5.1. INTRODUCTION TO PROVIDE FOR PERSONAL CARE NEEDS OF CLIENTS

Providing personal care for clients is the primary responsibility of the nursing assistant. Often referred to as Activities of Daily Living (ADLs), personal care includes anything that a client needs to maintain hygiene, well-being, self-esteem, and dignity. ADLs are the foundation of health and wellness and a part of providing holistic care. The manner in which personal care is provided has a large impact on the quality of life for those unable to care for themselves. A professional nursing assistant provides these services proficiently while also respecting the preferences of residents.

5.2. ACTIVITIES OF DAILY LIVING (ADLS)

The main function of a nursing assistant is to provide assistance to clients with activities of daily living. Activities of daily living (ADLs) include hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs. See Figure 5.1[1] for an illustration of ADLs. Hygiene refers to keeping the body clean and reducing pathogens by performing tasks such as bathing and oral care. Grooming also keeps the body clean but refers to maintaining a resident’s appearance through shaving, hair, and nail care.

Figure 5.1

Activities of Daily Living

Specific ADLs are provided based on the time of day and the needs of the resident. Personal care performed in the morning is referred to as A.M. care, and personal care performed in the evening is referred to as P.M. care. Full baths or showers may be provided with either A.M. or P.M. care, depending on resident preferences, but a partial bath should be provided each morning.

A.M. care includes tasks such as the following activities:

• Toileting, changing incontinence brief (if used), and providing perineal care
• Performing oral and/or denture care (before or after breakfast based on resident’s preference)
• Assisting with a partial bath, full bath, or shower depending on the resident’s personal schedule
• Changing the client’s hospital gown or assisting with dressing
• Assisting with grooming, such as shaving or hair care, and applying makeup, accessories, or jewelry per resident preference
• Assisting with eating breakfast
• Providing hand hygiene to the resident as needed
• Assisting with attending activities, physical therapy (PT), and occupational therapy (OT)
• Making the bed and tidying the resident’s room

P.M. care includes tasks such as the following activities:

• Toileting
• Assisting with lunch and dinner
• Assisting with a partial bath, full bath, or shower depending on the resident’s personal schedule
• Assisting with oral and denture care before bed
• Helping with oral care after meals if resident prefers
• Washing face and removing makeup if worn
• Changing into gown or pajamas
• Providing hand hygiene to resident as needed
• Tidying the resident’s room

5.3. PERSON-CENTERED CARE

Person-centered care is a care approach that considers the whole person, not just their physical and medical needs. It also refers to a person’s autonomy to make decisions about their care, as well as participate in their own care. This approach improves health outcomes of individuals and their families as care is provided according to the resident’s preferences, choices, and habits held before they required assistance to care for themselves.[1]

The term “person” acknowledges a human being has rights, especially in relation to decisions and choices as previously discussed in Chapter 2. It also recognizes that a person is a human being who is made of several human dimensions. These dimensions include intellectual, environmental, spiritual, sociocultural, emotional, and physical, all of which operate together to form the whole person. In providing person-centered care, health care professionals consider all these elements while meeting health care needs.[2]

A nurse aide can focus on an individual’s personhood by spending time communicating with them and finding out what interests them, what is important to them, what concerns them, and what causes them to feel unsafe. It also includes asking each person how they would like to be addressed, as well as avoiding demeaning terms like “honey,” “sweetie,” or “sweetheart.” Promote their dignity by using age-appropriate words and avoiding words like “diaper,” “bib,” “potty,” or “feeders.” The vital element of person-centered care is effective communication between the health care provider, the client, and the client’s family members or significant others. Effective communication facilitates information sharing and trust.[3]

When a nursing assistant helps clients with their ADLs, person-centered care means learning clients’ personal preferences and routines. Examples of using the person-centered care approach are knowing the time the resident prefers to wake up and go to bed; their preference for showers, tubs, or bed baths; their preferred arrangement of their belongings; and their mobility issues. Cares are individualized based on these preferences. Respecting residents’ dignity and privacy is demonstrated by keeping them covered and warm when bathing, explaining procedures prior to doing them, and protecting their health information. It also means respecting personal beliefs, being aware of cultural differences, and offering choices and options when available.

It is important to remember that it is often difficult for clients to feel dependent on others to provide their personal care. Nursing assistants must demonstrate empathy with clients, especially with those who are experiencing the loss of their independence. Caregivers should allow residents to do as much as possible for themselves, under appropriate supervision, while providing assistance as needed. Allow them to make decisions about their care and encourage them to perform as much self-care as possible to promote their independence, self-esteem, and sense of control over their care. An added physical benefit of encouraging residents to perform self-care is it maintains their strength and mobility, thereby preventing a decline in physical function for as long as possible.

5.4. PRE- AND POST-PROCEDURAL STEPS

Each time a nursing assistant provides personal cares, there are routine steps that should be performed before and after the interaction, regardless of the skills provided. Having a list of routine steps ensures the following:

• Important aspects of care won’t be overlooked.
• Dignity for the client and respect for their preferences are provided.
• Risk for transmission of pathogens is reduced.
• Safety is provided.
• Necessary equipment and supplies are present.

Before providing care to a resident, follow the SKWIPE acronym:

• Supplies: Many supplies are kept in the resident’s room, but ask yourself if anything is needed that is not available in the room. Being prepared prevents disruption of the procedure and possible delays that can result in discomfort for the resident.
• Knock: Always knock before entering a room, even if the door is open. Knocking maintains dignity for the client and shows respect for their privacy.
• Wash: Always perform hand hygiene when entering the resident’s room to reduce the risk of transmitting pathogens from other residents, equipment, or environmental surfaces.
• Introduce and Identify: Introduce yourself to the resident with your name and your title or position at the facility. Identify the client following facility policy. For example, properly identifying a client in a hospital setting may include asking them their name and date or birth and checking their medical ID band. However, in a long-term care setting, some residents may have cognitive or sensory deficits and may not correctly state their own name, so asking their name is not always a safe manner to identify them. Instead, identification in long-term care settings is typically performed by using a photograph in the medical record or by asking another experienced staff member to confirm identification.
• Privacy: Provide privacy by closing the door and pulling the privacy curtain to ensure dignity when providing personal care.
• Explain: Explain what care you will be providing so the resident can ask questions or decline care if it is not desired at that time.

After providing care to a resident, but before leaving the room, follow the CLOWD acronym:

• Comfort: Ask if the resident is comfortable and if they need anything else such as tissues, water, TV remote, etc.
• Light, Lock, and Low: Place the resident’s call light within reach so they can call for staff when they need assistance. Check the brakes on the bed to ensure they are locked, and the bed won’t move. Place the bed in the lowest position. These and other measures such as ensuring bed and/or chair alarms are in place and turned on are vital for ensuring patient safety. If a resident decides to self-transfer out of bed instead of requesting assistance, locking and lowering the bed will reduce the risk of injury because it is lower to the floor and won’t move suddenly out from underneath them.
• Open: Open the door and privacy curtain. For safety reasons, residents must be within staff eyesight when they are alone in their rooms, unless they are physically able to move independently.
• Wash: Perform hand hygiene before leaving the room to reduce the risk of transmitting pathogens to another resident, equipment, or environmental surfaces.
• Document: Ask yourself if you provided any cares that should be documented in the medical record or if you need to report anything to the nurse or other staff member. Routine cares (i.e., those cares provided to every resident every day) are not necessarily documented unless they are declined or something out of the ordinary occurred or was observed. Follow agency policy regarding documentation.

