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• C: Contain the fire by closing all doors and windows. • E: Extinguish the fire if it is small enough using a fire extinguisher and the PASS method. If the fire cannot be extinguished, then evacuate patients and oneself from the area. The PASS method includes the following actions: ◦ P: Pull the pin on the fire extinguisher. ◦ A: Aim the extinguisher nozzle at the base of the fire. ◦ S: Squeeze or press the handle. ◦ S: Sweep from side to side at the base of the flame until the fire appears to be out. Figure 3.3 RACE for Fire Safety View the UC San Diego Health’s YouTube video 15 on using RACE + PASS: RACE + PASS Training. 15. UCSD Visual Media Group. (2019, January 18). RACE + PASS training [Video]. YouTube. All rights reserved. https://youtu.be/pVHFdEivyNE 3.2 Emergency Situations | 111

Choking and Airway Clearance Choking is a common cause of unintentional injury and death. Over half of the people who die from choking are over the age of 70. 16 Food is often responsible for choking incidents in the elderly, especially those who have difficulty swallowing or have dentures. Many people who have dementia or who have had a previous stroke have difficulty swallowing. If you see any signs of choking, immediately notify the nurse and take action to clear the person’s airway. If you are in a setting without a nurse present, it is important for you to know what to do and how to rescue someone who is choking. If a person is continuing to cough forcefully, encourage continued coughing to clear the object. However, a person who can’t cough, speak, or breathe needs immediate help. Ask the person if they are choking and let them know you will use abdominal thrusts, known as the Heimlich maneuver, to help them clear their airway and breathe. (Keep in mind the Heimlich maneuver is not recommended for children younger than 1.) See Figure 3.4 17 for an image of the Heimlich maneuver. Figure 3.4 Heimlich Maneuver 16. National Safety Council. (n.d.). Choking prevention and rescue tips. https://www.nsc.org/home-safety/safety-topics/ choking-suffocation 17. “Heimlich_Adult_%26_Child.png” by BruceBlaus is licensed under CC BY-SA 4.0 112 | 3.2 Emergency Situations

To perform the Heimlich maneuver, perform the following steps 18 : • Stand behind the victim with one leg forward between the victim’s legs. If the person is sitting in a wheelchair or not able to stand, lean them forward in the chair and stand behind them. • For a child, move down to their level and keep your head to one side. • Reach around the abdomen and locate the navel. • Place the thumb side of your fist against the abdomen just above the navel. • Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks. • 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. • Continue thrusts until the victim expels the object or becomes unresponsive. • If the person becomes unconscious, perform standard cardiopulmonary resuscitation (CPR) with chest compressions and rescue breaths. • After choking stops, seek medical attention for the client. View the “Skills Checklist: Choking Maneuver” with an associated video of performing the Heimlich maneuver. 18. National Safety Council. (n.d.). Choking prevention and rescue tips. https://www.nsc.org/home-safety/safety-topics/ choking-suffocation 3.2 Emergency Situations | 113

3.3 Resident Environment When an individual moves into a nursing home, it can be a complicated, stressful, and sometimes confusing time for them and their loved ones. Because nurse aides spend more time with residents than any other staff member, your actions are critical to help ease their worries associated with a change in their environment. Reflective Activity Reflect about a time when you moved, changed schools, started a new job, or went to a new place on your own. What things made you feel more comfortable during those transitions? Applying how you felt during those experiences can help you empathize with and provide peace of mind for anyone experiencing a transition. In addition to experiencing a new environment, newly admitted residents have also typically had a recent major change in cognitive or physical functioning. They are adjusting to not only a new environment but also to how they feel, think, and move. Actions that were previously taken for granted, such as walking, eating, and performing self-care, now require assistance from others. Review the activity in the Chapter 1 subsection “Managing Clients’ and Family Members’ Stress” to increase your awareness of factors that may affect a resident’s outlook and the ways you can improve their quality of life. As a nurse aide, you can be a major factor in promoting better outcomes for residents by making observations related to their nutritional intake, physical activity, and psychosocial well-being and communicating these observations to the nurse. The Fulmer SPICES tool is a good framework for promoting health in the older adult population. SPICES is an acronym that stands for observing the following aspects that can affect well-being for older adults: 3.3 Resident Environment | 115

Sleep, Problems eating, Incontinence, Confusion, Evidence of falls, and Skin Breakdown 1 : • Sleep: Older adults need 7-9 hours of sleep per day. To promote good sleep, control environmental factors such as noise, lighting, and temperature. Report sleep disturbances such as excessive snoring or gasping for air or if the resident states they don’t feel rested on awakening. 2 • Problems Eating: Report issues with chewing and swallowing during meals, as well as residents’ food preferences. Insufficient nutritional intake can lead to skin breakdown issues, infection, and an overall decline in function. More information about eating problems can be found in Chapter 5. • Incontinence: Incontinence is a lack of voluntary control over urination or defecation. Offer toileting to your residents at least every two hours and on their request. Check incontinence products at least every two hours, especially for those residents with communication problems. More information about incontinence can be found in Chapter 5. • Confusion: Report any new onset of confusion because it can be a sign of infection. An example of a resident with new confusion would be not knowing the day of the week or where they are when normally they are aware and oriented. • Evidence of Falls: Report any new weakness or difficulty in transferring from bed to wheelchair or a change in the ability to walk. Read more about fall prevention in the “Emergency Situations” section of this chapter and in Chapter 9. • Skin Breakdown: Damage to the skin is called skin breakdown. Common preventable causes of skin breakdown are immobility and incontinence. For residents who are unable to independently move, reposition them at least every two hours. For residents with incontinence, provide proper 1. Aronow, H. U., Borenstein, J., Haus, F., Braunstein, G. D., & Bolton, L. B. (2014). Validating SPICES as a screening tool for frailty risks among hospitalized older adults. Nursing Research and Practice, 2014, 846759. https://doi.org/10.1155/2014/ 846759 2. Centers for Disease Control and Prevention. (2017, March 2). How much sleep do I need? https://www.cdc.gov/sleep/ about_sleep/how_much_sleep.html 116 | 3.3 Resident Environment

hygiene to keep their skin clean and dry. More information about skin breakdown can be found in Chapter 5. Transitioning to a New Environment Transitioning to a nursing home environment involves an abrupt change to an individual’s living environment in terms of privacy, size, and personal belongings. See an image of a typical shared room in a nursing home in Figure 3.5. 3 In addition to this change in environment, residents often cannot follow their typical schedule they had at home, although accommodations should be made to meet their preferences as much as possible. Figure 3.5 Typical Resident Environment in a Nursing Home Nurse aids help residents transition to a new environment. When a new admission is expected, a staff member should be at the entry area to greet the individual and their loved ones. The room should be prepared before arrival, which includes sanitization procedures and making the bed. Read more about how to make a hospital bed in the “Skills Checklist” section of this chapter. Actions to help residents transition to their new environment include the following: 3. “residentroom.jpg” by unknown for Stratford Manor. Image used under Fair Use. Access for free at https://stratfordrehab.com/ 3.3 Resident Environment | 117

• Introduce the resident to the staff and identify who is responsible for which resident care needs, such as CNAs, dietary aides, activities personnel, nurses, etc. • Provide a tour of the facility. • Show the resident where they can find the daily schedule of events and activities. • Assist the resident in organizing their belongings and arranging their room to fit their needs and preferences. • Introduce their roommate if they are sharing a room. • If possible, arrange to have a resident mentor. A resident mentor is another resident who can answer questions and encourage interaction. Every facility has their own admission procedures, but a common requirement is the completion of a written inventory of the resident’s belongings. This inventory is typically done by the nurse aide depending upon the care setting. See an example of a Resident Personal Belongings Inventory used in an adult family home in Figure 3.6. 4 4. “Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)” by Washington State Department of Social and Health Services is in the Public Domain. Access for free at https://www.dshs.wa.gov/officeof-the-secretary/forms 118 | 3.3 Resident Environment

3.4 Body Mechanics and Safe Equipment Use In addition to promoting safety for patients and their families, it is important for health care workers to be aware of safety risks in the environment and to take measures to protect themselves. Common safety risks to health care workers include sharps injuries, exposure to blood-borne pathogens, lack of personal protective equipment, and lifting injuries. A sharps injury is a penetrating wound from a needle, scalpel, or other sharp object that may result in exposure to blood-borne pathogens. Blood-borne pathogens are pathogenic microorganisms present in blood and body fluids that can cause disease such as hepatitis B (HBV) and human immunodeficiency virus (HIV). Personal protective equipment (PPE) is used to prevent transmission of blood-borne pathogens and infection and includes gloves, masks, goggles, gowns, and other types of protective equipment. This section will focus on lifting injuries related to moving clients, and the other safety risks will be discussed in Chapter 4. The health and well-being of nurse aides is directly related to the quality of care residents receive. When a health care worker is injured, they may be unable to provide care to the extent required by residents. With this in mind, it is vital for nursing assistants to know how to prevent injury in the workplace. An article published in the 2018 International Journal of Environmental Research and Public Health noted that 88% of nurse aides reported at least one of their body parts having a work-related musculoskeletal symptoms (WRMS). 1 The lower back was the most commonly affected WRMS area, followed by the arms and shoulders. According to this study, nursing assistants ranked first for occupational-related back sprains and strains, above construction workers, garbage collectors, and other health care workers. WRMS reported by nurse aides account for over 50% of all musculoskeletal injuries reported in the United States. These injuries are attributed to manual 1. Cheung, K., Szeto, G., Lai, G., & Ching, S. (2018). Prevalence of and factors associated with work-related musculoskeletal symptoms in nursing assistants working in nursing homes. International Journal of Environmental Research and Public Health, 15(2), 265. https://doi.org/10.3390/ijerph15020265 120 | 3.4 Body Mechanics and Safe Equipment Use

handling of clients, lifting heavy physical loads, assuming frequent awkward positions, and performing repetitive movements. 2 Using gait belts and mechanical lifts for transferring residents from one location to another, such as from the bed to a wheelchair or a wheelchair to the toilet, has greatly reduced the risk of lifting injuries to both residents and aides. These transferring techniques will be discussed in Chapter 8. Lifting injuries can also occur when repositioning residents while they are in bed. Repositioning is frequently performed for residents to provide hygiene, alleviate pain, or prevent skin breakdown. The ABC mnemonic for using proper body mechanics when transferring or repositioning residents stands for Alignment, Base of support, and Center of gravity 3 : • Alignment: Correct body alignment is also referred to as good posture. When standing up straight, an imaginary line should be able to be drawn straight down through the center of the body so that both sides of the body are mirror images of each other. Body parts should be lined up naturally, with arms at one’s side, palms directed forward, and feet pointed forward and slightly apart. Follow these guidelines to use proper alignment to prevent lifting injuries: ◦ Maintain correct body alignment when lifting or carrying an object. ◦ Keep the object close to your body, unless close proximity could transmit pathogens. ◦ Point your feet and body in the direction you are moving. ◦ Do not twist at the waist. • Base of support: Creating a good base of support improves your balance, whereas imbalance creates awkward positioning that can lead to injury. To create a strong base of support, place your feet about shoulder width apart or just slightly wider than your hips. 2. Cheung, K., Szeto, G., Lai, G., & Ching, S. (2018). Prevalence of and factors associated with work-related musculoskeletal symptoms in nursing assistants working in nursing homes. International Journal of Environmental Research and Public Health, 15(2), 265. https://doi.org/10.3390/ijerph15020265 3. North Carolina Department of Health and Human Services. (2019). State-approved curriculum: Nurse aide I Training program. https://info.ncdhhs.gov/dhsr/hcpr/curriculum/pdf/moduleI.pdf 3.4 Body Mechanics and Safe Equipment Use | 121

