interested, but “you have to have a doctor who really understands long term care,” says Scott. “Even for full-time geriatricians, there’s an adjustment to being full-time in a nursing home. It can be hard to predict.”

Getting the right doctor into each facility will “take a little time,” Hunter says. “We’re really focusing our energy on that.”

The newly hired physicians aren’t given special training on how to operate within a nursing facility environment, but LCCA does bring them to the company’s headquarters in Cleveland, Tenn., for orientation and discussion of what goals the company is trying to achieve.
Increased Referrals
The LCCA facilities that have demonstrated tremendous reduction in rehospitalizations are seeing increases in hospitals discharging to them more compromised residents in hopes that they will help protect the hospital from being financially penalized by returns within 30 days.

Despite hospitals sending sicker patients to LCCA facilities, “for the most part we’re still managing to keep those rehospitalization rates down,” says Scott, “but it’s becoming much more work for our doctor. I’m sure there’ll be a point where that’s maxed.”

“In a Florida LCCA building, our doctor’s return-to-hospital rate has remained 6.8 percent to 8 percent for about six months, and in November that rate was 5.8 percent,” says Scott. “In December, his rate was 10 percent, and he says it’s truly because of the patients he’s getting. But the hospital is going to push the boundaries.”

“Once we put a doctor in a building it even broadens the scope of what we can do,” says Scott. “We can take much more critically ill patients. It allows us to develop new programs, such as a cardiac care program in one of our Florida buildings.”
What’s Next?
Scott, focused as he is on getting top-notch doctors into LCCA’s facilities, already looks to the future. “I think this next year will be a banner year for us,” he says. “It took me about a year of working with Forrest, Beecher, and the team here to come up with a plan that we thought would work. In the past 15 months we’ve hired 33 doctors for 33 buildings, and at some point you start to get into a rhythm, and I think we’re there.” Scott expects 2012 to see LCCA “bust this open and hire at a more rapid pace, with the end effect of better quality of care and cost savings to the overall health care system.”

Once LCCA achieves a “critical mass of doctors in an area, camaraderie springs up among those doctors,” Scott says. “All the Arizona doctors get together once a month and talk about what’s working in their building, what issues [must be addressed] to improve quality of care,” among other related topics, Scott says.

“I think that process is the next step,” says Scott. “We have committed physicians in this process. I learn from them. We take those gains, and we use that to improve what we’re doing across the nation.

“Next is a physician-led program that results in the quality-of-care outcomes [that the company has seen in its efforts to reduce rehospitalizations], which not only improves the care but also reduces the cost to the federal government,” Scott says. “We’re seeing that on the bounce-backs, but I think we’re going to see it in other areas, and those doctors” will be leading the charge.

“We hope that other companies will follow suit on this,” says Hunter. “The more companies that do that, [the] greater the positive impact on the residents we all service, and good for all is good individually.”

Kathleen Lourde is a freelance writer based in Dacoma, Okla.

Friday, February 10, 2012

Utah CNA SCHOOL The Hoyer Lift

We got a new Hoyer lift in the ccCNA classroom and we've been having a little fun!





Thursday, February 9, 2012

Bladder questions

•You should check your patients for incontinence:
Every 2 hours

Rationale: Because you should be rounding on your patients and checking on them every 2 hours, this is the best time to check to see if they have been incontinent of bowel or bladder. Urine is acidic, and the longer it remains touching the skin, the more chance a patient has of skin breakdown. If needed, patients should be changed more often, but some may only need changed a few times a day.

•The purpose of bladder training is:
A way for patients to manage urinary incontinence

Rationale: Bladder training is way patients learn to manage urinary incontinence. This lengthens the amount of time between bathroom trips, expands the bladder so it can hold more urine and improves a patient's urge to urinate. The training must be strictly followed according to the program the physician sets up or else it will not work.

•Your patient tells you that she hasn't had a bowel movement in 3 days and feels like she needs to go but she can't. You tell the nurse this patient:
Has constipation

Rationale: Constipation is irregular bowel movements or having difficulty passing stool. This can be painful and frustrating for patients. Let the nurse know you think the patient may be constipated so he/she can assess the patient and treat them accordingly. Constipation can be dangerous for some patients, especially those who just had surgery as the straining can cause the incision to open up.

