Role of the Nurse Assistant and Basic Nursing Skills
What you may and may not do
The nurse assistant (NA) performs care that a licensed nurse delegates and then reports the results back. Typical NA tasks include bathing, grooming, mouth care, toileting, feeding, turning and positioning, ambulation and transfers, vital signs, weights, intake and output, and routine specimen collection per facility policy. Tasks outside the role include assessing (deciding what a symptom means), teaching residents or families, evaluating care, giving any medication, inserting or removing tubes, sterile procedures, and writing the care plan. If a nurse or family member asks you to do something you were not trained for, the correct move is to say so and notify the nurse - never "try your best."
Reporting and documenting
Report changes to the licensed nurse right away, not at the end of the shift: new confusion, chest pain, trouble breathing, a fall, a skin change, refusal of care, or anything that worries you. Documentation must be objective and factual - what you observed, what you did, and how the resident responded. Write "ate 50% of lunch," not "ate well"; write "crying, said she misses her son," not "depressed." Chart only care you personally gave, and correct errors per policy with one line, initials, and date - never erase or use correction fluid.
Traps
Watch for answer choices that let you document for a coworker, accept a verbal order from a provider, share resident information with a caller, or skip reporting because the nurse "looks busy." Also know that the chain of command exists for a reason: unresolved problems go up the chain, not sideways to another aide.
Rule of thumb: if a task requires judgment or a license, report it instead of doing it.