• Center of gravity: A person’s center of gravity is where most of one’s weight is concentrated. When standing, the pelvis is the center of gravity. Maintaining a low center of gravity provides a stable base of support and improves balance. For example, when lifting objects or people, keep your center of gravity low with a good base of support by bending at the knees with the feet shoulder width apart. Keep in mind that your center of gravity also includes the resident or the object, so keep them as close to your body as possible. To maintain good alignment, face the person or object you are moving and use both sides of your body equally. Figure 3.7 4 illustrates safer body mechanics in Option “C” by maintaining good alignment, establishing a base of support, and keeping the load close and near to one’s center of gravity while bending the knees. Figure 3.7 Center of Gravity Facilities have specialized equipment used to assist in lifting and transferring clients that significantly reduces the risk of lifting injuries. Manufacturers provide specific instructions for the safe use and maintenance of their equipment. Be certain that you receive extensive training on safely using this 4. “Centre_of_Gravity.png” by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-2-body-mechanics/ 122 | 3.4 Body Mechanics and Safe Equipment Use

equipment during your orientation to the facility. Orientation to lifting equipment should include becoming familiar with all parts of the device, the requirements for the mobility status of residents who will use that device, and potential risks to residents and caregivers while using the device. See Figure 3.8 5 for an image of lifting equipment. Figure 3.8 Lifting Equipment For additional information on OSHA regulations for using lifting equipment and preventing lifting injuries, refer to this document: Guidelines for Nursing Homes PDF. 5. “User-Integra-lifter1.jpg” by Integracp is licensed under CC BY-SA 3.0 3.4 Body Mechanics and Safe Equipment Use | 123

3.5 Skills Checklist: Making an Unoccupied Bed Checklist Bed making is a necessary skill for nursing assistants to keep the environment clean, prevent skin breakdown and the spread of infection, and respect the resident’s dignity by providing an orderly environment. Linens should be changed at least weekly or whenever they become soiled. Follow these infection control guidelines when making beds: • Never allow linens to touch your uniform. • Do not transfer linens from one room to another. • Do not place soiled linens on the floor. • If linens touch the floor, they should be placed in the soiled laundry for cleaning and not used. • Do not shake linens because it can spread airborne pathogens. • Store clean linens in a closed closet or a covered cart. Making an Unoccupied Bed Checklist 1. Gather Supplies: Linens 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: ◦ Place a clean barrier on a flat surface. Flip the linens over and place them on the barrier so the fitted sheet is on top. ◦ Don gloves. 124 | 3.5 Skills Checklist: Making an Unoccupied Bed Checklist

◦ Look for any personal belongings that may have been left in the bed and return them to their proper place. ◦ Untuck the corners and roll all linens together to the middle of the bed. ◦ Place soiled linens in a linen bag or other appropriate container according to facility policy. ◦ Remove gloves. ◦ Perform hand hygiene. ◦ If the bed is soiled, sanitize it or notify environmental services to sanitize it. ◦ After the bed has dried from sanitization, place the fitted sheet on the bed. Seams should be against the mattress and away from the resident. Smooth the sheet to prevent wrinkles that can cause injury to fragile skin. (Note: If a flat sheet is used as the bottom sheet, refer to sub-bullets below for details on making mitered corners.) ◦ Place the lift sheet where it is estimated the resident’s shoulders to hips will be when they are in bed. ◦ Place a soaker pad or other waterproof barrier on top of the lift sheet. ◦ Place the flat sheet on top and smooth it out. Make mitered corners at the foot of the bed by doing the following: ▪ Tuck the entire end of the sheet under the foot of the bed. ▪ While facing the foot of the bed, create a 45-degree angle from the corner of the bed with the sheet. ▪ Place the angled edge of the sheet on top of the bed and tuck in anything hanging below the bed frame. ▪ Lower the angled sheet back over the edge of the bed. ◦ Place a bedspread or blanket on top of the sheet per the resident’s preference. Make a mitered corner in the bedspread or blanket by performing the steps above. ◦ Lay a pillow on the bed and slide the pillowcase over the pillow. ◦ Put the pillow at the head of the bed with the open end of the pillowcase faced away from the door. Repeat for multiple pillows. 3.5 Skills Checklist: Making an Unoccupied Bed Checklist | 125

4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check on 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. ◦ Report abnormal findings to the nurse. View a YouTube video 1 of a nursing instructor demonstrating making an unoccupied bed: One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=230#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Making an Unoccupied Bed. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/K0c9fSd46JA 126 | 3.5 Skills Checklist: Making an Unoccupied Bed Checklist

3.6 Skills Checklist: Making an Occupied Bed Bed making is a necessary skill for nursing assistants to keep the environment clean, prevent skin breakdown and the spread of infection, and respect the resident’s dignity by providing an orderly environment. Linens should be changed at least weekly or whenever they become soiled. Follow these infection control guidelines when making beds: • Never allow linens to touch your uniform. • Do not transfer linens from one room to another. • Do not place soiled linens on the floor. • If clean linens touch the floor, they should be placed in the soiled laundry for cleaning and not used. • Do not shake linens because it can spread airborne pathogens. • Store clean linens in a closed closet or a covered cart. Making an Occupied Bed Checklist 1. Gather Supplies: Linens 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: ◦ Place a clean barrier on a flat surface, flip linens over, and place them on the barrier so the fitted sheet is on top. ◦ Don gloves. 3.6 Skills Checklist: Making an Occupied Bed | 127

◦ Look for any personal belongings that may have been left in the bed and return them to their proper place. ◦ Put the side rail up. ◦ Move to the opposite side of the bed. ◦ Using the lift sheet, roll the resident towards the side rail. ◦ Begin rolling soiled linens to the middle of the bed and under the resident. ◦ Remove gloves. ◦ Perform hand hygiene. ◦ Place a fitted sheet on the half of the bed you are working on. ◦ Place the lift sheet and soaker pad in the same manner, fan folding them under the resident. ◦ Raise the side rail. ◦ Move to the opposite side of the bed. ◦ Put on gloves. ◦ Lower side rail on working side of the bed. ◦ Roll the resident to the opposite side. ◦ Remove the soiled linens and place them in a linen bag. ◦ Remove gloves. ◦ Perform hand hygiene. ◦ Pull through the fitted sheet, lift sheet, and soaker pad, ensuring there are no wrinkles. ◦ Assist the resident to a supine position. ◦ Keeping the resident covered, place a new flat sheet on top of them. ◦ Make mitered corners at the foot of the bed by doing the following: ▪ Tuck the entire end of the sheet under the foot of the bed. ▪ Facing the foot of the bed, create a 45-degree angle from the corner of the bed with the sheet. ▪ Place the angled sheet on top of the bed and tuck in anything hanging below the bed frame. ▪ Lower the angled sheet over the edge of the bed. ◦ Put a clean pillowcase on a new pillow and exchange it for the soiled pillow. Put the pillow at the head of the bed with the open end of the 128 | 3.6 Skills Checklist: Making an Occupied Bed

pillowcase faced away from the door. Repeat for multiple pillows. ◦ Repeat steps for any blankets or bedspreads. ◦ Make a toe pleat (i.e., a pleat in the sheet which allows an individual to move feet) to prevent pressure. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check on 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. ◦ Report abnormal findings to the nurse. View a YouTube video 1 of a nursing instructor demonstrating making an occupied bed: One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=1920#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Making an Occupied Bed. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/AN9pvC499P4 3.6 Skills Checklist: Making an Occupied Bed | 129

3.7 Learning Activities An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=232#h5p-9 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=232#h5p-10 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=232#h5p-70 130 | 3.7 Learning Activities

III Glossary Ambulating: Walking. Angina: Sudden chest pain beneath the sternum (breastbone) associated with a heart attack (myocardial infarction), often radiating down the left arm in male patients. Assistive devices: Devices such as gait belts and walkers that are used when moving a patient. Blood-borne pathogens: Pathogenic microorganisms present in blood and body fluids that can cause disease such as hepatitis B (HBV) and human immunodeficiency virus (HIV). Cardiac arrhythmias: Irregularities in a person’s heart rate and/or rhythm. Cerebrovascular attack (CVA): The medical term for what is commonly referred to as a “stroke,” caused by a lack of blood flow and oxygen to the brain. FAST: An acronym used to remember the early signs of a stroke: Facial drooping, Arm weakness, Slurred speech, and Time (meaning the quicker the response, the better the outcome). Heimlich maneuver: A procedure used for someone who is choking that uses abdominal thrusts to clear the airway so they can breathe. Incontinence: A lack of voluntary control over urination or defecation. Myocardial infarction (MI): The medical term for what is commonly referred to as a “heart attack,” caused by a lack of blood flow and oxygen to the heart. Nonskid footwear: Shoes or socks with rubberized soles used to prevent falls. PASS: An acronym for using a fire extinguisher that stands for the following: • P: Pull the pin on the fire extinguisher. III Glossary | 131

• A: Aim the extinguisher nozzle at the base of the fire. • S: Squeeze or press the handle. • S: Sweep from side to side at the base of the flame until the fire appears to be out. Personal protective equipment (PPE): Equipment used to prevent transmission of blood-borne pathogens and infection, including gloves, masks, goggles, gowns, and other types of protective equipment. RACE: An acronym for responding to a fire that stands for the following: • R: Rescue anyone in immediate danger from the fire if it doesn’t endanger your life. • A: Activate the alarm by pulling the nearest fire alarm or calling 911. • C: Contain the fire by closing all doors and windows. • E: Extinguish the fire if it is small enough using a fire extinguisher and the PASS method. Evacuate patients and oneself if the fire cannot be extinguished. Resident mentor: A resident who can answer questions and encourage interaction for a new resident recently admitted to a long-term care facility. Seizure: A transient occurrence of signs and/or symptoms due to abnormal neuronal activity in the brain. Sharps injury: A penetrating wound from a needle, scalpel, or other sharp object that may result in exposure to blood-borne pathogens. Shortness of breath (SOB): Difficulty breathing or a feeling of not being able to catch one’s breath. Skin breakdown: Damage to the skin due to common preventable causes like immobility and incontinence. SPICES: An acronym that stands for observing the following aspects of wellbeing for older adults: Sleep, Problems eating, Incontinence, Confusion, Evidence of falls, and Skin breakdown. 132 | III Glossary