5.5. SKIN CARE

Skin is made up of three layers: epidermis, dermis, and hypodermis. See Figure 5.2[1] for an illustration of skin layers. The epidermis is the thin, topmost layer of the skin. It contains sweat gland duct openings and the visible part of hair known as the hair shaft. Underneath the epidermis lies the dermis where many essential components of skin function are located. The dermis contains hair follicles (the roots of hair shafts), sebaceous oil glands, blood vessels, endocrine sweat glands, and nerve endings. The bottommost layer of skin is the hypodermis (also referred to as the subcutaneous layer). It mostly consists of adipose tissue (fat), along with some blood vessels and nerve endings. Beneath the hypodermis layer lie bone, muscle, ligaments, and tendons.[2]

Figure 5.2

Layers of the Skin

As discussed in Chapter 4, the skin is the body’s first layer of defense against pathogens entering the body. Maintaining healthy skin is an integral responsibility of the nursing assistant. Nursing assistants provide the vast majority of bathing and are able to observe and report any changes to skin integrity while performing ADLs on a daily basis. Impaired skin integrity refers to skin that is damaged or not healing normally. An example of impaired skin integrity is a pressure injury (also called a bedsore or pressure ulcer) with damage to the skin and surrounding tissue. See Figure 5.3[3] for an image of a pressure injury on a client’s lower back above their buttocks.

Figure 5.3

Pressure Injury

Age-Related Changes in the Skin

Several changes occur in the skin as one ages. As people age, the amount of adipose tissue decreases. Adipose tissue (i.e., body fat) provides insulation to keep one warm, as well as protection against injury by cushioning underlying structures. See Figure 5.4[4] for an image of age-related changes in the skin on the hand of an older adult.

Figure 5.4

Age-Related Changes in Skin

Oil glands are less productive, making skin drier and more susceptible to cracking. Dry skin and cracked skin make older adults more susceptible to injuries, like skin tears and pressure injuries, that create openings for pathogens and increase the risk of infection. NAs can encourage good nutrition and hydration to help maintain good skin integrity.

Older residents also have reduced production of sweat, which affects the ability of their body to regulate their temperature. This makes them more susceptible to heat-related illness such as exhaustion and heat stroke, especially when being physically active in the heat.[5]

Chronic Conditions Affecting Skin Integrity

Skin needs oxygen and nutrients carried in blood to stay healthy. Any condition that impairs blood flow will increase the risk of skin conditions. As a person ages, a general decline in cardiac function decreases blood flow and oxygen to the skin, putting all older adults at increased risk for skin breakdown. Common medical disorders affecting skin health include high cholesterol that causes blockages of blood flow in the arteries, heart failure, high blood pressure, and diabetes.

Clients with diabetes are prone to developing wounds on their feet that can quickly become infected and require amputation. See Figure 5.5[6] for an image of wounds on the foot of a client with diabetes. Nursing assistants should carefully observe the client’s feet and in between their toes daily and report any concerns to the nurse to preserve skin integrity. Nail care for diabetics should be performed by the Registered Nurse (RN) due to the increased risk of infection.

Figure 5.5

Wounds on the Foot of a Client With Diabetes

Skin care is important for all clients, but additional moisturizing and frequent repositioning should be performed for clients with increased risk for skin breakdown. See Chapter 8 and 11 for more specific information on risks for skin breakdown and maintaining skin integrity.

5.6. TYPES OF BATHS AND TECHNIQUES

There are four basic types of baths that are provided based on the needs, preferences, and mobility of clients: a partial bath, shower, tub bath, or full bed bath.

A partial bath includes washing the face, underarms, arms, hands, and perineal (genital and anal) area. Partial baths are given daily to maintain hygiene. They preserve skin integrity by not drying out skin with excessive soap and water use. A shower is provided for those who can safely sit in a shower chair or stand with supervision in the shower. See Figure 5.6[1] for an image of a shower chair with a transfer bench. A tub bath can be performed in a regular tub or whirlpool. A tub bath may be used for a fully independent resident or if there is a provider order for a bath treatment such as Epsom salts or oatmeal. A complete bed bath is a bath provided for clients who have difficulty getting out of bed, are experiencing excessive pain, or have other physical or cognitive issues that make other types of bathing less tolerable.

Figure 5.6

Shower Chair With Transfer Bench

A resident has the right to choose any type of bath as long as it is safe to do so. A whirlpool bath can be relaxing and enjoyable for any resident, whereas a bed bath can maintain warmth while keeping the majority of the body covered.

If a resident is hesitant about bathing, different types of baths should be offered based on their preference. It is also possible to delay a scheduled bath to a different time of day or an alternate day, as long as their hygiene needs are being met. If a resident continues to be resistant to bathing, different approaches should be attempted until the person is comfortable and hygiene is maintained. Keep in mind that resistance to bathing can be common during the aging process, especially in clients with dementia as the disease progresses.

Visit the following site to read additional bathing techniques and products for unique situations: Bathing Without a Battle.

5.7. ASSISTING WITH NUTRITION AND FLUID NEEDS

Mealtime should be as enjoyable as possible, especially for those clients requiring assistance. As with any other aspect of providing personal care, nursing assistants should use empathy. Think about what it would feel like if you had cognitive or sensory deficits and could not ask for what you want to eat even though it is on the plate in front of you. Recognize how the presentation of the food and the table influence one’s appetite. Consider with whom you like to share your meal. All these factors should be considered when feeding a resident.

Avoid using feeding techniques that are used with young children, such as making noises, moving utensils like airplanes, etc. Residents should be offered a clothing protector to avoid soiling their clothes or gown, but to maintain their dignity, these protectors should never be referred to as a “bib.”

When the meal is ready to consume, describe to the resident what they have on their tray to eat and drink. If the client is visually impaired, use the clock method to describe their plate so they know where each food is located. For example, the nursing assistant can state, “Your mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your plate.” If a resident has an order for a pureed diet (i.e., all food is blended to smooth consistency), know what each food is and name it when assisting the resident.

Nutritional requirements for each resident are determined by the dietary staff. Each resident has a specific type of diet ordered, including texture and consistency of liquids. It is imperative for nursing assistants to check the resident’s care plan to know what type of diet is currently ordered and be familiar with the appearance of these types of diets. These steps ensure the correct foods and fluids are provided to residents and reduces the risk of choking and aspiration. Aspiration refers to inadvertently breathing fluid or food into the airway instead of swallowing it. Diets are further discussed in Chapter 6. See the “Preparing Clients for Meals and Assisting With Feeding” checklist for specific steps when assisting clients with feeding.

Things to observe for and report during feeding include the following:

• Coughing or frequent clearing of the throat while eating. This may be a sign of aspiration.
• A wet voice, meaning vocalization with sounds as if food or fluids remain in the mouth or throat.
• Difficulty swallowing.
• Pain with chewing or swallowing.
• Broken or cracked teeth or dentures that don’t fit properly.
• Changes in appetite.