•You are providing peri-care to a female patient that just had a bowel movement in her adult brief. When you wipe, you should:
Wipe front to back

Rationale: When providing peri-care for a female, always wipe the patient front to back. Stool contains E. Coli, and if a patient is wiped incorrectly, E. Coli can be wiped into the female's urethra. E. Coli is the most common organism causing urinary tract infections which can develop into much worse conditions and be very expensive to treat.

•Which of the following is NOT appropriate when collecting a urine specimen:
Having the nurse label the urine collected

Rationale: When collecting a urine, wipe the patient from front to back first to remove dead skin. Then have the patient start urinating in the toilet, and then begin urinating in the cup, if possible. When finished, label the urine with the patients name & date of birth, or whatever your facility policy says. Only the person collecting the specimen should label it. Refrigerate the urine immediately unless you have specific instructions not to do so.

•The following is an abnormal finding when a patient urinates:
Amber urine

Rationale: Amber urine occurs when a patient is dehydrated or the kidneys are not working properly. This dark-colored urine should alert the nursing assistant that something is wrong with the patient and the nurse should be notified immediately of this finding. This may be a normal finding for a patient with known kidney disease, but if it it new, the longer it goes on means the longer it will take for the patients kidney function to return to normal, if at all.

•You notice that your patients stools are black and tarry. You should notify the nurse of this immediately because:
They could be bleeding internally

Rationale: Black, tarry stools are a major sign that a patient is bleeding somewhere in their intestine and, if left untreated, will lead to death. Medications like iron can cause stools to look like this also, but it is expected and is not a medication reaction. Do not assume they are on iron. Inform the nurse and let them decide the next course of action.

•You notice a patient that was previously continent have frequent episodes of incontinence. You should:
Notify the nurse

Rationale: Although increased incontinence can be normal, other factors may cause this. Diseases of the bladder or intestines, abuse, social problems and more can cause a previously continent patient to suddenly be unable to control their bladder. The nurse will investigate further into this and let you know if an adult brief is necessary to place on the patient or not.

•A patient tells you that it burns every time he urinates and sometimes his urine is reddish in color. You should tell the nurse immediately because you know this is a sign of:
Urinary tract infection

Rationale: Burning sensation, frequent urination, dark urine and blood in the urine are all signs of a urinary tract infection. Patients should be treated for this quickly to prevent it from spreading to the bladder or worse. If left untreated, this infection can go to the blood and cause sepsis, or can cause the kidneys to fail. Notify the nurse immediately if any of these signs are present in your patients.

•You have a patient that is constipated. You should provide them with fluids to drink:
More often than before

Rationale: Extra fluids can help the patient move their bowels easier because it may moisten the stool. When constipated, a patient's stool is usually dry and hard, making it painful to pass through the rectum. Extra fluids can assist with this. Report any complaints or signs of constipation to the nurse so she can also assist the patient with this by medicating them with a stool softener.

Bathing questions

•You are assigned to dress a rehab patient that doesn’t like to assist you in dressing them. To try and get their assistance, you should:
Explain to them that showing they can help will play a part in them being able to go home

Rationale: Rehab patients aren’t discharged home until the doctor feels the patient can perform all of the activities of daily living by themselves, or with very minimal help. Getting dressed is a basic activity that the patient must be independent in doing before being discharged.

•You should not do which of the following when bathing a patient:
Leave the patient to answer a call light

Rationale: Patients who need help bathing often feel embarrassed or ashamed and privacy should be respected. Communicate with the patient and tell them what you will be washing next. Never leave the patient alone in the middle of bathing. Instead, have someone else answer your call lights while you are bathing your patient.

•Mouth care should be performed on a patient:
Several times a day

Rationale: Mouth care should be done on patients every morning, afternoon and evening. This is often overlooked, but is one of the most important parts of patient care. Mouth care includes brushing the teeth, wiping the mouth, using mouthwash and possibly even flossing.

•You are dressing a patient with right arm weakness. Which side do you start dressing first?
The right side

Rationale: Because the patient’s right arm is weak and they won’t be able to assist as much with that side, start with that side first because it will be easier to maneuver. They will be able to assist you in putting their left arm through a sleeve hole much easier. This will be the most comfortable for the patient, too.