Thrombolytic medication: Medication (such as tPA) used to dissolve clots in arteries. Transient ischemic attack (TIA): A medical term for what is commonly referred to as a ministroke. A TIA is a temporary period of symptoms similar to those of a stroke that usually last only a few minutes and don’t cause permanent brain damage. Work-related musculoskeletal symptoms (WRMS): Symptoms from musculoskeletal injuries experienced at work, such as lower back pain, that are attributed to manual handling of clients, heavy physical loads, frequent awkward positions, and repetitive movements. III Glossary | 133

4.1 Introduction to Adhere to Principles of Infection Control Learning Objectives • Discuss principles of medical asepsis for client and personal safety • Describe methods to prevent blood-borne pathogen transmission • Apply principles of standard and transmission-based precautions and infection prevention Infection control, also called infection prevention, prevents or stops the spread of infections in health care settings. 1 Facilities hire licensed health professionals who are in charge of infection prevention, but everyone is responsible for reducing the spread of infection. This chapter will discuss the manner in which infections spread, common signs and symptoms of infection, and infection control basics, including methods to protect you and those you care for from infection. 1. Centers for Disease Control and Prevention. (2020, April 29). Infection control. https://www.cdc.gov/infectioncontrol/ index.html 4.1 Introduction to Adhere to Principles of Infection Control | 137

4.2 Chain of Infection The chain of infection, also referred to as the chain of transmission, describes how an infection spreads based on these six links of transmission: • Infectious Agent • Reservoirs • Portal of Exit • Modes of Transmission • Portal of Entry • Susceptible Host See Figure 4.1 1 for an illustration of the chain of infection. If any “link” in the chain of infection is removed or neutralized, transmission of infection will not occur. Health care workers must understand how an infectious agent spreads via the chain of transmission so they can break the chain and prevent the transmission of infectious disease. Routine hygienic practices, standard precautions, and transmission-based precautions are used to break the chain of transmission. 1. “Chain-of-Transmission” by unknown author is licensed under CC BY-NC 4.0. Access for free at https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/40/ 138 | 4.2 Chain of Infection

Figure 4.1 Chain of Infection The links in the chain of infection include Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, and Susceptible Host 2 : • Infectious Agent: Microorganisms, such as bacteria, viruses, fungi, or parasites, that can cause infectious disease. • Reservoir: The host in which infectious agents live, grow, and multiply. Humans, animals, and the environment can be reservoirs. Examples of reservoirs are a person with a common cold, a dog with rabies, or standing water with bacteria. Sometimes a person may carry an infectious agent but is not symptomatic or ill. This is referred to as being colonized, and the person is referred to as a carrier. For example, many health care workers carry methicillin-resistant Staphylococcus aureus (MRSA) bacteria in their noses but are not symptomatic. • Portal of Exit: The route by which an infectious agent escapes or leaves the reservoir. In humans, the portal of exit is typically a mucous membrane or other opening in the skin. For example, pathogens that 2. Department of Health. (n.d.). Chain of infection in infection prevention and control (IPAC). The Government of Nunavut. https://www.gov.nu.ca/health/information/infection-prevention-and-control 4.2 Chain of Infection | 139

cause respiratory diseases usually escape through a person’s nose or mouth. • Mode of Transmission: The way in which an infectious agent travels to other people and places because they cannot travel on their own. Modes of transmission include contact, droplet, or airborne transmission. For example, touching sheets with drainage from one person’s infected wound and then touching another person without washing one’s hands is an example of contact transmission of an infectious agent. Examples of droplet or airborne transmission are coughing and sneezing, depending on the size of the microorganism. • Portal of Entry: The route by which an infectious agent enters a new host (i.e., the reverse of the portal of exit). For example, mucous membranes, skin breakdown, and artificial openings in the skin created for the insertion of medical equipment (such as intravenous lines) are at high risk for infection because they provide an open path for microorganisms to enter the body. Tubes inserted into mucous membranes, such as a urinary catheter, also facilitate the entrance of microorganisms into the body. A person’s immune system fights against infectious organisms that have entered the body through the use of nonspecific and specific defenses. Read more about defenses against microorganisms in the “Defenses Against Transmission of Infection” section of this chapter. • Susceptible Host: A person at elevated risk for developing an infection when exposed to an infectious agent due to changes in their immune system defenses. For example, infants (up to 2 years old) and older adults (aged 65 or older) are at higher risk for developing infections due to underdeveloped or weakened immune systems. Additionally, anyone with chronic medical conditions (such as diabetes) are also at higher risk of developing an infection. In health care settings, almost every patient is considered a “susceptible host” because of preexisting illnesses, medical treatments, medical devices, or medications that increase their vulnerability to developing an infection when exposed to infectious agents in the health care environment. As caregivers, it is the NA’s responsibility to protect susceptible patients by breaking the chain of infection. 140 | 4.2 Chain of Infection

After a susceptible host becomes infected, they become a reservoir that can then transmit the infectious agent to another person. If an individual’s immune system successfully fights off the infectious agent, they may not develop an infection, but instead the person may become an asymptomatic “carrier” who can spread the infectious agent to another susceptible host. For example, individuals exposed to COVID-19 may not develop an active respiratory infection but can spread the virus to other susceptible hosts via sneezing. Learn more about the chain of infection by clicking on the following activities. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-29 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-30 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. 4.2 Chain of Infection | 141

An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-31 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-32 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-33 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. 142 | 4.2 Chain of Infection

An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-36 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. PUNot TTING IT ALL T e OGETHER : To enlarge the print, you can expand the activity by clicking the arrows in the right upper corner of the text box. Please drag and drop the descriptors and actions into the appropriate boxes to demonstrate the various steps in the chain of infection. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-16 This H5P activity is a derivative of original activities by Michelle Hugues and licensed under CC BY-NC 4.0 unless otherwise noted. Healthcare-Acquired Infections An infection that develops in an individual after being admitted to a health care facility or undergoing a medical procedure is a healthcare-associated infection (HAI), formerly referred to as a nosocomial infection. About 1 in 31 hospital patients develops at least one healthcare-associated infection every 4.2 Chain of Infection | 143

day. HAIs increase the cost of care and delay recovery. They are associated with permanent disability, loss of wages, and even death. An example of an HAI is a skin infection that develops in a patient’s incision after they had surgery due to improper hand hygiene of health care workers. 3 , 4 It is important to understand the dangers of Healthcare-Acquired Infections and actions that can be taken to prevent them. Read more details about healthcare-acquired infections in the “Infection” chapter of Open RN Nursing Fundamentals. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=351#h5p-42 Healthcare-Associated Infections by Michelle Hughes is licensed under CC BY 4.0. 3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 4. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health & Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html 144 | 4.2 Chain of Infection

4.3 Defenses Against Transmission of Infection The body tries to protect itself from infectious agents by using specific and nonspecific defenses. Specific defenses are immune system processes that include white blood cells attacking particular pathogens. Nonspecific defenses are generic barriers that prevent pathogens from entering the body, including physical, mechanical, or chemical barriers. Physical Defenses Physical defenses are the body’s most basic form of defenses against infection. Physical defenses include barriers such as skin and mucous membranes, as well as mechanical defenses, that physically remove microbes from areas of the body. 1 SKIN One of the body’s most important physical barriers is the skin barrier that is composed of three layers of closely packed cells. See Figure 4.2 2 for an illustration of layers of the skin. The topmost layer of skin, called the epidermis, consists of cells that are packed with keratin. Keratin makes the skin’s surface mechanically tough and resists degradation by bacteria. When the skin barrier becomes broken, such as becoming cracked from dryness, microorganisms can enter and cause infection. 3 1. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 2. “OSC_Microbio_17_02_Skin.jpg” by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax.org/ books/microbiology/pages/17-1-physical-defenses 3. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 4.3 Defenses Against Transmission of Infection | 145

Figure 4.2 Skin Layers MUCOUS MEMBRANES Mucous membranes lining the nose, mouth, lungs, and urinary and digestive tracts provide another nonspecific barrier against pathogens. Mucous is a moist, sticky substance that covers and protects the layers beneath it and also traps debris, including microbes. Mucus secretions also contain antimicrobial agents. 4 In many regions of the body, mechanical actions flush mucus (along with trapped microbes) out of the body or away from potential sites of infection. For example, in the respiratory system, inhalation can bring microbes, dust, mold spores, and other small airborne debris into the body. This debris becomes trapped in the mucus lining the respiratory tract. The cells lining the upper parts of the respiratory tract have hair-like appendages known as cilia. Movement of the cilia propels debris-laden mucus out and away from the lungs. The expelled mucus is then swallowed (and destroyed in the stomach) or coughed out. However, smoking limits the efficiency of this system, making smokers more susceptible to developing respiratory infections. Additionally, as people age, their chest muscles weaken, and coughing 4. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 146 | 4.3 Defenses Against Transmission of Infection

becomes less productive, which also increases the risk of developing a respiratory infection. Mechanical Defenses In addition to physical barriers, the body has several mechanical defenses that physically remove pathogens from the body and prevent infection. For example, the flushing action of urine carries microbes away from the body and is responsible for maintaining a sterile environment of the urinary tract. The eyes have additional physical barriers and mechanical mechanisms for preventing infections. Eyelashes and eyelids are physical barriers that prevent dust and airborne microorganisms from reaching the surface of the eye. Any microbes or debris that make it past these physical barriers are flushed out by the mechanical action of blinking. Blinking bathes the eye in tears and washes debris away. 5 See Figure 4.3 6 for an example of eyelashes as a mechanical defense. Figure 4.3 Eyelashes Are a Mechanical Defense Against Pathogens Chemical Defenses In addition to physical and mechanical defenses, our immune system uses 5. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 6. “Eyelashes_of_a_2-month-old_baby_boy.png” by Karthik.yerramilly is licensed under CC BY-SA 4.0 4.3 Defenses Against Transmission of Infection | 147

several chemical defenses that inhibit microbial invaders. The term chemical mediators refers to a wide array of substances found in various fluids and tissues throughout the body. For example, sebaceous glands in the dermis secrete an oil called sebum that is released onto the skin surface through hair follicles. Sebum provides an additional layer of defense by helping seal off the pore of the hair follicle and preventing bacteria on the skin’s surface from invading sweat glands and surrounding tissue. However, environmental factors can affect these chemical defenses of the skin. For example, low humidity in the winter dries the skin and makes it more susceptible to pathogens that are normally inhibited by the skin’s low pH. Application of skin moisturizer restores moisture and essential oils to the skin and helps prevent dry skin from becoming infected. 7 Other types of chemical defenses are pH levels, chemical mediators, and enzymes. For example, in the urinary tract, the slight acidity of urine inhibits the growth of potential pathogens in the urinary tract. The respiratory tract has various chemical mediators in the nasal passages, trachea, and lungs that have antibacterial properties. Enzymes in the digestive tract eliminate most microorganisms that survive the acidic environment of the stomach. However, feces, the end product of the digestive system, can still contain some microorganisms. For this reason, hand hygiene is vital after using the restroom or assisting a client with perineal care to prevent the spread of infection. 8 7. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 148 | 4.3 Defenses Against Transmission of Infection