Thinking back to Maslow’s Hierarchy, physiological needs such as food and fluids are the basis of a healthy existence. Digestive, circulatory, and urinary system changes related to aging will be discussed further in Chapter 11, but aging can pose several risk factors to nutritional and fluid intake. Poor dentition can cause changes in food choices. Someone with missing, cracked, or painful teeth, ill-fitting dentures, or other oral concerns may choose softer foods. A declining sense of smell, taste, or vision can decrease appetite. Pain with movement or other factors that limit mobility may make elimination difficult, which may be a factor in decreasing intake, so toileting needs are less frequent. These are just a few of the aging issues that can lead to malnutrition, dehydration, or both in aging clients and those unable to care for themselves.

Feeding Aids

There are several assistive devices that allow residents to more easily feed themselves.

Built-up handles allow the use of utensils by individuals with limited functional ability of their fingers to hold a smaller handle (such as for someone with severe arthritis). Silverware with prebuilt handles can be purchased, or a foam tube can be placed around regular silverware and removed for washing.

Weighted silverware has a weighted handle for individuals with tremors or unsteady hands. The weight slows down the shaking and allows food to remain on the utensil. See Figure 5.7[1] for an image of built-up handles and weighted silverware.

Figure 5.7

Built-Up and Weighted Silverware

Swivel spoons rotate so if the resident’s hand shakes, the spoon doesn’t move, and the food remains on the utensil. See an image of a swivel spoon in Figure 5.8.[2]

Figure 5.8

Swivel Spoon

Covered cups prevent liquids from spilling due to tremors and also slow down the rate of fluid leaving the cup. For example, individuals with aspiration risk (as discussed in Chapter 6.2, “Nutrition and Fluid Needs”) may be permitted to drink regular liquids out of a covered cup rather than requiring thickened liquids. See an image of a covered cup in Figure 5.9.[3]

Figure 5.9

Covered Cup

Nosey cups are used for clients with limited neck mobility. The nosey cup allows them to drink all of the fluid in the cup without tipping their head back. The cut-out portion of the cup fits around the person’s nose so it can be tilted up to finish the fluid. See an image of a nosey cup in Figure 5.10.[4]

Figure 5.10

Nosey Cup

Plate guards are used for individuals who can use only one hand or who have difficulty maneuvering utensils. Food can be pushed onto the utensil by pushing it against the plate guard. The plate guard can be placed on any plate (such as the image of the plate in Figure 5.11[5]), or it may be on a special plate made with the guard built on the plate surface (as in Figure 5.12[6]).

Figure 5.11

Plate Guard

Figure 5.12

Built-Up Plate

Documentation of Food and Fluids

Documentation of food and fluids gives insight to the overall health and well-being of clients. It gives nurses, dieticians, health care providers, and other staff insight into possible health concerns. Documenting intake is an important responsibility of nurse aides. Unless otherwise indicated, food intake is documented by estimating to the nearest 25% of intake. It is also appropriate to note that a resident only ate “bites of food.” See Figures 5.13 – 5.16[7] for examples of food intake.

Figure 5.13

25% intake or “bites”

Figure 5.14

50% intake

Figure 5.15

75% intake

Figure 5.16

100% intake

Any fluids documented in health care are converted to milliliters (mL) or cubic centimeters (cc). Milliliters and cubic centimeters are the same units, so 1 mL = 1 cc. Typically, fluids are measured in ounces in the United States, so a conversion is necessary. To do so, multiple the number of ounces by 30, as 1 ounce = 30 cc = 30 mL. Examples of fluid conversions are provided in Table 5.7.

Table 5.7

Conversions of Ounces to Milliliters (mL) or Cubic Centimeters (cc)

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Fluid Ounces	Conversion	Milliliters or Cubic Centimeters
6 oz	x 30	180 mL or cc
4 oz	x 30	120 mL or cc
1 cup = 8 oz	x 30	240 mL or cc

In addition to beverages, anything that melts at room or body temperature is documented as fluids. This includes food items such as clear broth, ice chips, ice cream, popsicles, and Jell-O. However, soup is documented as part of the client’s food intake.

5.8. ASSISTANCE WITH TOILETING

Just as there are several bathing techniques based on a resident’s functioning and mobility, there are multiple methods for assisting residents with their bladder and bowel elimination. Regardless of the method used, residents should be offered toileting assistance at least every two hours. The following subsections provide an overview of each toileting method and when it may be implemented.

Bedpan

Bedpans are used for residents who cannot bear weight or prefer to stay in bed, such as when having to urinate during the night. Residents who require a full body lift to transfer typically require the use of a bedpan, but there are also toileting slings to assist a fully dependent resident to use a toilet or commode. See Figure 5.17[1] for an image of two types of bedpans. The image on the left is a standard bedpan and the image on the right is called a fracture pan. Fracture bedpans are smaller than standard bedpans and have one flat end. They are designed for individuals recovering from a hip fracture or hip replacement.

Figure 5.17

Bedpan Examples

For residents with strong hip mobility who require a bedpan, ask them to bend their knees and push their hips upwards. While they are raised, place a barrier (e.g., a towel, waterproof soaker pad, disposable pad, etc.) under them and then place a standard bedpan underneath their buttocks. Ensure the handle of the fracture pan (or the opening of the rim on a full bedpan) is pointed towards the foot of the bed before they lower themselves onto the bedpan. For residents with limited hip mobility, use their lift sheet to roll them away from you towards a raised side rail. While they are lying on their side and holding the side rail, return the lift sheet on top of the bed and then place a barrier on top of the lift sheet. Place a fracture pan behind the resident’s buttocks and then gently roll both the resident and the fracture pan back to the bed surface, ensuring proper placement of the pan.

Please see Skills Checklist for additional information.

Commode

A commode looks like a toilet, but it is a movable device with a bucket underneath the seat. See Figure 5.18[2] for an image of a commode. Commodes are typically placed near the bed for residents who have limited weight-bearing ability, do not want to share a bathroom with another resident, or have urge incontinence. Urge incontinence means that as soon as the person feels the need to empty their bladder, they have very little time before urine escapes.

Figure 5.18

Bedside Commode

Urinary Catheter

A urinary catheter is a device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag. Urinary catheters are used sparingly due to increased risk of urinary tract infections. Catheters are typically used for clients with urinary retention, have a wound near the perineal area that may become infected due to incontinence, or have a neurological condition that does not allow them to control their bladder function. See Figure 5.19[3] for an illustration of an indwelling urinary catheter attached to a collection bag. Nursing assistants may assist in emptying/documenting urine output from the collection bag or providing catheter care according to agency policy. Please see 5.25 Skills Checklist for additional information.

Figure 5.19

Indwelling Urinary Catheter With a Collection Bag

Urostomy

A urostomy is placed surgically to collect urine from the ureters when the bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag. See Figure 5.20[4] for an illustration of a urostomy.

Figure 5.20

Urostomy

Observation and Documentation of Urinary Output

When assisting residents with urinary elimination, their urine should be observed for the characteristics described in Table 5.8. Terms used to document these characteristics are included.