•Patients should be bathed:

Rationale: Patients should be bathed everyday. This includes either a shower or bed bath. Clean skin prevents infection and skin breakdown and promotes confidence in patients. Patients usually have an assigned shower schedule which may only allow for 2-3 showers a week. Nursing assistants can be found negligent and lose their license if they do not bath patients daily.

•A patient’s hair should be brushed:
After getting them ready for the day

Rationale: A patient’s hair should be brushed every morning after they are dressed for the day, or after a shower. Keeping a patient well-groomed can help them be confident and socialize with other patients. If it is not a shower day, wet the hair and comb it to prevent pulling it.

•Peri-care should be provided:
During bathing and after each episode of incontinence

Rationale: Peri-care prevents patients from getting urinary tract infections and yeast infections. It should be performed each time a patient is bathed and after each episode of bowel and/or bladder incontinence. Nursing assistants can use a washing cloth with gentle soap and warm water, or with a special wipe made specifically for peri-care.

•The following should be done after a patient is bathed:
Put lotion on the patient to prevent any dryness or skin breakdown

Rationale: Unless there is a restriction, lotion should always be put on a patient after bathing to prevent skin breakdown. Never send the patient to an activity in a robe or gown unless it is their wish to go that way, and never leave them alone in the bathroom unless they are an independent patient.

•The best way to get a patient to participate in getting dressed is:
Let them make decisions about what to wear

Rationale: Patient’s will cooperate best and be more helpful in getting dressed if they can make decisions about what to wear and how to put on the clothes. Threatening them or doing the work for them does not foster independence.

•The following is NOT appropriate when bathing a patient:
Using the same washcloth throughout the bath

Rationale: Several washcloths should be used during bathing to prevent the spreading of bacteria to openings in the body such as the mouth, or genital area. Using a bath blanket to provide privacy is a must, covering all areas of the body that aren’t currently being washed. When bathing, start with the face first, working your way down, leaving the peri-area for last.

rest and sleep questions

•Compared to the sleep habits of young adults, elderly adults need:
To take naps more often

Rationale: The elderly often have trouble sleeping in the night due to illness, stress and more. This requires them to take a nap or two throughout the day to re-energize them for activities.

•Your patient rings her call light at midnight and tells you that she is having trouble sleeping. You should:
Notify the nurse

Rationale: Many patients have prescriptions or standing orders for a sleeping pill if they have difficulty sleeping. The nurse should be notified right away so the patient can be medicated and it can take effect.

•The following is something a nursing assistant can do to help a patient fall asleep:
Give a backrub

Rationale: A backrub is a simple task that a nursing assistant can do to help a patient fall asleep. Do not threaten the patient about getting up early. If the backrub doesn't work, a nurse can give the patient a sleeping pill but passing medications is out of the nursing assistant's scope of practice.

•You are assigned to a patient that just had hip surgery. They ring their call light because they can't sleep and you know that this could be because:
They could be in pain from the surgery

Rationale: New post-op patients often have trouble resting and sleeping because they are in pain. Notify the nurse that the patient is having trouble sleeping and she may be able to treat the pain with medication. If that is unsuccessful, a sleeping pill may help.

•The recommended number of hours of sleep an adult should get each night is:
8 hours

Rationale: On average, adults should have 8 hours of sleep at night to keep their bodies healthy and their minds functioning properly. Children may need up to 11 hours of sleep, and infants will sleep about 16 hours a day.

diet questions

•You are assigned to feed a patient that gets their food pureed. Their meal tray arrives and it has not been pureed. You should:
Send it back and ask them to puree it

Rationale: Patients are on pureed diets to prevent them from choking. Because patient's are weak and/or unable to chew, pureed diets will essentially do the chewing for them to prevent large pieces of food getting stuck in the esophagus and choking the patient.

•You are setting up a meal tray for a patient who had a stroke and has left-sided weakness. You should set the eating utensils:
On the right side

Rationale: Utensils should be used by the strong hand, and when a nursing assistant sets up the meal, they should place them on the strong side. Physical therapy may eventually want the patient to use the affected side, but unless otherwise instructed, set up the utensils on the unaffected side.