4.4 Precautions Used to Prevent the Spread of Infection Health care agencies use several methods to prevent the spread of infection: standard precautions and transmission-based precautions. Standard Precautions Standard precautions are used by health care workers during client care when contact or potential contact with blood or body fluids may occur. Standard precautions should also be used when assisting a client with activities of daily living (ADLs) and using water, soap, or lotion. Standard precautions are based on the principle that all blood, body fluids (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. These precautions reduce the risk of exposure for the health care worker and protect patients from potential transmission of infectious organisms. 1 According to the Centers for Disease Control and Prevention (CDC), standard precautions include the following 2 : • Using proper hand hygiene at the appropriate times • Using personal protective equipment (e.g., gloves, gowns, masks, eyewear) whenever exposure to infectious agents may occur • Implementing respiratory hygiene for staff, patients, and visitors • Proper cleaning and sanitizing of the environment, equipment, and devices • Handling laundry safely • Using transmission-based precautions when indicated 1. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 2. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 4.4 Precautions Used to Prevent the Spread of Infection | 149

Hand Hygiene The easiest and most effective way to break the chain of infection is by using proper hand hygiene at appropriate times during patient care. Knowing when to wash your hands, how to properly wash your hands, and when to use soap and water or hand sanitizer are vital for reducing the spread of infection and keeping yourself healthy. Hand hygiene is the process of removing, killing, or destroying microorganisms or visible contaminants from the hands. There are two hand-hygiene techniques: handwashing with soap and water and the use of alcohol-based hand rub (ABHR), also referred to as hand hygiene gel or hand sanitizer. 3 Health care providers’ hands are the most common mode of transmission of microorganisms. As a nursing assistant, your hands will touch many people and objects when providing care. When you touch a client, their personal items, medical equipment, or their surrounding environment, you can indirectly transmit microorganisms to the client, another client, yourself, equipment, or a new environment. Microorganisms can easily be transferred from your hands to others or objects in the health care setting if proper hand hygiene practices are not followed. Consistent and effective hand hygiene is vital for breaking the chain of transmission. 4 It is essential for all health care workers to use proper hand hygiene during specific moments of patient care 5 : • Immediately before touching a patient • Before performing an aseptic task, such as emptying urine from a Foley catheter bag • Before moving from a soiled body site to a clean body site • After touching a patient or their immediate environment 3. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 4. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 5. Centers for Disease Control and Prevention. (2019, April 29). Hand hygiene in healthcare settings. https://www.cdc.gov/handhygiene/ 150 | 4.4 Precautions Used to Prevent the Spread of Infection

• After contact with blood, body fluids, or contaminated surfaces (with or without gloves) • Immediately after glove removal See Figure 4.4 6 for an illustration of the five moments of hand hygiene. Figure 4.4 Moments of Hand Hygiene Hand hygiene also includes health care workers keeping their nails short with tips less than 0.5 inches and no nail polish. Nails should be natural, and artificial nails or tips should not be worn. Artificial nails and chipped nail polish have been associated with a higher level of pathogens carried on the hands of health care workers despite using proper hand hygiene. 7 Review the Moments of Hand Hygiene by clicking on the interactive activity below. 6. “5Moments_Image.gif” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ 7. Blackburn, L., Acree, K., Bartley, J., DiGiannantoni, E., Renner, E., & Sinnott, L. T. (2020). Microbial growth on the nails of direct patient care nurses wearing nail polish. Oncology Nursing Forum, 47(2), 155-164. https://doi.org/10.1188/ 20.onf.155-164 4.4 Precautions Used to Prevent the Spread of Infection | 151

An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=380#h5p-37 This work is a derivative of Your 4 Moments for Hand Hygiene by Michelle Hughes and is licensed under CC BY 4.0. Proper hand hygiene includes handwashing with soap and water or the use of alcohol-based hand rub. Both procedures are described in the following sections. HANDWASHING WITH SOAP AND WATER Handwashing involves the use of soap and water to physically remove microorganisms from one’s hands. Certain health care situations require handwashing with soap and water instead of using alcohol-based hand rub (ABHR). For example, hands must be washed with soap and water if they are visibly soiled, have been exposed to blood or body fluids, or have been exposed to norovirus, C. difficile, or Bacillus anthracis. The mechanical action of lathering and scrubbing with soap for a minimum of 20 seconds is vital for removing these types of microorganisms. 8 Soap is required during handwashing to dissolve fatty materials and facilitate their subsequent flushing and rinsing with water. Soap must be rubbed on all surfaces of both hands followed by thorough rinsing and drying. Water alone is not suitable for cleaning soiled hands. The entire procedure should last 40 to 60 seconds, and soap approved by the health agency should be used. 9 8. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 9. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 152 | 4.4 Precautions Used to Prevent the Spread of Infection

When washing with soap and water, the Centers for Disease Control and Prevention (CDC) recommends the following steps 10 : • Wet hands with warm or cold running water and apply facility-approved soap. • Lather hands by rubbing them together with the soap. Use the same technique as the hand rub process to clean the palms and fingers, between the fingers, the backs of the hands and fingers, the fingertips, and the thumbs. • Scrub thoroughly for at least 20 seconds. • Rinse hands well under clean, running water. • Dry the hands, using a clean towel or disposable toweling, from fingers to wrists. • Use a clean paper towel to shut off the faucet. See Figure 4.5 11 for an illustration of handwashing with soap and water. 10. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 11. “How_To_HandWash_Poster.pdf” by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO. Access for free at https://www.who.int/infection-prevention/campaigns/clean-hands/5moments/en/ 4.4 Precautions Used to Prevent the Spread of Infection | 153

Figure 4.5 How to Handwash with Soap and Water See the “Skills Checklist: Hand Hygiene With Soap and Water” section later in this chapter for a checklist of steps and an associated demonstration video of this procedure. Common safety considerations and errors when washing hands are described in the following box. Safety Considerations 12 • Always wash hands with soap and water if hands are visibly soiled. • When working with clients where C. difficile, norovirus, or Bacillus anthracis is suspected or confirmed, soap and water must be used. It is more effective in physically removing the C. difficile spores compared to ABHR, which is not as effective at penetrating the spores. • Friction and rubbing are required to remove transient bacteria, oil, and debris from hands. • Always use soap and water if hands are exposed to blood, body fluids, or other body substances. • Multistep rubbing techniques using soap and water are required to promote coverage of all surfaces on hands. Common Errors When Washing Hands With Soap and Water 13 • Not using enough soap to cover all surfaces of the hands and wrists. • Not using friction when washing hands. • Not washing hands long enough. The mechanical action of 12. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 13. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 4.4 Precautions Used to Prevent the Spread of Infection | 155

lathering and scrubbing should be a minimum of 20 seconds, and the entire procedure should last 40 to 60 seconds. • Missing areas such as the fingernails, wrists, backs of hands, and thumbs. • Not removing all soap from hands and wrists. • Shaking water off hands. • Not thoroughly drying the hands. • Drying hands from wrists to fingers or in both directions. Practice your knowledge by clicking on this interactive learning activity. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=380#h5p-38 This work is a derivative of the YouTube Hand Washing Video by Michelle Hughes and is licensed under CC BY-NC 4.0. ALCOHOL-BASED HAND RUB When performing hand hygiene using the alcohol-based hand rub (ABHR) technique, a liquid, gel, or foam alcohol-based solution is used. ABHR is the preferred method for hand hygiene when soap and water handwashing is not required. It reduces the number of transient microorganisms on hands and is more effective for preventing healthcare-acquired infections (HAIs) caused by 156 | 4.4 Precautions Used to Prevent the Spread of Infection

Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycinresistant enterococcus (VRE). Hand hygiene with ABHR should be performed in front of the client prior to the beginning of care and at the end of the interaction. ABHR provided by the agency should be used with a 70–90% alcohol concentration. 14 The benefits of ABHR include the following 15 : • It kills the majority of microorganisms (including viruses) from hands. • It requires less time than soap and water handwashing. • It provides better skin tolerability and reduces skin irritation because it contains emollients. • It is easy to use and available at the point of care (i.e., where three elements of the client, the health care provider, and care involving the client occur together). Read safety considerations and common errors when using ABHR in the following box. See the “Skills Checklist: Hand Hygiene With Alcohol-Based Hand Sanitizer” section later in this chapter for a checklist of steps and an associated demonstration video of this procedure. Safety Considerations 16 • Do not use ABHR in combination with soap and water because it may increase skin irritation. • Use ABHR that contains emollients (oils) to help reduce skin irritation and overdrying. 14. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 15. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 16. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 4.4 Precautions Used to Prevent the Spread of Infection | 157

• Allow hands to dry completely before initiating tasks (e.g., touching the client or the environment or applying clean gloves). • Use ABHR for all moments of hand hygiene if soap and water are not required. • DO NOT use ABHR if hands are visibly soiled, have been exposed to blood or body fluids, or the client is suspected to have C. difficile, norovirus, or Bacillus anthracis. • Only use ABHR supplied by the facility. Common Errors When Performing an ABHR 17 • Not letting hands air dry (for example, rubbing one’s hands on pants to dry it off). • Shaking hands to dry. • Applying too much alcohol-based solution. • Not applying enough alcohol-based solution. • Not rubbing hands long enough (a minimum of 20 seconds) and until hands are dry. • Missing areas such as the fingernails, wrists, backs of the hands, and thumbs. Practice your knowledge by clicking on this interactive learning activity. 17. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 158 | 4.4 Precautions Used to Prevent the Spread of Infection