Characteristics of urine can be indicative of a urinary tract infection or dehydration and should be reported to the nurse. Dark urine, minimal urine output, or the infrequent need to void can be signs of dehydration. Characteristics of an infection are described in the previous “Urinary Tract Infection (UTI)” subsection. If noted and reported promptly, fluids can be encouraged to help treat these conditions.

Table 5.8

Urine Characteristics

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Characteristic	Normal Observation	Abnormal Observation	Documentation Terminology
Color	Amber (like a stoplight) or straw-colored	Dark amber or possibly root beer or cola-colored	Amber or cola
Odor	Acidic	Noticeably stronger odor than usual	Strong
Clarity	Clear	Cloudy	Cloudy
Sediment	None present	Particles present	Sediment noted
Amount	Generally 250-350 cc	More or less than usual amount	Amount in milliliters or cubic centimeters. Minimal amount may be described as scant

If a resident is regularly incontinent and uses a brief or disposable pad for elimination, the nursing assistant should document the number of times the resident is incontinent rather than recording the amount. For a continent resident, use a toilet hat to measure urine output as described in the “Specimen Collection” subsection below. If the resident uses a commode or bedpan, place a graduated cylinder on a barrier, carefully pour the urine into the graduated cylinder, and observe and document the characteristics. See Figure 5.21[8] for an image of a graduated cylinder.

Figure 5.21

Graduated Cylinder

Observation and Documentation of Stool

Similar to urine, stool output and characteristics can indicate underlying health concerns. Risk factors to healthy stool elimination will be discussed further in the “Digestive System” section in Chapter 11, but slowing of the digestive system, decreased intake, and lower mobility can all contribute to constipation and even cause bowel obstruction. Documentation and reporting of unusual characteristics can assist nurses in providing interventions that can prevent more serious health concerns.

Elimination patterns vary for each individual, but a typical range for bowel elimination is twice daily to once every other day. When regular bowel movements do not occur, stool becomes hardened in the colon, making it difficult to push out, especially for those who are physically declined. Stool should be soft and formed when eliminated to prevent additional problems like hemorrhoids. Stool that is loose or liquid may indicate an infection or other chronic intestinal issues.

Nursing assistants should note the size of a client’s bowel movement as “small,” “medium,” or “large” as an estimation. Using agency protocol, the consistency of the stool should also be documented. The Bristol Stool Chart is a common tool used to easily observe and document the consistency of stool. See Figure 5.22[9] for an image of the Bristol Stool Chart. Additionally, if any blood or dark tarry stool is observed, this should be reported immediately to the nurse.

Figure 5.22

Bristol Stool Chart

Specimen Collection[10]

Urinary Samples

Urinary samples may need to be collected to detect infection. When needed, obtain a toilet hat (see Figure 5.23^{“Toilet Hat” and “Commode with Toilet Hat” by Landon Cerny are licensed under CC BY 4.0[/footnote]}. Ask the nurse to label a specimen cup before collecting urine (see Figure 5.24[11]).

Figure 5.23

Toilet Hat

Figure 5.24

Specimen Cup

When assisting in collecting a urine specimen, place the cup and toilet hat on a barrier to prevent contamination with bacteria from the environment. Apply gloves and assist the client when needed to clean around the urethra to remove any external pathogens. If able, ask the resident to void a small amount of urine into the toilet. Place the toilet hat in the front of the toilet and instruct the resident to void into the hat. Do not put toilet paper or any other products into the toilet hat. After urination, assist the resident in completing perineal care and transferring from the toilet. Remove dirty gloves, perform hand hygiene, and apply new gloves to prevent contamination of the urine with bacteria from the perineal area. Pour the urine sample from the toilet hat into the specimen cup and tightly put on its cover. Remove gloves and perform hand hygiene before writing the time of collection on the label. Immediately bring the urine sample to the nurse.

Stool Samples

Stool samples are collected from patients to test for cancer, parasites, or for occult blood (i.e., hidden blood). The Guaiac-Based Fecal Occult Blood Test (gFOBT) is a commonly used test to find hidden blood in the stool that is not visibly apparent. As a screening test for colon cancer, it is typically obtained by the patient in their home using samples from three different bowel movements. Nursing assistants may collect gFOBT specimens for clients.

Before the test, the nurse should verify that the client has avoided red meat for three days and has not taken aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for seven days prior to the test. (Blood from the meat can cause a false positive test, and aspirin and NSAIDS can cause bleeding, also leading to a false positive result.) Vitamin C (more than 250 mg a day) from supplements, citrus fruits, or citrus juices should be avoided for 3 to 7 days before testing because it can affect the chemicals in the test and make the result negative, even if blood is present.

To perform a gFOBT in an inpatient setting, perform the following steps.

• Verify with the nurse that the client has met dietary and medication requirements.
• Explain the procedure to the client. Assist the resident to a clean, dry commode and instruct them not to put any toilet paper in the commode, as this may alter the test result. Request they use the call light when they have had a bowel movement.
• Review the manufacturer’s instructions with the nurse.
• Label the card with the patient’s name and medical information per agency policy. Open the flap of the guaiac test card.
• Apply nonsterile gloves. Use the applicator stick to apply a thin smear of the stool specimen to one of the squares of filter paper on the card. Obtain a second specimen from a different part of the stool and apply it to the second square of filter paper on the card. (Occult blood isn’t typically equally dispersed throughout the stool.)
• Place the labeled test card in a transport bag.
• Remove gloves and perform hand hygiene.
• Give the transport bag to the nurse to send to the laboratory for analysis.

5.9. SKILLS CHECKLIST: PARTIAL BATH

1.

Gather Supplies: Wash basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, clean clothes or gown, and linen bag or hamper. See Figure 5.25[1] at the end of this checklist for an image of a wash basin.

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Put on gloves.
• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Raise the bed height to a working height.
• Keep the resident covered as much as possible using a bath blanket or bed linens.
• Wash the resident’s face using water only.
• Pat dry the face.
• Remove the gown from one arm, keeping the rest of the body covered.
• Place a towel under one arm, only exposing the arm.
• Wet a washcloth, put soap on the washcloth, and wash the arm with soap.
• Wash the hand with soap.
• Wash the underarm with soap. Place the washcloth containing soap on the edge of the basin or barrier.
• Rinse the arm with the second washcloth.
• Rinse the hand.
• Rinse the underarm.
• Pat dry the arm.
• Pat dry the hand.
• Pat dry the underarm.
• Move to the other side of the bed and repeat actions on the other side of the body.
• Dispose of the gown into a linen bag or laundry hamper.
• Ask the resident if they would like lotion. When applying lotion, wear gloves.
• Assist the resident to put on a clean gown or clothes.
• While wearing gloves, empty the equipment.
• Rinse the equipment.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in the designated laundry hamper.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and if anything else is needed.
• Be sure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

Figure 5.25

Wash Basin

5.10. SKILLS CHECKLIST: FULL BED BATH

1.