•The nurse informs you that your patient is on aspiration precautions. You know this effects how the patient eats because:
They are at risk for choking

Rationale: Patient's on aspiration precautions are at risk for choking on their food and drink and inhaling it into the lungs which leads to pneumonia and even death. The patients should be fed slowly, while they are sitting up, and be on thickened liquids. If the nursing assistant has any concerns or questions, they should ask the nurse for advice.

•You are taking care of a patient that isn't able to set themselves up to take a drink. You should check on them and offer them a drink:
Every 1-2 hours

Rationale: Because you should be checking on your patients every 1-2 hours, ask this patient during rounds if he/she would like a drink of water during this time. Make sure the water is cold and fresh.

•You are collecting meal trays and notice that your patient didn't eat much of their dinner. You should:
Ask the patient if they would like a different meal

Rationale: Good nutrition is an important part in a patient's healing process. Proteins play a vital role in the healing process, and without eating, many of these proteins are not available for the body to use. The patient may simply not like the food offered and would like a different meal. Never take the meal away if it wasn't eaten and simply disregard the fact that the patient didn't eat.

•You should pass fresh water and ice to your patients:
Every 8 hours

Rationale: Fresh water and ice should be passed every 8 hours or sooner if the patient is out or requests it. Ideally, fresh water and ice should be passed every 4-6 hours, but it must be passed every 8 hours to prevent the growth of bacteria and particles in the water.

•Your patient ate all of their main course, and one side dish. He still has one side dish leftover and doesn't want it. You record that the patient ate this much:

Rationale: Facilities generally count 0, 25, 50, 75 and 100% In this case, the main course would count for 50% and each side dish 25%. Since only one side dish was consumed, 75% of the meal was eaten. Check your facilities policies for specifics on intake documentation.

•You see that your patient is on a NAS diet. You know that this means:
There should be no added salt

Rationale: NAS, or no added sodium, is for patients with cardiac problems, kidney disease and/or high blood pressure. Sodium attracts fluids and can cause fluids overload, high blood pressure, and more. The amount of sodium should be restricted to 2 grams per day.

•Your patient is diagnosed with dehydration. You should make the following change in the amount of fluid consumed daily:
Offer your patient a drink more frequently than normal

Rationale: Dehydration is caused by a number of things, but as part of treatment, a patient should consume a lot of fluids. Because they will need to drink more than patients that aren't dehydrated, they should be offered water more often. Do not force the patient to drink, or threaten that they won't get better. If the patient continually refuses the water, tell the nurse so they can be educated on it being part of their treatment.

•You are assigned to help a patient eat dinner and notice that their beverages must be thickened. This is because:
Thin liquids can cause the patient to choke

Rationale: Patients who are at risk for choking or aspirating their drink are put on thickened liquids to prevent that from happening. Thickener comes in powder and liquid form and can be mixed with any beverage.

•Your diabetic patient asks for an evening snack. Because they are a diabetic, you know the best snack for them is:

Rationale: Many kinds of nuts are a great snack for diabetics. They are filling and low in sugar. Chips, cooking, pudding, ice creams and more are full of sugar and should be avoided as a snack for a diabetic. If you are unsure of a good snack idea, ask your nurse for further advice.

•You are assigned to take care of a patient with cancer that is being treated with chemotherapy. You know that their eating habits and appetite will:

Rationale: Chemotherapy patients lose their appetite because the treatment makes them nauseous and tired. They generally eat little at meal, or not at all. Do not force them to eat if they are ill. If they are nauseous, let the nurse know and he/she may be able to give them medicine to help with that so they are able to eat.

•Which of the following is NOT appropriate when feeding a patient:
Feeding them in 10 minutes so you have a chance to feed all of your patients

Rationale: When feeding a patient, you should never rush because this can cause the patient to choke or just give up on trying to eat. Feeding patients can take a while, especially if they are weak or tired and chew slowly. Do not to try speed up the process because this can make them choke. Ask for assistance in feeding your other patients if you are running behind.

•You are getting a new patient on the unit that has a PEG tube. You know that you won't need to feed this patient because:
They will be fed by a nurse through the tube

Rationale: Patients with PEG tubes are fed a special concoction of food through their tube. Only a nurse can set up their tube feedings, and a machine regulates how much they get and how often. These are usually given to patients that aren't able to eat through their mouths and can be temporary or permanent.