An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=380#h5p-20 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=380#h5p-21 This work is a derivative of Performing an Alcohol-Based Hand Rub by Michelle Hughes and is licensed under CC BY-NC 4.0. Respiratory Hygiene and Other Hygienic Practices Respiratory hygiene should be used by any person with signs of illness, including cough, congestion, or increased production of respiratory secretions to prevent the spread of infection. Respiratory hygiene refers to coughing or sneezing into the inside of one’s elbow or covering one’s mouth/ nose with a tissue when coughing and promptly disposing of used tissues. Hand hygiene should be immediately performed after contact with one’s respiratory secretions. A coughing person should also wear a surgical mask to contain secretions. 18 Additional hygiene measures are also used to prevent the spread of infection. For example, regularly changing bed linens, towels, and hospital gowns 18. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 4.4 Precautions Used to Prevent the Spread of Infection | 159

eliminates potential reservoirs of bacteria. Gripper socks should be removed before patients get into bed to prevent pathogens from the floor from being transferred to the patient’s bed linens. Mobile devices should be cleaned regularly. Research has shown that cell phones and mobile devices carry many pathogens and are dirtier than a toilet seat or the bottom of a shoe. Patients, staff, and visitors routinely bring mobile devices into health care facilities that can cause the spread of infection. Mobile devices should be frequently wiped with disinfectant. Disinfection and Sterilization Disinfection and sterilization are procedures used to remove harmful pathogens from equipment and the environment to decrease the risk of spreading infection. Disinfection is the removal of microorganisms, but it does not destroy all spores and viruses. Sterilization destroys all pathogens on equipment or in the environment, including spores and viruses, and includes methods such as steam, boiling water, dry heat, radiation, and chemicals. Because of the harshness of sterilization methods, skin can only be disinfected and not sterilized. 19 Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the absence of all microorganisms during any type of invasive procedure, such as during surgery or heart catheterizations. Sterilization is performed on equipment used during invasive procedures. As a nursing assistant, you may assist a registered nurse during a procedure requiring sterile technique; however, performing sterile procedures independently is not in the scope of practice for nursing assistants. In long-term care and other health care settings other than surgery, medical asepsis is used. Medical asepsis refers to techniques used to prevent the transfer of microorganisms from one person or object to another but do not 19. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 160 | 4.4 Precautions Used to Prevent the Spread of Infection

eliminate all microorganisms. Nursing assistants implement medical asepsis in the following ways: • Performing hand hygiene at the appropriate moments of patient care. (See previous Figure 4.4.) • Using a barrier when placing clean linens, wash basins, and other items on a shared surface such as the countertop in a resident’s room. • Pulling the privacy curtain when one resident has a droplet-transmitted infection to protect transmission to the other resident in a shared room. • Cleaning equipment (such as blood pressure cuffs) between use on residents. • Starting with “cleaner” areas of the body when assisting with care and then moving to areas with higher levels of microorganisms. For example, when bathing a client, the face is washed first, followed by the upper body and then finishing with perineal care. (Perineal care involves washing the genital and rectal areas of the body.) Laundry When handling dirty linens, textiles, and patients’ clothing, follow agency policy regarding transport to prevent the potential spread of infection. The Centers for Disease Control and Prevention (CDC) states that contaminated textiles and fabrics should be handled with minimal agitation to avoid contamination of air, surfaces, and other individuals. They should be bagged at the point of use, and leak-resistant bags should be used for textiles and fabrics contaminated with blood or body substances. 20 Transmission-Based Precautions When providing care for individuals with known or suspected infections, additional precautions are used in addition to the previously discussed standard precautions. Certain types of pathogens and communicable 20. Centers for Disease Control and Prevention. (2020, April 29). Infection control. https://www.cdc.gov/infectioncontrol/ index.html 4.4 Precautions Used to Prevent the Spread of Infection | 161

diseases are easily transmitted to others and require additional precautions to interrupt the spread of infectious agents to health care workers and other clients. For example, Coronavirus disease (COVID-19), C. difficile (C-diff), Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), Respiratory Syncytial Virus (RSV), measles, and tuberculosis (TB) require transmission-based precautions. Transmission-based precautions (commonly referred to as isolation precautions) use specific types of personal protective equipment (PPE) and practices based on the pathogen’s mode of transmission. It is vital for nursing assistants to understand what PPE should be used in specific client care situations, which is determined by the pathogen’s mode of transmission and their possible risk of exposure. 21 Transmission-based precautions include three categories: contact, droplet, and airborne precautions. Read more about each type of transmission-based precaution in Table 4.1. Table 4.1 Categories of Transmission-Based Precautions 22 , 23 , 24 21. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 22. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health & Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html 23. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 24. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/ index.html 162 | 4.4 Precautions Used to Prevent the Spread of Infection

Transmission-Based Precaution PPE Required Special Considerations Contact Gloves and gown, possibly face shield Used for clients with known or suspected infections such as C-difficile (C-diff), methicillin-resistant staphylococcus aureus (MRSA), vancomycin resistant enterococcus (VRE), or norovirus transmitted by touch (e.g., drainage from wounds or fecal incontinence). Contact precautions should be used when there is expected contact with the source of the pathogen or any surfaces within the resident’s room. For example, MRSA in a client’s wound transmits with direct contact with the wound, so wearing gloves and a gown when entering the room with a meal tray is typically sufficient. However, MRSA in a client’s urine could be accidentally splashed onto one’s mucous membrane when emptying the bag of an indwelling urinary catheter, so a face shield is also necessary for this task, in addition to wearing gloves and a gown. Droplet Gloves and a mask Used for clients with a diagnosed or suspected pathogen that is spread in small droplets from sneezing or other oral and nasal secretions, such as influenza or pertussis. Droplets can travel six feet, so using barriers such as privacy curtains and closing doors can also prevent the spread of infection to others. Airborne Gloves and respirator Used for clients with diagnosed or suspected pathogens spread by very small airborne particles from nasal and oral secretions that can float long distances through the air, such as measles and tuberculosis. Respirators are specially designed masks that fit closely on the face and filter out small particles, including the virus that causes COVID. Clients must be placed in a room with specialized air handling equipment found in doctors’ offices and hospitals. Residents in long-term care settings suspected of having an airborne illness should be transferred immediately to prevent the spread of infection to other residents. Signage for Transmission-Based Precautions When a resident has an infectious illness requiring transmission-based precautions, a sign is placed on their door and a cart of PPE supplies is placed 4.4 Precautions Used to Prevent the Spread of Infection | 163

nearby. Signs vary by facility but look similar to the image in Figure 4.6. 25 Due to HIPAA regulations, the type of the pathogen and the source cannot be displayed publicly, so the sign instructs anyone wishing to enter the room to ask the nurse first. Additional information regarding the type and source of the infection can be found in the client’s nursing care plan. After you become aware of the pathogen, the source, and the required PPE, you can safely enter the room. If you are unsure about any aspect of PPE required or your risk of exposure, talk to the nurse before entering the room or providing care. 25. “contact-precautions-sign-P.pdf” by U.S. Department of Health and Human Services and Centers for Disease Control and Prevention is licensed in the Public Domain. Access for free at https://www.cdc.gov/infectioncontrol/basics/ transmission-based-precautions.html#anchor_1564058318 164 | 4.4 Precautions Used to Prevent the Spread of Infection

Figure 4.6 Example of Isolation Precautions Sign View the following YouTube video from the University of Iowa about isolation precautions in a health care setting: Standard and Isolation Precautions. 4.4 Precautions Used to Prevent the Spread of Infection | 165

4.5 Personal Protective Equipment (PPE) In health care settings, personal protective equipment (PPE) refers to specialized clothing or equipment used to prevent the spread of infection, including gloves, gowns, facial protection (masks and eye protection), and respirators. PPE is a barrier that protects the health care worker from exposure to infectious agents and also prevents the transmission of microorganisms to other individuals including staff, patients, and visitors. Gloves Gloves are disposable, one-time-use coverings that protect the hands of health care providers. See Figure 4.7 1 for an image of nonsterile medical gloves in various sizes in a health care setting. Gloves are used to protect the hands of a health care worker from coming into contact with a client’s potentially infected body fluids and to protect patients from coming into contact with potential contaminants on health care workers’ hands during certain procedures and treatments. Gloves should also be worn by a health care worker when there is a risk of transmitting their own body fluids from nonintact skin on their hands to other individuals. However, gloves should not be worn for routine activities such as taking vital signs or transferring a client in a wheelchair unless indicated due to transmission-based precautions. 1. “Surgery Centre Accriditation.jpg” by Accredia is licensed under CC BY-SA 4.0 166 | 4.5 Personal Protective Equipment (PPE)

Figure 4.7 Gloves Gloves are typically made from latex, nitrile, and vinyl. Many people are allergic to latex, so be sure to check for latex allergies for the patient and other members of the health care team. Most gloves are not hand-specific and can be worn on either the left or right hand. Gloves come in a variety of sizes such as small, medium, large, and extra large and should have a snug fit, not too tight or too loose, to provide better protection to the health care provider. 2 Gloves should always be used in combination with proper hand hygiene that is performed prior to applying gloves and repeated again after gloves are removed. Gloves are task-specific and should not be worn for more than one task or procedure on the same client because some tasks may have a greater concentration of microorganisms than others. For example, gloves are worn to assist a client with incontinent care, but gloves should be removed, hand hygiene performed, and new gloves applied before assisting with oral care. Gloves should never be reused or washed to be reused. Reusing gloves has been linked with the transmission of infectious microorganisms. Gloves should never replace hand hygiene for several reasons 3 : 2. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 3. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 4.5 Personal Protective Equipment (PPE) | 167

• Gloves may have imperfections such as holes or cracks that are not visible. • Hands may have become contaminated while removing the gloves. • Gloves may have become damaged while wearing. Fingernails should be short prior to applying gloves so they do not puncture the gloves. Put on (don) gloves after hands are completely dry after performing hand hygiene. There is no specific method for putting on gloves, but care should be taken when donning gloves to avoid tearing. Gloves should be applied so they completely cover the wrists. Gloves must be removed carefully, followed by proper hand hygiene, to prevent the spread of infection. 4 REMOVING GLOVES See Figure 4.8 5 for an illustration of properly removing gloves. Hand hygiene should be performed following glove removal to ensure the hands will not carry potentially infectious agents that might have penetrated through unrecognized tears or contaminated the hands during glove removal. Properly removing gloves includes the following steps 6 : • Grasp the outside of one glove near the wrist. Do not touch your skin. • Peel the glove away from your body, pulling it inside out. • Hold the removed glove in your gloved hand. • Put your fingers inside the glove at the top of your wrist and peel off the second glove. • Turn the second glove inside out while pulling it away from your body, leaving the first glove inside the second. 4. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 5. “poster-how-to-remove-gloves.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www.cdc.gov/vhf/ebola/resources/posters.html 6. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/ index.html 168 | 4.5 Personal Protective Equipment (PPE)

• Dispose of the gloves safely. Do not reuse. • Perform hand hygiene immediately after removing the gloves. Figure 4.8 How to Remove Gloves to Prevent Contamination Review infection prevention and control practices related to glove usage in the following interactive activity. 4.5 Personal Protective Equipment (PPE) | 169