Gather Supplies: Basin, warm water, soap, shampoo and conditioner if used, lotion, six washcloths, two towels, barrier, gloves, clean clothes or gown, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Place a towel under one leg, keeping the rest of the body covered with the bath blanket.
• Wash the leg with soap, only exposing the leg.
• Wash the feet with soap.
• Rinse the leg and feet.
• Pat the leg and feet dry.
• Repeat on the other leg.
• Raise the side rail on one side of the bed.
• Move to the opposite side of the bed and assist the resident to roll on their side using a lift sheet or other supportive device.
• Wash the back while keeping the rest of the body covered.
• Rinse the back.
• Pat the back dry.
• Dispose of the gown and used linens into the linen bag or laundry hamper.
• Ask the resident if they would like lotion. If applying lotion, wear gloves.
• Perform perineal care using clean linens according to Chapters 5​.18 & 5​.19 “Perineal Care Skills Checklists.”
• Assist the resident to put on a clean gown or clothes and apply an incontinence product if needed.
• While wearing gloves, empty the equipment.
• Rinse the equipment.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in the designated laundry hamper.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and if anything else is needed.
• Be sure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

Note: Shampooing can be done before washing face, after washing back, or after perineal care per resident preference. See “ Shampoo Skills Checklist ” for specific steps.

5.11. SKILLS CHECKLIST: SHOWER

1.

Gather Supplies: Soap, shampoo and conditioner if used, lotion, two washcloths, several towels, barrier, gloves, clean clothes or gown, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Assist the resident to the shower per facility protocol. See the “Considerations During Bathing” subsection in this chapter and implement comfort measures. Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Repeatedly check the water temperature throughout the shower.
• Put on gloves.
• Wet a washcloth and wash the face without soap.
• Put soap on the washcloth and wash the resident, starting with their upper body and then their legs.
• Lift any skin-on-skin areas and wash gently with soap.
• Wash the front of the perineal area.
• Reach through the bottom of the shower chair and wash the rectal area from front to back.
• Remove the gloves, turning them inside out.
• Perform hand hygiene.
• Put on clean gloves.
• Rinse the resident starting with the upper body, followed by the legs, front perineal area, and rectal area.
• Change the gloves and perform hand hygiene if the perineal area was touched during rinsing.
• Turn off the water and place warm towels to cover the resident
• Pat dry.
• Ask the resident if they would like lotion. If applying lotion, wear gloves.
• Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair and avoiding getting the gown or clothes wet.
• Place nonskid footwear on the client.
• Assist the resident to stand per their care plan.
• Dry the back of their legs
• Dry the perineal area from front to back
• Finish putting on clothes.
• Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the resident is safely seated.
• Place all linens and soiled gown or clothing in a linen bag or designated hamper.
• Sanitize the shower chair per facility policy.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Be sure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.12. SKILLS CHECKLIST: TUB BATH

1.

Gather Supplies: Soap, shampoo and conditioner if used, lotion, four washcloths, four towels, barrier, gloves, clean clothes or gown, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Assist the resident to the tub per facility protocol. See the subsection in this chapter called “Considerations During Bathing” for comfort measures. Repeatedly check the water temperature throughout the bath.
• Put on gloves.
• Wash the client’s face with a washcloth and no soap.
• Put soap on the washcloth and wash the resident starting with their upper body and then their legs.
• Lift any skin-on-skin areas and wash gently with soap.
• Perineal care can be performed in the bed prior to the bath. See Skills Checklists 5​.18 and 5​.19 for perineal care specifics.
• Wash the client’s hair. See the “Shampoo” checklist for specific steps.
• Drain the tub per facility protocol and rinse the resident.
• Place warm towels to cover the resident.
• Pat dry.
• Ask the resident if they would like lotion. If applying lotion, wear gloves.
• Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair to prevent getting the gown or clothes wet.
• Place nonskid footwear on the client.
• Assist the resident to stand per their care plan.
• Dry the back of their legs.
• Dry the perineal area from front to back.
• Finish putting on clothes.
• Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the resident is safely seated.
• Place all linens and soiled gown or clothing in a linen bag or designated hamper.
• Sanitize the bath chair per facility policy.
• Remove the gloves by turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Be sure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.13. SKILLS CHECKLIST: SHAMPOO

1.

Gather Supplies: Shampoo basin if in bed, shampoo, conditioner if used, two washcloths or small towels, one large towel, gloves, and linen bag

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Place a basin underneath the client’s head and neck if they are in bed and place the drain over the garbage can located on the floor.
• Give the client a dry washcloth or towel to cover their face if desired.
• Check the water temperature for safety and comfort. Have the resident check the water temperature by placing their hand in the water in the basin or putting a wet washcloth on the back of their hand. Ask the resident if the temperature is comfortable to them.
• Wet their hair with a wet washcloth or by gently pouring water over their hair.
• Apply shampoo and lather while massaging scalp gently.
• Rinse their hair.
• Apply conditioner if used, massaging the scalp gently.
• Rinse their hair.
• Dry their hair gently and style it per the resident’s preference.
• While wearing gloves, empty the equipment.
• Rinse the equipment.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in a designated laundry hamper.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin or scalp issues or changes noted with the resident.

5.14. SKILLS CHECKLIST: FOOT CARE

1.

Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Fill a foot basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Remove their socks.
• Immerse their feet in warm water for 5 to 20 minutes.
• Use water and a soapy washcloth.
• Wash each foot and between the toes.
• Rinse the entire foot with the wet washcloth, including between the toes.
• Dry the foot thoroughly, including between the toes.
• Ask the resident if they would like lotion. If applying lotion, wear gloves.
• Massage the lotion over the foot but avoid applying any lotion between the toes.
• Wipe off any excess lotion with a dry towel.
• Replace the socks or preferred footwear.
• While wearing gloves, empty the equipment.
• Rinse the equipment.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in a designated laundry hamper.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin or nail issues or changes noted with the resident.

5.15. SKILLS CHECKLIST: NAIL CARE

NOTE: Nail care for clients with diabetes should be performed by a Registered Nurse (RN).

1.

Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, manicure stick, emery board, nail clipper, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Have the resident perform hand hygiene with sanitizer.
• Immerse the client’s hands in warm water for 5 to 20 minutes.
• Place their hand on a barrier.
• Using a manicure stick, clean underneath each nail, wiping any debris on the barrier after each nail.
• If necessary, trim nails using a clipper. Sanitize the clipper prior to and after use.
• Using an emery board, file each nail from the outside of the nail towards the middle of the nail.
• Check each nail for snags and file until smooth.
• Rinse the hand in water, return to the barrier, and dry.
• Repeat the procedure for the second hand.
• Offer lotion. If applying lotion, wear gloves.
• Rub the lotion gently into the skin if requested.
• Wipe off any excess lotion with a dry towel.
• While wearing gloves, empty the equipment.
• Rinse the equipment.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in a designated laundry hamper.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene
• Document and report any skin or nail issues or changes noted with the resident.

5.16. SKILLS CHECKLIST: SKIN CARE

1.

Gather Supplies: Gloves and lotion

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene and put on gloves.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Position the resident as needed and only expose the skin that will be moisturized.
• Put on gloves.
• Place a quarter-sized circle of lotion on one palm.
• Rub the hands together to warm the lotion.
• Apply the lotion to dry skin but avoid getting lotion between the toes.
• Use additional lotion, warming between your hands as needed, until all dry skin has been moisturized.
• Wipe off any excess lotion gently with a dry towel.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

It is important to properly clean the wash basin and other supplies after performing any type of skin care to prevent the spread of infection.