•The nurse tells you that one of the patients on your assignment is NPO. This means:
They aren't allowed to have anything to eat or drink

Rationale: Patients that are NPO should consume nothing by mouth until the physician says they may. Patients are generally NPO before surgery, if they are intubated or if they have a feeding tube. Their mouths may be swabbed with a moist swab, and ice chips may be allowed. NPO patients are not allowed to consume food or drink beverages

vital sign questions

•The nurse asks you to take a patient’s blood pressure. You notice that the blood pressure cuff is a bit too small. You should:
Find a blood pressure cuff that fits the patient

Rationale: A blood pressure cuff that is too small or too big can make the result inaccurate. A patient’s treatment and blood pressure medications are adjusted according to results, and inaccurate results can lead to unnecessary changes. Always make sure the cuff fits appropriately according to the scale on the inside of the cuff.

•You are bathing your patient and you notice a small abrasion on her wrist that you haven’t noticed before. You should:
Notify the nurse of the abrasion after the bath

Rationale: Because the abrasion is on the wrist, the nurse can check it after the bath. If it is in a more discreet place like the buttocks, have another nursing assistant get the nurse. Never leave the patient alone while he/she is bathing. This is both a privacy and safety issue. Any skin issues that the nursing assistant thinks may be new should be brought to the attention of the nurse for him/her to evaluate and treat.

•The nurse should be notified of the following vital sign immediately:
Respirations of 28

Rationale: Respirations should be between 12 and 20. When a patient is sleeping, they can be as low as 8-10. If respirations are high, the patient is struggling to get enough air and is trying to breathe more rapidly to compensate. The nurse should be notified immediately because this patient may have an infection like pneumonia and will need evaluated further.

•The best time to do a skin assessment is:
While you are bathing the patient

Rationale: Doing a skin assessment while bathing the patient is the easiest and most efficient. Because the patient will already be undressed while being bathed, it is the best time to doing a quick assessment for any new skin tears, bruises, abrasions or reddened areas. It is unnecessary to undress the patient just to do a skin assessment and this takes away from their privacy. If there are any changes in the skin, notify the nurse.

•You would NOT need to report the following to the nurse:
An Alzheimer’s patient confused on what day it is

Rationale: In general, an Alzheimer’s patient being confused on the day isn’t something abnormal. Only abnormal things should be reported to the nurse. If you are unsure as to whether it is normal or not, report them and let the nurse decide the next course of action.

•You are taking a patient’s pulse. You know that the normal pulse range is:
60-100 beats per minute

Rationale: A pulse of 60-100 beats per minute is healthy. A pulse that is too high or too low isn’t efficiently pumping blood to the rest of the body. Because oxygen is in the blood, the body isn’t being properly oxygenated either. This can cause problems in every body system and the nurse should be notified of the pulse if it is too high or low.

•The following location is the most common place for skin breakdown on a patient:

Rationale: The coccyx is the most common place for skin breakdown to occur and for ulcers to start forming. The most pressure is usually exerted on this area due to patient’s sitting and laying down. This area should be checked everyday for changes, and any changes should be reported to the nurse. Pressure ulcers cost millions annually to treat, and the quicker it’s caught, the quicker it can be treated.

•A nursing assistant is allowed to do the following data collecting techniques:
Weighing the patient

Rationale: Part of a nursing assistant’s job is to weigh patients and report any dramatic changes to the nurse. All weights should be documented. Assessing a patient is not under the scope of practice for a nursing assistant unless they are checking the skin for new problems.

•You are checking a patient’s oxygen level with the pulse oximeter. It isn’t reading well, and you notice the patient has fingernail polish on. Your next action would be:
Removing the nail polish on one finger and trying again

Rationale: Nail polish can interfere with the machine’s ability to accurately determine a patient’s oxygen level. Simply remove the nail polish on the finger you are using and trying again. This should fix the problem. If not, the machine may be broken and you should get a new one.