An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=397#h5p-23 This work is a derivative of Infection Prevention and Control Practices by Michelle Hughes and Kendra Allen is licensed under CC BY 4.0. Isolation Gowns Isolation gowns are protective garments worn to protect clothing from the splashing or spraying of body fluids and reduce the transmission of microorganisms. Isolation gowns can be disposable or reusable. The gowns should have long sleeves with a snug fit at the wrist, cover both the front and the back of the body from the neck to the thighs, and overlap at the back. Gloves should fit over the cuffs of the gown. Gowns should fasten at the neck and waist using ties, snaps, or Velcro. 7 Disposable gowns are made from materials that make them resistant to fluids. Reusable gowns are made of tightly woven cotton or polyester and are chemically finished to improve their ability to be fluid resistant; they are laundered after each use. Gowns are considered task-specific and should be changed if they become heavily soiled or damaged. Isolation gowns should be put on immediately prior to providing client care and should be removed immediately after care is completed before leaving the room. After use, gowns should be discarded into an appropriate receptacle for disposal or to 7. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 170 | 4.5 Personal Protective Equipment (PPE)

be laundered if the gown is reusable. See Figure 4.9 8 for an image of an isolation gown. Figure 4.9 Isolation Gown Special care should be taken when removing the gown to prevent contamination of clothing and skin. The front of the gown is always considered to be contaminated. Ties at the front are considered contaminated, but ties at the side and the back are considered uncontaminated. 9 See the “Donning/Doffing PPE” checklists later in this chapter for steps for proper removal of gowns. Review information related to using isolation gowns in the following interactive activity. 8. “U.S. Navy Doctors, Nurses and Corpsmen Treat COVID Patients in the ICU Aboard USNS Comfort (49825651378).jpg” by Navy Medicine is in the Public Domain 9. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 4.5 Personal Protective Equipment (PPE) | 171

An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=397#h5p-24 This work is a derivative of Important Considerations When Wearing Gowns by Audrey Kenmir and is licensed under CC BY 4.0. Eye Protection Eye protection in health care settings includes face shields, visors attached to masks, and goggles that are used to protect the eyes from blood or body fluids. Eye protection should be worn by health care workers during patient care when there may be splashing or spraying of body fluids or within six feet of a coughing client. For example, eye protection is worn when emptying a urinary catheter or assisting a nurse in irrigating a wound or suctioning a client’s airway. Eye protection can be disposable, like face shields, or reusable, like eye goggles. If eye protection is reusable, it should be cleaned before reuse. Face shields and visors attached to masks offer better visibility than goggles. Eye protection should fit comfortably and securely while allowing for visual acuity. Eyeglasses can be worn under face shields or goggles. 10 See Figure 4.10 11 for an image of eye goggles with and without a face shield. 10. This work is a derivative of Introduction to Infection Prevention and Control Practices for the Interprofessional Learner by Hughes, Kenmir, St-Amant, Cosgrove, & Sharpe and is licensed under CC BY-NC 4.0 11. “IMG_2021-scaled” and “IMG_2026-scaled” by unknown author are licensed under CC BY-NC-4.0. Access for free at https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/eye-protection/ 172 | 4.5 Personal Protective Equipment (PPE)

Figure 4.10 Eye Goggles With and Without a Face Shield Review information related to the use of eye protection in the following learning activity. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=397#h5p-25 This work is a derivative of Important Considerations When Wearing Eye Protection by Michelle Hughes and is licensed under CC BY-NC 4.0. Masks Masks are protective coverings worn by health care providers to protect the mucous membranes of their nose and mouth. In long-term care settings, masks are typically secured by elastic loops around the ears. The top edge of the mask has a bendable strip to secure the seal of the mask over the bridge of the nose. Some situations require masks to be combined with a face shield 4.5 Personal Protective Equipment (PPE) | 173

or a visor that covers the eyes. See Figure 4.11 12 for an image of masks used with eyeglasses and an eyeshield. Figure 4.11. Medical Mask With and Without an Eye Shield Medical masks should be worn when providing care that may cause splashing or spraying of blood or body fluids or within six feet of a client who is coughing or has been placed in droplet precautions. Medical masks should also be worn by health care providers who are coughing to prevent transmission of exhaled respiratory droplets to clients. Medical masks can differ in their filtration effectiveness and the way in which they fit. Single-use disposable medical masks are effective when providing care to most clients and should be changed when damp or soiled. When medical masks become moist, they may not provide an effective barrier to microorganisms. A medical mask, when properly worn, should fit snugly over the nose, mouth, and under the chin so that microorganisms and body fluids cannot enter or exit through the sides of the mask. If the health care worker wears glasses, the glasses should be placed over the top edge of the mask. This will help prevent the glasses from becoming foggy as the person wearing the mask exhales. 12. “Screen-Shot-2021-05-05-at-3.57.19-PM” and “Screen-Shot-2021-05-05-at-3.57.41-PM” by unknown author are licensed under CC BY-NC 4.0. Access for free at https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/masks/ 174 | 4.5 Personal Protective Equipment (PPE)

REMOVING FACEMASKS Like the isolation gown, the front of the mask is considered contaminated. The mask should be removed by taking the ear loop off and placing it in the appropriate disposal area. It is important to properly remove masks to avoid contamination. See Figure 4.12 13 for an illustration of how to remove a facemask according to the CDC. See the “Donning/Doffing PPE With a Mask and Face Shield or Goggles” checklist for more details. 13. “fs-facemask-dos-donts.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html 4.5 Personal Protective Equipment (PPE) | 175

Review information on wearing medical masks in the following interactive learning activities. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=397#h5p-26 This work is a derivative of Important Considerations When Wearing Medical Masks by Michelle Hughes and is licensed under CC BY 4.0. An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=397#h5p-27 This work is a derivative of Important Considerations When Wearing Medical Masks by Michelle Hughes and is licensed under CC BY 4.0. Respirators and PAPRs Residents requiring airborne transmission precautions are transferred to a hospital immediately upon suspicion or confirmation of an airborne illness as respiratory protection used with airborne transmission precautions requires special equipment. Respirator masks with N95 or higher filtration are worn by health care professionals to prevent inhalation of infectious small airborne particles. It is important to apply, wear, and remove respirators appropriately to avoid contamination. A user-seal check should be performed by the wearer each time a respirator is donned to minimize air leakage around the 4.5 Personal Protective Equipment (PPE) | 177

facepiece. See Figure 4.13 14 for CDC recommendations when wearing disposable respirators. 14. “fs-respirator-on-off.pdf” by Centers for Disease Control and Prevention is in the Public Domain. Access for free at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html 178 | 4.5 Personal Protective Equipment (PPE)

A newer piece of equipment used for respiratory protection is the powered air-purifying respirator (PAPR). A PAPR is an air-purifying respirator that uses a blower to force air through filter cartridges or canisters into the breathing zone of the wearer. This process creates an air flow inside either a tight-fitting facepiece or loose-fitting hood or helmet, providing a higher level of protection against aerosolized pathogens, such as COVID-19, during respiratory suctioning. See Figure 4.14 15 for an example of PAPR in use. Figure 4.14 PAPR Resident Considerations During Isolation Precautions There are a lot of things to consider when preventing the spread of infection among residents, staff, equipment, and surfaces. It is important to think about the tasks you will be performing for residents and determine ahead of time what you might be exposed to in order to select the appropriate PPE. The perspective and needs of clients placed in isolation precautions should also be considered. PPE makes communication more difficult by hiding facial expressions and making hearing more difficult, and therapeutic touch is less personal when wearing gloves. Caregivers often spend less time interacting with clients in transmission-based precautions due to the labor intensiveness of putting on and taking off PPE, resulting in clients often developing feelings of loneliness and social isolation due to less frequent interactions. Try to keep 15. “PAPRs_in_use_01.jpg" by Ca.garcia.s is licensed under CC BY-SA 4.0 180 | 4.5 Personal Protective Equipment (PPE)

the resident’s routine as normal as possible and apply extra effort to interact with the client. When transporting a client with transmission-based precautions within a facility, keep these principles in mind 16 : • Limit transport for essential purposes only, such as diagnostic and therapeutic procedures that cannot be performed in the patient’s room. • When transporting, use appropriate barriers on the patient consistent with the route and risk of transmission. For example, for a resident with a skin infection with MRSA, be sure the area is covered. • Notify health care personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission. 16. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/ index.html 4.5 Personal Protective Equipment (PPE) | 181

4.6 Blood-borne Pathogen Standard Blood-borne pathogens are infectious microorganisms in blood and body fluids that can cause disease. These pathogens include, but are not limited to, hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV). Workers in many health-related occupations, including nursing assistants and other health care personnel, are at risk for exposure to bloodborne pathogens. Needlesticks and other sharps-related injuries may expose workers to bloodborne pathogens. As a nursing assistant, your highest risk for blood-borne exposure is during shaving and any related disposal of the razor. Typically, residents use electric razors that have low risk of causing any open cuts, but you should always wear gloves when shaving a resident. Any disposable razor or objects that can cause a break in the skin, such as broken glass or needles, should be disposed of in a sharps container. 1 See Figure 4.15 2 for an image of a sharps container. Figure 4.15 Sharps Container Health care employers must follow OSHA’s guidelines for handling blood 1. Occupational Safety and Health Administration. (n.d.). Bloodborne pathogens and needlestick prevention. United States Department of Labor. https://www.osha.gov/bloodborne-pathogens 2. "Sharps Container" by Landon Cerny is licensed under CC BY 4.0 182 | 4.6 Blood-borne Pathogen Standard

called the “Blood-borne Pathogens Standard.” If you handle a spill of blood or body fluids, you should wear a face shield, gown, and gloves. You should receive training during your orientation at an agency on how to properly handle a blood spill and the PPE and cleaning solutions available. See Figure 4.16 3 for an image of a typical blood spill kit. Figure 4.16 Blood Spill Kit If you do experience an exposure to a patient’s blood or body fluids, follow agency policy and wash/flush the area and notify the nurse supervisor. Part of OSHA’s “Blood-borne Pathogens Standard” is to complete a postexposure assessment to determine if additional medical treatment is required. It is extremely important that this assessment occurs immediately after your exposure. The standard also requires your employer to offer the vaccine series for hepatitis B and hepatitis C at no cost to you if you have not previously received them. To read more information on OSHA’s Blood-borne Pathogens Standard, visit OSHA’s FactSheet PDF. 3. "Blood Spill Kit" by Landon Cerny is licensed under CC BY 4.0 4.6 Blood-borne Pathogen Standard | 183