5.17. SKILLS CHECKLIST: BACK RUB

1.

Gather Supplies: Gloves and lotion

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Raise the side rail on one side of the bed.
• Move to the opposite side of the bed and assist the resident to roll towards the raised side rail.
• Only expose the resident’s back from the shoulders to the top of the hips.
• Place a quarter-sized circle of lotion on one palm.
• Rub the hands together to warm the lotion.
• Begin with long, gentle strokes starting at the top of hips and moving to the top of the shoulders. Repeat about five times.
• Throughout the back rub, ask the resident if there is any pain or discomfort. If pain is present, stop the procedure and report it to the nurse.
• Apply more lotion to gloved hands as needed to reduce friction on the resident’s skin.
• Make large circles with both hands from the top of hips to the top of shoulders. Repeat about five times.
• Apply additional lotion to gloved hands as needed to reduce friction on resident’s skin.
• Make small circles with both hands from the top of the hips to the top of the shoulders. Repeat about five times.
• Apply additional lotion to gloved hands if needed to reduce friction on resident skin.
• End with long, gentle strokes starting at the top of hips and moving to the top of shoulders. Repeat about five times.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Cover the resident completely per resident preference.
• Assist the resident to their preferred position.
• Lower the side rail that was raised.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.18. SKILLS CHECKLIST: PERINEAL CARE (FEMALE)

1.

Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Raise one side rail of the bed after checking the resident’s mobility and their preferred side to lie on.
• Put on gloves.
• Raise the bed height if needed.
• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Turn the resident or raise their hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their buttocks.
• Expose their perineum only.
• Separate the labia.
• Use water and a soapy washcloth.
• Clean one side of the labia from top to bottom.
• Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom.
• Using a clean portion of the first washcloth, clean the vaginal area from top to bottom.
• Put the first washcloth in the linen bag.
• Using the second clean washcloth, rinse one side of the labia from top to bottom.
• Using a clean portion of the second washcloth, rinse the other side of the labia from top to bottom.
• Using a clean portion of the second washcloth, rinse the vaginal area from top to bottom.
• Put the second washcloth in the linen bag.
• Avoid overexposure throughout the procedure.
• Pat dry.
• Cover the exposed area with the bath blanket.
• Assist the resident to turn onto their side facing away from you and ask the resident to hold onto the raised side rail.
• Using the third clean washcloth, apply water and soap.
• Using a clean portion of the third washcloth, clean one side of the buttock, wiping away from vagina.
• Using a clean portion of the third washcloth, clean the other side of the buttock, wiping away from the vagina.
• Using a clean portion of the third washcloth, clean the rectal area wiping away from the vagina.
• Put the third washcloth in the linen bag.
• Using the fourth washcloth, rinse one side of the buttock wiping away from the vagina.
• Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the vagina.
• Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from vagina.
• Put the fourth washcloth in the linen bag.
• Pat dry.
• Safely remove the waterproof pad from under the buttocks.
• Remove the gloves, turning them inside out.
• Perform hand hygiene.
• Position the resident on her back.
• Put on clean gloves.
• Dispose of soiled linen in the designated laundry hamper.
• Empty the equipment.
• Rinse the equipment.
• Dry the equipment.
• Return the equipment to storage.
• Remove the gloves, turning them inside out.
• Dispose of the gloves in an appropriate container.

4.

Post- Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.19. SKILLS CHECKLIST: PERINEAL CARE (MALE)

1.

Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Raise one side rail of the bed. Check the resident’s mobility and their preferred side to lie on.
• Put on gloves.
• Raise the bed height if needed.
• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Turn the resident or raise the hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their buttocks.
• Expose the perineum only.
• Use water and a soapy washcloth.
• If the resident is not circumcised, gently move the foreskin away from their urethra toward the base of the penis.
  • Using a clean portion of the first washcloth, start from the urethra and clean in a circular motion toward their scrotum.
  • Using a clean portion of the first washcloth, clean one groin fold and the scrotum.
  • Using a clean portion of the first washcloth, clean the other groin fold and the other side of scrotum.
  • Put the first washcloth in a linen bag.
  • Using the second clean washcloth, rinse from the urethra in a circular motion toward the scrotum.
  • Using a clean portion of the second washcloth, rinse one groin fold and the scrotum.
  • Using a clean portion of the second washcloth, rinse the other groin fold and the other side of the scrotum.
  • Put the second washcloth in the linen bag.
  • Avoid overexposure throughout the procedure.
  • Pat dry.
• If uncircumcised, gently return the foreskin toward the urethra.
  • Cover the exposed area with the bath blanket.
  • Assist the resident to turn onto their side away from you and ask the resident to hold onto the raised side rail.
  • Using the third clean washcloth, apply water and soap.
  • Using a clean portion of the third washcloth, clean one side of the buttock wiping away from the urethra.
  • Using a clean portion of the third washcloth, clean the other side of the buttock wiping away from the urethra.
  • Using a clean portion of the third washcloth, clean the rectal area wiping away from the urethra.
  • Put the third washcloth in the linen bag.
  • Using the fourth washcloth, rinse one side of the buttock wiping away from the urethra.
  • Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the urethra.
  • Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from the urethra.
  • Put the fourth washcloth in the linen bag.
  • Pat dry.
• Safely remove the waterproof pad from under the buttocks.
• Remove the gloves, turning them inside out.
• Perform hand hygiene.
• Position the resident on his back.
• Put on clean gloves.
• Dispose of soiled linen in the designated laundry hamper.
• Empty the equipment.
• Rinse the equipment.
• Dry the equipment.
• Return the equipment to storage.
• Remove the gloves, turning them inside out.
• Dispose of gloves in an appropriate container.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.20. SKILLS CHECKLIST: ORAL CARE

1.

Gather Supplies: Gloves, toothbrush, toothpaste, emesis/oral basin, cup of water, clothing protector (towel), barrier (paper towel), and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.
• Procedure Steps:
• Place all supplies on a barrier.
• Put on gloves.
• If the resident is in bed, elevate the head of the bed if it is permissible per the care plan.
• Cover the resident’s chest with a towel to keep their clothing or gown clean.
• Wet the toothbrush in the sink or in a cup of water.
• Apply a small amount of toothpaste to the toothbrush.
• Brush the resident’s teeth, including the inner, outer, and chewing surfaces of all upper and lower teeth.
• After each quadrant of the mouth (i.e., lower right, lower left, upper right, or upper left), allow the resident to rinse with water and spit into an emesis basin if needed.
• Clean the resident’s tongue being careful not to cause the resident to gag.
• Assist the resident in rinsing their mouth.
• Wipe the resident’s mouth with the towel on their chest.
• Remove the towel and place it in a linen bag.
• Empty the emesis basin.
• Rinse the emesis basin.
• Dry the emesis basin.
• Rinse the toothbrush.
• Return the equipment to storage.
• Remove the gloves, turning them inside out.
• Dispose of the gloves in an appropriate container.

3.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any oral issues or changes noted with the resident.

5.21. SKILLS CHECKLIST: DENTURE CARE

1.