•The nurse asks you to check a patient’s temperature. You know that you should never check a patient’s temperature if:
They just got done drinking a beverage

Rationale: Drinking or eating right before having an oral temperature taken can make the results inaccurate. Instruct the patient not to eat or drink for 15 minutes, and then return to the room and take the temperature. If the nursing assistant takes the temperature right after eating or drinking, it may give the wrong result and cause the patient to be unnecessarily treated.

•You would report the following patient complaint to the nurse:
A patient claiming a nursing assistant is abusing them

Rationale: Any claims of abuse should be reported to the nurse immediately so it can be investigated. Even if the patient doesn’t verbalize it and you suspect it or find bruises, you must still report it so it can be looked into further. Abuse is not only physical but can also be sexual, mental or emotional.

•You get ready to take a patient’s blood pressure knowing that a normal blood pressure is:
120/80 mmHg

Rationale: Blood pressure is the force that blood is exerting on the walls of the blood vessels. If it is too low or too high, it can be damaging to the body and have both short and long term effects. There is allowed to be a little bit of variation, but anything below 100/50 or above 150/90 should be a little concerning and the nurse should be notified. Some patients have chronically low or high blood pressure and these can still be normal, but that is for the nurse to determine.

•You should get report about the patient’s you are assigned to:
At the beginning of your shift

Rationale: As a nursing assistant, you must ask your nurses for any information you may need to take care of your patients safely and effectively. This will include their diagnosis, limitations, toileting habits, etc. You should always ask at the beginning of your shift, because that is when you will start taking care of your patients, not in the middle of your shift or on a break.

•A nursing assistant is responsible for documenting which of the following:
Intake and output

Rationale: Nursing assistants are responsible for documenting a patient’s intake and output, weight, mood, skin assessment, bathing and toileting routine, as well as a number of other things. Nursing assistants are not allowed to do physical assessments other than skin, give medications or treatments, therefore they will not document any information on that.

•Knowing about the patient's on the nursing assistants assignment is the responsibility of:
The nursing assistant that will be working with those patients

Rationale: It is the responsibility of the nursing assistant to know about the conditions, treatments, etc. of the patients they are caring for. It is their responsibility to ask questions about each patient as far as their toileting and bathing habits, how they ambulate and anything else related to the care the nursing assistant will provide. If a patient is injured because a nursing assistant did not get this information, they can be held accountable in a court of law for negligence and can lose their job and license.

•The following vital signs is abnormal and should be reported to the nurse immediately:
Oxygen saturation of 91%

Rationale: A normal oxygen saturation should be between 93% and 100%. Patients with chronic lung disease may have a normal oxygen saturation as low as 85%, but anything lower than 93% should be reported to the nurse immediately so she can decide if it is okay. If a patient is wearing oxygen, instruct them to breathe in through their nose and out through their mouth to improve their oxygen levels. Do not adjust the amount of oxygen they are receiving through their tank even if their levels are low.

•Your patient fell earlier and you now notice a bruise on their thigh. You should:
Notify the nurse

Rationale: Injures may not show up right away after a patient falls. Any new injuries should be reported to the nurse right away, even if they are expected. Assessing the patient for further injury is something the nurse will do when she checks on the bruised thigh.

•When checking a pulse manually, you will check it:
On the wrist

Rationale: When manually checking a heart rate, check the radial pulse located on the patient’s wrist. This will be on the palm side of the wrist, located below the thumb. Use your index and middle finger to do this, not the thumb. You can count the pulse for 15 seconds and then multiply it by 4. For the most accurate result, you should count for a full 60 seconds.

•It is important for the nursing assistant to document a patient’s vital signs because:
The nurses and physicians can see if there is any changes from the patient’s normal vitals

Rationale: The purpose of documentation is so that nurses and physicians can monitor any changes in a patient’s condition. Without knowing the pattern of vital signs, they won’t be able to tell if there is a variation from the patient’s normal condition or not. Although a patient has a heart rate of 90, their normal could be 60. This drastic difference can only be noted if vital signs are documented consistently. Make sure that all vitals are documented by the end of your shift, according to your employer’s policy.

•The following vital sign is abnormal and should be reported immediately:
Temperature of 100.7

Rationale: Anything above 100 degrees should be reported to the nurse for further evaluation. This is the first sign of an infection and it should be treated quickly.