4.7 Signs and Symptoms of Infection Nursing assistants spend a great deal of time with clients, so it is important to recognize early signs and symptoms of infection and report them to the nurse. While there are specific symptoms associated with specific types of infection, there are some general symptoms that can occur with all infections. These general symptoms include a feeling of malaise (i.e., a feeling of discomfort, illness, or lack of well-being), headache, fever, and lack of appetite. A fever is a common sign of inflammation and infection. A temperature of 38 degrees Celsius (100.4 degrees F) is generally considered a low-grade fever, and a temperature of 38.3 degrees Celsius (101 degrees F) is considered a fever. Fever is part of the body’s nonspecific immune response and can be beneficial in destroying pathogens. However, extremely elevated temperatures can cause cell and organ damage, and prolonged fever can cause dehydration. Infection raises the metabolic rate, which causes an increased heart rate. The respiratory rate may also increase as the body rids itself of carbon dioxide created during increased metabolism. If either of these conditions are noted, they should be reported to the nurse right away. As an infection develops, the lymph nodes that drain that area often become enlarged and tender. The swelling indicates the lymph nodes are fighting the infection. If a skin infection is developing, general signs of inflammation, such as redness, warmth, swelling, and tenderness, will occur at the site. As white blood cells migrate to the site of infection, yellow or green drainage (i.e., purulent drainage) may occur. Some viruses, bacteria, and toxins cause gastrointestinal inflammation, resulting in loss of appetite, nausea, vomiting, and diarrhea. See Table 4.7 for a comparison of expected findings in body systems versus unexpected findings that can indicate an infection and require notification of the nurse and/or health care provider. 184 | 4.7 Signs and Symptoms of Infection

Table 4.7 Expected Versus Unexpected Findings Related to Infection 1 Assessment Expected Findings Unexpected Findings to Report to the Nurse Vital Signs Within normal range New temperature over 100.4 F or 38 C or lower than the patient’s normal. Neurological Within baseline level of consciousness New confusion and/or worsening level of consciousness. Wound or Incision Progressive healing of a wound with no signs of infection New redness, warmth, tenderness, or purulent drainage from a wound. Respiratory No cough or production of sputum New cough and/or productive cough of purulent sputum. New shortness of breath. Genitourinary Urine clear and light yellow without odor Malodorous, cloudy, or bloody urine, with increased frequency, urgency, or pain with urination. Gastrointestinal Good appetite and food intake; feces formed and brown Loss of appetite. Nausea, vomiting, or diarrhea. Discolored or unusually malodorous feces. *CRITICAL CONDITIONS indicating a possible life-threatening infection (called sepsis) requiring immediate notification of the nurse: Two or more of the following criteria in a patient with an existing infection: • Body temperature over 38 or under 36 degrees Celsius • Heart rate greater than 90 beats/ minute • Respiratory rate greater than 20 1. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health & Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html 4.7 Signs and Symptoms of Infection | 185

Other Considerations The effectiveness of the immune system gradually decreases with age, making older adults more vulnerable to infection. Early detection of infection can be challenging in older adults because they may not have a fever, but instead develop subtle changes like new confusion or weakness that may result in a fall. The most common infections in older adults are urinary tract infections (UTI), pneumonia, influenza, and skin infections. 2 2. Office of Infectious Disease and HIV/AIDS Policy. (n.d.). Health care-associated infections. U.S. Department of Health & Human Services. https://www.hhs.gov/oidp/topics/health-care-associated-infections/index.html 186 | 4.7 Signs and Symptoms of Infection

4.8 Skills Checklist: Hand Hygiene With Soap and Water 1. Gather/Ensure Adequate Supplies: Soap and paper towels 2. Procedure Steps: ◦ Remove jewelry according to agency policy; push your sleeves above your wrists. ◦ Turn on the water and adjust the flow so that the water is warm. Wet your hands thoroughly, keeping your hands and forearms lower than your elbows. Avoid splashing water on your uniform. ◦ Apply a palm-sized amount of hand soap. ◦ Perform hand hygiene using plenty of lather and friction for at least 15 seconds: ▪ Rub hands palm to palm ▪ Rub back of right and left hand (fingers interlaced) ▪ Rub palm to palm with fingers interlaced ▪ Perform rotational rubbing of left and right thumbs ▪ Rub your fingertips against the palm of your opposite hand ▪ Rub wrists ▪ Repeat sequence at least two times ▪ Keep fingertips pointing downward throughout ◦ Clean under your fingernails with disposable nail cleaner (if applicable). ◦ Wash for a minimum of 20 seconds. ◦ Keep your hands and forearms lower than your elbows during the entire washing. ◦ Rinse your hands with water, keeping your fingertips pointing down so water runs off your fingertips. Do not shake water from your hands. ◦ Do not lean against the sink or touch the inside of the sink during the hand-washing process. ◦ Dry your hands thoroughly from your fingers to wrists with a paper towel or air dryer. ◦ Dispose of the paper towel(s). ◦ Use a new paper towel to turn off the water. 4.8 Skills Checklist: Hand Hygiene With Soap and Water | 187

◦ Dispose of the paper towel. View a YouTube video 1 of an instructor demonstrating hand hygiene with soap and water: One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=410#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Hand Hygiene With Soap and Water. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/w29Ad7Cmsxo 188 | 4.8 Skills Checklist: Hand Hygiene With Soap and Water

4.9 Skills Checklist: Hand Hygiene With Alcohol-Based Hand Sanitizer 1. Gather Supplies: Antiseptic hand rub 2. Procedure Steps: ◦ Remove jewelry according to agency policy; push your sleeves above your wrists. ◦ Apply enough product into the palm of one hand and enough to cover your hands thoroughly per product directions. ◦ Rub your hands together, covering all surfaces of your hands and fingers with antiseptic until the alcohol is dry (a minimum of 30 seconds): ▪ Rub hands palm to palm ▪ Rub back of right and left hand (fingers interlaced) ▪ Rub palm to palm with fingers interlaced ▪ Perform rotational rubbing of left and right thumbs ▪ Rub your fingertips against the palm of your opposite hand ▪ Rub your wrists ◦ Repeat hand sanitizing sequence a minimum of two times. ◦ Repeat hand sanitizing sequence until the product is dry. View a YouTube video 1 of an instructor demonstrating hand hygiene with alcohol-based hand sanitizer: One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=412#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Hand Hygiene With Alcohol-Based Hand Sanitizer. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/rTuO8SYYfNo 4.9 Skills Checklist: Hand Hygiene With Alcohol-Based Hand Sanitizer | 189

4.10 Skills Checklist: Removing Gloves 1. Procedure Steps: ◦ Using either hand, grasp the glove at the palm of the other hand. ◦ Remove the glove. ◦ Grasp the empty glove within the palm of the gloved hand. ◦ Using the index and middle fingers of the bare hand, slide fingers underneath the remaining glove at the wrist. ◦ Turn the remaining glove inside out while containing the first glove inside. ◦ Discard in an appropriate receptacle. ◦ Perform hand hygiene. View a YouTube video 1 of an instructor demonstrating removing gloves: One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=414#oembed-1 Figure 4.17 2 Glove Removal 1. Chippewa Valley Technical College. (2022, December 3). Removing Gloves. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/nYDB6b3K-MY 2. “Ch.5-Taking-off-PPE-–-Step-8,” Ch.5-Taking-off-PPE-Step-1a-.png,” “Ch.5-Taking-off-PPE-Step-1c.png,” “Ch.5-Takingoff-PPE-Step-1d,” “Ch.5-Taking-off-PPE-Step-1e.png,” and “Ch.5-Taking-off-PPE-Step-2.png” by unknown author are licensed under CC BY-NC 4.0. Access for free at https://ecampusontario.pressbooks.pub/introductiontoipcp/chapter/ putting-it-all-together-putting-on-and-taking-off-full-ppe/ 4.10 Skills Checklist: Removing Gloves | 191

4.11 Skills Checklist: Donning/Doffing PPE Without a Mask 1. Gather Supplies: Gown, gloves, and alcohol-based sanitizer 2. Procedure Steps: ◦ Perform hand hygiene. ◦ Face the back opening of the gown. ◦ Unfold the gown. ◦ Put your arms into the sleeves. ◦ Secure the neck opening behind your head. ◦ Secure the waist, making sure that the back flaps overlap each other and cover your clothing as completely as possible. ◦ Put on gloves. ◦ Ensure the gloves overlap the gown sleeves at the wrist. ◦ When care has been completed and before leaving the room, remove the gloves BEFORE removing the gown. ◦ Remove the gloves, turning them inside out. ◦ Dispose of the gloves in the appropriate container. ◦ Perform hand hygiene. ◦ Unfasten the gown at the neck. ◦ Unfasten the gown at the waist. ◦ Remove the gown starting at the top of the shoulders, turning it inside out and folding soiled area to soiled area. ◦ Dispose of the gown in an appropriate container. ◦ Perform hand hygiene. View a YouTube video 1 of an instructor demonstrating donning/doffing PPE without a mask: 1. Chippewa Valley Technical College. (2022, December 3). Donning/Doffing PPE Without a Mask. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/yP1eIqGJSS8 4.11 Skills Checklist: Donning/Doffing PPE Without a Mask | 193

One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=418#oembed-1 194 | 4.11 Skills Checklist: Donning/Doffing PPE Without a Mask

4.12 Skills Checklist: Donning/Doffing PPE With a Mask and Face Shield or Goggles 1. Gather Supplies: Gown, mask, face shield, goggles, and alcohol-based sanitizer 2. Procedure Steps: ◦ Face the back opening of the gown. ◦ Unfold the gown. ◦ Put your arms into the sleeves. ◦ Secure the neck opening at the back of your neck. ◦ Secure the waist, making sure that the back flaps overlap each other and covering your clothing as completely as possible. ◦ Put on a mask and, if needed, goggles or face shield. ◦ Put on gloves. ◦ Ensure the gloves overlap the gown sleeves at the wrist. ◦ When care is complete and before leaving the room, remove the gloves BEFORE removing the gown. ◦ Remove the gloves, turning them inside out. ◦ Dispose of the gloves in the appropriate container. ◦ Perform hand hygiene. ◦ Remove any goggles or face shield and place in the appropriate receptacle. ◦ Unfasten the gown at the neck. ◦ Unfasten the gown at the waist. ◦ Remove the gown starting at the top of the shoulders, turning it inside out and folding soiled area to soiled area. ◦ Dispose of the gown in an appropriate container. ◦ Remove the mask by grasping loop behind ear or untying at back of head. ◦ Perform hand hygiene. 4.12 Skills Checklist: Donning/Doffing PPE With a Mask and Face Shield or Goggles | 195

Review the Sequence for putting on personal protective equipment PDF handout 1 from the Centers for Disease Control and Prevention (CDC) with current recommendations for putting on and removing PPE. View a YouTube video 2 of an instructor demonstrating donning/doffing PPE with a mask and face shield or goggles: One or more interactive elements has been excluded from this version of the text. You can view them online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=420#oembed-1 1. Centers for Disease Control and Prevention. (n.d.). Sequence for putting on personal protective equipment [Handout]. https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf 2. Chippewa Valley Technical College. (2022, December 3). Donning/Doffing PPE With a Mask and Face Shield or Goggles. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/H-rXxFkmWBY 196 | 4.12 Skills Checklist: Donning/Doffing PPE With a Mask and Face Shield or Goggles