Gather Supplies: Gloves, denture brush, denture toothpaste if available, dentures, denture cup, denture cleansing tablet if desired, emesis/oral basin, oral swab, cup of water, clothing protector (towel), barrier (paper towel), sink liner (paper towel or washcloth), and linen bag or hamper. See Figure 5.26[1] at the end of this checklist for an image of an oral swab.

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Place all supplies on a barrier.
• Place a clothing protector on the resident.
• Line the sink with a washcloth or paper towel.
• Remove dentures from the cup or remove them from the resident’s mouth and place them in the denture cup or emesis basin.
• Handle the dentures carefully to avoid damage or contamination.
• Wet the denture brush and apply denture toothpaste if available. Water alone is acceptable to clean dentures if toothpaste is not available.
• Thoroughly brush the inner, outer, and chewing surfaces of each denture.
• Rinse the dentures using clean, cool water and place them on a clean barrier or in an emesis basin.
• Rinse the denture cup.
• Place the dentures in a rinsed cup.
• Wet an oral swab and gently clean all surfaces of the resident’s gums and tongue.
• Allow the resident to rinse and spit into the emesis basin.
• Place the dentures in the resident’s mouth if desired.
• Wipe the resident’s mouth and remove the clothing protector, placing it in an appropriate container.
• In the evening, place the dentures in the denture cup and add cool, clean water to the denture cup to cover the dentures.
• Put a denture cleansing tablet in the cup, if desired.
• Rinse the equipment (denture brush and emesis basin).
• Return the equipment to storage.
• Discard the protective lining in an appropriate container.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any oral issues or changes noted with the resident.

Figure 5.26

Oral Swab

5.22. SKILLS CHECKLIST: PREPARING CLIENTS FOR MEALS AND ASSISTING WITH FEEDING

1.

Gather Supplies: Clothing protector, meal, diet card, eating utensils, sanitizer or soapy and wet washcloths

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door unless they are in the dining room.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Verify the name on the diet card matches the resident.
• Verify the diet, diet texture, and liquid consistency matches the diet card.
• Position the resident in an upright position, at least 45 degrees.
• Place a clothing protector on the resident if desired (e.g., a paper or cloth towel or a large napkin).
• Ask the resident if they would like oral care before eating.
• Assist the resident to clean their hands before feeding using sanitizer or soapy and wet washcloths.
• Position yourself at eye level facing the resident.
• Describe the foods and fluids being offered to the resident.
• Offer small amounts of food at a reasonable rate.
• Offer fluids frequently.
• Allow the resident time to chew and swallow.
• Wipe the resident’s face whenever necessary.
• Continue to alternate foods and fluids until the resident indicates they are full.
• Clean the resident’s face and hands.
• Ask the resident if they would like oral care.
• Leave the resident with their head elevated at least 30 degrees.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Record the intake as a percentage of total solid food eaten.
• Record the sum of estimated fluid intakes in mL or cc.
• Check for resident comfort and ask if anything else is needed.
• If in the resident’s room, ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any feeding issues or changes noted with the resident.

5.23. SKILLS CHECKLIST: CHOKING MANEUVER

1.

Call out for help or tell another staff member to get the nurse if you think a resident is choking. If no nurse is available, direct someone to call 911 while proceeding with the following steps.

2.

Until help arrives, stand behind the victim with one leg forward between the victim’s legs.

3.

For a child, move down to their level and keep your head to one side.

4.

Reach around their abdomen and locate the navel.

5.

Place the thumb side of your fist against their abdomen just above the navel.

6.

Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks.

7.

For a responsive pregnant victim, any victim you cannot get your arms around, or for anyone in whom abdominal thrusts are not effective, give chest thrusts while standing behind them. Avoid squeezing the ribs with your arms.

8.

Continue thrusts until the victim expels the object or becomes unresponsive.

9.

If the person becomes unconscious, notify the nurse. If no nurse is available, call 911.

5.24. SKILLS CHECKLIST: CATHETER CARE

1.

Gather Supplies: Basin, warm water, soap, two washcloths, one towel, barrier, gloves, and linen bag or hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Raise the bed height to a working height.
• Expose only the urethra and catheter.
• Follow the tubing from the resident toward the drainage bag, ensuring that the tubing is at a lower level as it goes toward the bag. Be sure no kinks or elevation can cause backflow to the bladder.
• Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, or disposable pad) under their buttocks.
• Use the first washcloth with soap and water to carefully wash around the catheter where it exits the urethra.
• Hold the catheter where it exits the urethra with one hand.
• While holding the catheter, clean 3-4 inches down the catheter tube.
• Clean with strokes moving away from the urethra.
• Use a clean portion of washcloth for each stroke.
• Put the soiled first washcloth in the linen bag.
• Wet the second washcloth and rinse, using strokes only away from the urethra while continuing to hold the catheter where it exits the urethra.
• Rinse using a clean portion of washcloth for each stroke.
• Put the soiled second washcloth in the linen bag.
• Pat dry with a towel.
• Do not allow the tube to be pulled at any time during the procedure.
• Replace the gown over the resident’s perineal area.
• While wearing gloves, empty the basin.
• Rinse the basin.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in a designated laundry hamper.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any issues or changes noted with the resident.

5.25. SKILLS CHECKLIST: EMPTYING CATHETER DRAINAGE BAG

1.

Gather Supplies: Gloves, two barriers, graduated cylinder, and alcohol swab

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Place a barrier (e.g., paper towel or disposable pad) on the floor under the drainage bag.
• Place the graduated cylinder on the barrier.
• Open the drain to allow the urine to flow into the graduated cylinder.
• Avoid touching the tip of the tubing to the sides of the graduated cylinder.
• Close the drain.
• Wipe the drain with an alcohol wipe.
• Wipe the drain holder, if present, with an alcohol wipe.
• Replace the drain into the holder.
• Place a clean barrier on a level, flat surface.
• Place the graduated cylinder on the barrier.
• With the graduated cylinder at eye level, read the amount of output.
• Note the characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine.
• Empty the urine in the graduated cylinder into the toilet.
• Rinse the graduated cylinder and empty it into the toilet.
• Return the equipment to storage.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document urinary output in mL and report any issues or changes noted with the resident.

5.26. SKILLS CHECKLIST: ASSISTING WITH A BEDPAN

1.

Gather Supplies: Gloves, bedpan, barrier, and toilet tissue

2.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the client.

3.

Procedure Steps:

• Put on gloves.
• Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, disposable pad) under their buttocks.
• Position the resident on the bedpan/fracture pan correctly. The deeper portion of the bedpan should be directed toward their toes, and the resident should be centered on the bedpan. For fracture bedpans, the handle should be directed toward their toes.
• Raise the head of the bed to a comfortable level.
• Cover the resident with linens or a bath blanket.
• Leave toilet tissue within reach of the resident.
• Leave the call light within reach of the resident.
• Wait nearby allowing for resident privacy.
• When the resident signals, return and assist the resident to perform hand hygiene.
• Discard the soiled linen in the designated laundry hamper.
• Gently remove the bedpan/fracture pan.
• Assist with perineal care.
• Empty the bedpan into the toilet or into a graduated cylinder if output is being recorded. Note the amount and characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine. Empty the urine from the graduated cylinder used into the toilet.
• Rinse the equipment used and empty the rinse water into the toilet.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document urinary output in mL and report any issues or changes noted with the resident.