4.13 Learning Activities An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=422#h5p-11 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=422#h5p-17 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=422#h5p-19 An interactive H5P element has been excluded from this version of the text. You can view it online here: https:/ wtcs.pressbooks.pub/nurseassist/?p=422#h5p-71 4.13 Learning Activities | 197

IV Glossary Airborne precautions: Transmission-based precautions used for clients with diagnosed or suspected pathogens spread by very small airborne particles from nasal and oral secretions that can float long distances through the air, such as measles and tuberculosis. Blood-borne pathogens: Infectious microorganisms in blood and body fluids that can cause disease, including hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV). Carrier: An individual who is colonized with an infectious agent. Chain of infection: The process of how an infection spreads based on six links of transmission: Infectious Agent, Reservoir, Portal of Exit, Modes of Transmission, Portal of Entry, and Susceptible Host. Colonization: A condition when a person carries an infectious agent but is not symptomatic or ill. Contact precautions: Transmission-based precautions used for clients with known or suspected infections transmitted by touch such as C-difficile (Cdiff), methicillin-resistant staphylococcus aureus (MRSA), vancomycin resistant enterococcus (VRE), or norovirus. Disinfection: The removal of microorganisms. However, disinfection does not destroy all spores and viruses. Doff: Take off personal protective equipment (PPE). Don: Put on personal protective equipment (PPE). Droplet precautions: Transmission-based precautions used for clients with a diagnosed or suspected pathogen that is spread in small droplets from sneezing or in oral and nasal secretions, such as influenza or pertussis. Eye protection: Face shields, visors attached to masks, and goggles that are used to protect the eyes from blood or body fluids. 198 | IV Glossary

Fever: A temperature of 38 degrees Celsius (100.4 degrees F). Hand hygiene: The process of removing, killing, or destroying microorganisms or visible contaminants from the hands. There are two handhygiene techniques: handwashing with soap and water and the use of alcohol-based hand rub (ABHR). Healthcare-associated infection (HAI): An infection that develops in an individual after admission to a health care facility or undergoing a medical procedure. Infection control: Methods to prevent or stop the spread of infections in health care settings. Infectious agent: Microorganisms, such as bacteria, viruses, fungi, or parasites that can cause infectious disease. Inflammation: Redness, warmth, swelling, and tenderness associated with early signs of infection. Isolation gowns: Protective garments worn to protect clothing from the splashing or spraying of body fluids and reduce the transmission of microorganisms. Malaise: A feeling of discomfort, illness, or lack of well-being that is often associated with infection. Masks: Protective coverings worn by health care providers to protect the mucous membranes of their nose and mouth. Medical asepsis: Techniques used to prevent the transfer of microorganisms from one person or object to another but do not completely eliminate microorganisms. Mode of transmission: The way an infectious agent travels to other people and places. Moments of hand hygiene: Appropriate times during patient care to perform IV Glossary | 199

hand hygiene, including immediately before touching a patient; before performing an aseptic task; before moving from a soiled body site to a clean body site; after touching a patient or their immediate environment; after contact with blood, body fluids, or contaminated surfaces (with or without glove use); and immediately after glove removal. Nonspecific defenses: Generic barriers that prevent pathogens from entering the body, including physical, mechanical, or chemical barriers. PAPR: An air-purifying respirator that uses a blower to force air through filter cartridges or canisters into the breathing zone of the wearer. This process creates an air flow inside either a tight-fitting facepiece or loose-fitting hood or helmet, providing a higher level of protection against aerosolized pathogens. Perineal care: Cleansing the genital and rectal areas of the body. Personal protective equipment (PPE): Specialized clothing or equipment used to prevent the spread of infection, including gloves, gowns, facial protection (masks and eye protection), and respirators. Portal of entry: The route by which an infectious agent enters a new host. Portal of exit: The route by which an infectious agent escapes or leaves the reservoir. Purulent drainage: Yellow, green, or brown drainage associated with signs of infection. Reservoir: The host in which infectious agents live, grow, and multiply. Respirator masks: Masks with N95 or higher filtration worn by health care professionals to prevent inhalation of infectious small airborne particles. Respiratory hygiene: Methods to prevent the spread of respiratory infections, including coughing/sneezing into the inside of one’s elbow or covering one’s mouth/nose with a tissue when coughing and promptly disposing of used tissues. Hand hygiene should be immediately performed after contact with 200 | IV Glossary

one’s respiratory secretions. A coughing person should also wear a surgical mask to contain secretions. Specific defenses: Immune system processes like white blood cells attacking particular pathogens. Standard precautions: Precautions used by health care workers during client care when contact or potential contact with blood or body fluids may occur based on the principle that all blood, body fluids (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. These precautions reduce the risk of exposure for the health care worker and protect patients from potential transmission of infectious organisms. Sterilization: A process used on equipment and the environment that destroys all pathogens, including spores and viruses. Sterilization methods include steam, boiling water, dry heat, radiation, and chemicals. Surgical asepsis: The absence of all microorganisms during any type of invasive procedure; used for equipment used during invasive procedures, as well as the environment. Susceptible host: A person at elevated risk of developing an infection when exposed to an infectious agent. Transmission-based precautions: Specific types of personal protective equipment (PPE) and practices used with clients with specific types of infectious agents based on the pathogen’s mode of transmission. IV Glossary | 201

5.1 Introduction to Provide for Personal Care Needs of Clients Learning Objectives • Provide for personal grooming and hygiene • Assist with nutrition and fluid needs • Assist client with bowel and bladder elimination • Maintain a urinary catheter • Assist client with bowel and bladder retraining 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, selfesteem, 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. 5.1 Introduction to Provide for Personal Care Needs of Clients | 205

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 1. “ADL-1024x534.jpg" by unknown is licensed under CC BY-SA 4.0. Access for free at https://ecampusontario.pressbooks.pub/healthassessment/chapter/functional-health 206 | 5.2 Activities of Daily Living (ADLs)

• 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 5.2 Activities of Daily Living (ADLs) | 207

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 1. This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 2. This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 3. This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 208 | 5.3 Person-Centered Care

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. 5.3 Person-Centered Care | 209

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 210 | 5.4 Pre- and Post-Procedural Steps

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. 5.4 Pre- and Post-Procedural Steps | 211

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 1. “501 Structure of the skin.jpg” by OpenStax is licensed under CC BY 3.0. Access for free at https://openstax.org/books/ anatomy-and-physiology/pages/5-1-layers-of-the-skin 2. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 212 | 5.5 Skin Care

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. 3. “Decubitus 01.jpg” by AfroBrazilian is licensed under CC BY-SA 3.0 5.5 Skin Care | 213

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 4. “hands-578918_1280.jpg” by Gaertringen on Pixabay.com is licensed under CC0 214 | 5.5 Skin Care

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 Skin Care Needs of Older Adults Due to less oil and sweat production as one ages, daily showering or full body bathing is not necessary and can even be damaging to skin. Additionally, residents in long-term care settings don’t typically venture out into the community regularly, thus reducing their exposure to pathogens. Due to these factors, daily partial baths are provided to maintain hygiene, but full body bathing is typically performed only weekly. It is important to adequately dry skin folds and moisturize the skin regularly to maintain skin integrity and prevent dryness, cracking, and infection. Additionally, clients who are immobile should be repositioned at least every two hours to reduce the risk of pressure injuries. Repositioning techniques can be found in Chapter 8. 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 5. Balmain, B. N., Sabapathy, S., Louis, M., & Morris, N. R. (2018). Aging and thermoregulatory control: The clinical implications of exercising under heat stress in older individuals. BioMed Research International, 2018, 8306154. https://doi.org/10.1155/2018/8306154 5.5 Skin Care | 215

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 6. “Two_ischaemic_ulcers_on_the_foot_of_an_individual_with_type_2_diabetes.jpg” by Bondegezou is licensed under CC BY-SA 4.0 216 | 5.5 Skin Care

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 1. “Transfer_bench.jpg” by Roger Mommaerts is licensed under CC BY-SA 2.0 218 | 5.6 Types of Baths and Techniques

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. Considerations During Bathing Nursing assistants should maintain privacy and comfort for those receiving assistance with bathing. Residents can become uncomfortable due to many factors during bathing. For example, if they require transportation to the shower area in the hallway on a shower chair, the chair can be uncomfortable or cold, or they may be concerned about being exposed. Bath blankets should be placed over the resident, paying attention to tucking the blanket behind the resident’s back and underneath their legs to keep any skin from showing. Residents should also wear shoes or socks to prevent any skin injuries to feet. A towel over the top of their head can assist in keeping them warm, and the shower chair can be padded around the seat with towels or washcloths. Often the seat back is made of mesh to aid in water drainage, which can be covered with a towel to prevent irritation to the resident’s back and shoulders. If the resident’s feet don’t reach the support bar of the chair, a wash basin can be 5.6 Types of Baths and Techniques | 219

turned upside down and placed under their feet to give them a more secure feeling during transport. There is an increased risk for patient falls during bathing, and NAs must take appropriate measures to prevent falls due to unsteadiness or wet floors or equipment. During the bath, the aide should work from head to toe to prevent spreading pathogens from the perineal area to other parts of the body. Start with the face and neck, then proceed to the front and back of the upper body, then the front and back of the legs, and finish with the perineal area. The aide must ensure gloves are changed and hand hygiene is performed immediately after performing perineal care. See Skills Checklists 5.18 and 5.19 regarding performing perineal care for more information. Because much of the body’s heat is lost through the head, it may be preferable to wash the resident’s hair last. Provide the resident with a dry washcloth or towel to cover their face and prevent shampoo from getting in their eyes. Gently tipping the head back will keep the majority of the water from falling onto their face. When assisting a client with bathing, there are several things to observe, consider, and report to the nurse: • Report any open or reddened areas; dry, flaky skin; bruises; rashes; or irritation. Check all areas of the skin, especially where moisture can be trapped, such as underneath breasts, in abdominal and groin folds, in armpits, and between the toes. If a client has an existing wound or skin breakdown, the nurse should be notified prior to the bath so that an assessment can be completed. • Report any foul odors that remain after bathing. • Report subjective or objective signs of pain. For example, the client may pull away when a painful area on their body is touched with a washcloth. • Report changes in behavior, such as withdrawal or agitation during bathing. • Report any discharge from any mucous membranes. 220 | 5.6 Types of Baths and Techniques

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. 222 | 5.7 Assisting With Nutrition and Fluid Needs

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 5.7 Assisting With Nutrition and Fluid Needs | 223

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 1. “Built-Up-Silverware-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 2. “Swivel-Spoon-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 224 | 5.7 Assisting With Nutrition and Fluid Needs

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 3. “Kennedy-Cup-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 4. “Nosey-Cup-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 5.7 Assisting With Nutrition and Fluid Needs | 225