5.27. SKILLS CHECKLIST: ASSISTING WITH A URINAL

1.

Gather Supplies: Gloves, urinal, and barrier

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Assist the resident to their preferred position of comfort and mobility status (e.g., seated on the side of the bed, lying in bed, or standing).
• Place the urinal with the shaft of the penis well within the opening. Keep the urinal level to prevent urine spillage while the resident is urinating. If the resident has discomfort, a washcloth can be placed around the rim of the urinal to prevent skin issues.
• Provide privacy while the resident voids.
• Place a barrier on a flat surface.
• Place the urinal on the barrier.
• With the urinal at eye level, read the amount of urine and note its characteristics (i.e., color, clarity, sediment, or unusual odor).
• Empty the urinal into the toilet.
• Rinse the urinal and empty the rinse water into the toilet.
• Return the urinal to storage.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document urinary output in mL and report any skin issues or changes noted with the resident.

5.28. SKILLS CHECKLIST: CHANGING INCONTINENCE BRIEF

1.

Gather Supplies: Gloves and brief

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• If the resident is in bed, raise one side rail.
• Moving to the opposite side of bed, assist the resident to raise their hips or turn towards the side rail. Remove the soiled brief.
• Remove the gloves, turning them inside out.
• Perform hand hygiene.
• Put on gloves.
• Assist with perineal care.
• Remove the gloves, turning them inside out.
• Perform hand hygiene.
• Put on gloves.
• Place a new brief under the resident’s buttocks and center the brief. Gently tuck the tabs under the resident.
• Assist the resident to roll onto their back.
• Position the brief over the front of the resident and secure the brief with tabs.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document output from the soiled brief and report any skin issues or changes noted with the resident.

5.29. SKILLS CHECKLIST: DRESSING A CLIENT WHO NEEDS TOTAL ASSISTANCE

1.

Gather Supplies: Resident clothing, socks and footwear, and hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Raise the bed height.
• Keep the resident covered while removing their gown.
• Remove the gown from the unaffected (most mobile) side first.
• Place the used gown in a designated laundry hamper.
• Ask the resident their preferences for desired clothing.
• Start dressing them on their affected (least mobile) side first. Insert their hand through the sleeve of their shirt and grasp the hand of the resident to guide it through the sleeve.
• Put pants on both legs, starting with the affected (least mobile) side first. If the resident is able, assist them to raise their buttocks. If they are unable to raise their hips, put the side rail on their unaffected (most mobile) side up. Assist the resident to turn towards the side rail. Pull the pants over their buttocks and up to their waist.
• While still on the unaffected (most mobile) side, tuck the resident’s shirt underneath their unaffected side.
• Assist the resident onto their back.
• Raise the side rail if the resident is unable to lift their hips.
• Move to the unaffected side of the resident.
• Place their unaffected arm in the shirt sleeve, grasping the hand of the resident. Finish putting on their shirt by buttoning and zipping closures.
• Assist the resident to turn onto their affected side and pull their pants up to their waist.
• Return the resident to lying on their back.
• Put on the resident’s socks. Draw the socks up the resident’s foot until they are smooth.
• Put on the resident’s nonskid footwear by slipping each nonskid footwear on the resident’s feet.
• Leave only when the resident is properly dressed.

4.

Post-Procedure Steps:

• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.30. SKILLS CHECKLIST: SHAVING WITH AN ELECTRIC RAZOR

1.

Gather Supplies: Gloves, clothing protector (towel), razor, and hamper

2.

Routine Pre-Procedure Steps:

• Knock on the resident’s door.
• Perform hand hygiene.
• Maintain respectful, courteous, and professional communication at all times.
• Introduce yourself and identify the resident.
• Provide for privacy.
• Explain the procedure to the resident.

3.

Procedure Steps:

• Put on gloves.
• Sit the resident upright and place a clothing protector over their chest.
• Hold the shaver at a right angle to the resident’s face, using your free hand to pull their skin taught as you shave. This will minimize snagging and the risk of cutting the resident.
• Shave all areas of the face and neck per resident preference.
• Gather the clothing protector so their whiskers do not fall onto their clothing.
• Place the clothing protector in the designated hamper.
• Clean the razor per facility guidelines and charge or plug it in.
• Remove the gloves, turning them inside out.

4.

Post-Procedure Steps:

• Perform hand hygiene.
• Check for resident comfort and ask if anything else is needed.
• Ensure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Perform hand hygiene.
• Document and report any skin issues or changes noted with the resident.

5.31. LEARNING ACTIVITIES

V. GLOSSARY

Activities of daily living (ADLs)

Hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs of clients.

A.M. care

Personal care performed in the morning.

Aspiration

Inadvertently breathing fluid or food into the airway instead of swallowing it.

Clock method

A method used with clients with visual impairments to describe where the food on their plate is located. For example, state, “Your mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your plate.”

CLOWD

An acronym to consider after providing personal care but before leaving the room that stands for Comfort; Light, Lock and Low; Open; Wash; and Document.

Colostomy

A surgically placed opening when a client’s colon function is impaired. A piece of the colon is diverted to an artificial opening in the abdominal wall called a stoma, and feces is collected in a pouch.

Commode

A movable device with a bucket underneath the seat that is used for elimination when the client has difficulty getting to the bathroom.

Complete bed bath

A bath provided in bed for clients who have difficulty getting out of bed, are experiencing excessive pain, or have other physical or cognitive issues that make other types of bathing less tolerable.

Grooming

Maintaining a resident’s appearance through shaving, hair, and nail care.

Hygiene

Keeping the body clean and reducing pathogens by performing tasks such as bathing and oral care.

Impaired skin integrity

Skin that is damaged or not healing normally. An example of impaired skin integrity is a pressure injury (also called a bedsore or pressure ulcer) with damage to the skin and surrounding tissue.

Incontinence briefs or pads

Disposable products used for clients with little to no control over bladder or bowel function.

Partial bath

Washing the face, underarms, arms, hands, and perineal area. Partial baths are given daily to maintain hygiene. They preserve skin integrity by not drying out skin with excessive soap and water use.

Perineal

The genital and anal area.

Personal care

Care that a client needs to maintain hygiene, well-being, self-esteem, and dignity.

Person-centered care

A care approach that considers the whole person, not just their physical and medical needs. It also refers to a person’ autonomy to make decisions about their care, as well as participate in their own care.

P.M. care

Personal care performed in the evening.

Pureed diet

A diet order indicating all food is blended to smooth consistency.

Routine cares

Personal cares provided to every resident every day, such as assisting them in getting dressed for breakfast.

Sepsis

Life-threatening infection that has spread throughout the body.

SKWIPE

An acronym to consider before providing cares to clients that stands for Supplies, Knock, Wash, Introduce, Privacy, and Explain.

Timed voiding

Encourages the patient to urinate on a set schedule.

Urge incontinence

A condition where as soon as the person feels the need to empty their bladder they have very little time before urine escapes.

Urinary catheter

A device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag.

Urinary tract infection (UTI)

A common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the bladder or kidneys.

Urostomy

A surgically placed opening to collect urine from a person’s ureters when their bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag.

Wet voice

Vocalization with sounds as if food or fluids remain in the mouth or throat.