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Plate guards are used for individuals who can use only one hand or who have difficulty maneuvering utensils. Food can be pushed onto the utensil by pushing it against the plate guard. The plate guard can be placed on any plate (such as the image of the plate in Figure 5.11 5 ), or it may be on a special plate made with the guard built on the plate surface (as in Figure 5.12 6 ). Figure 5.11 Plate Guard Figure 5.12 Built-Up Plate 5. “Plate-Guard-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 6. “Built-Up-Plate-scaled.jpg” by Myra Reuter for Chippewa Valley Technical College is licensed under CC BY 4.0 226 | 5.7 Assisting With Nutrition and Fluid Needs

Documentation of Food and Fluids Documentation of food and fluids gives insight to the overall health and wellbeing of clients. It gives nurses, dieticians, health care providers, and other staff insight into possible health concerns. Documenting intake is an important responsibility of nurse aides. Unless otherwise indicated, food intake is documented by estimating to the nearest 25% of intake. It is also appropriate to note that a resident only ate “bites of food.” See Figures 5.13 – 5.16 7 for examples of food intake. Figure 5.13 25% intake or “bites” Figure 5.14 50% intake 7. “25 percent intake.png,” “50 percent intake.png,” “75 percent intake.png,” and “100 percent intake.png” by Nic Ashman for Chippewa Valley Technical College are licensed under CC BY 4.0 5.7 Assisting With Nutrition and Fluid Needs | 227

Figure 5.15 75% intake Figure 5.16 100% intake Any fluids documented in health care are converted to milliliters (mL) or cubic centimeters (cc). Milliliters and cubic centimeters are the same units, so 1 mL = 1 cc. Typically, fluids are measured in ounces in the United States, so a conversion is necessary. To do so, multiple the number of ounces by 30, as 1 ounce = 30 cc = 30 mL. Examples of fluid conversions are provided in Table 5.7. Table 5.7 Conversions of Ounces to Milliliters (mL) or Cubic Centimeters (cc) Fluid Ounces Conversion Milliliters or Cubic Centimeters 6 oz x 30 180 mL or cc 4 oz x 30 120 mL or cc 1 cup = 8 oz x 30 240 mL or cc In addition to beverages, anything that melts at room or body temperature is documented as fluids. This includes food items such as clear broth, ice chips, 228 | 5.7 Assisting With Nutrition and Fluid Needs

5.8 Assistance With Toileting Just as there are several bathing techniques based on a resident’s functioning and mobility, there are multiple methods for assisting residents with their bladder and bowel elimination. Regardless of the method used, residents should be offered toileting assistance at least every two hours. The following subsections provide an overview of each toileting method and when it may be implemented. Toilet The resident should be able to stand independently, walk, or pivot transfer with assistance. A mechanical lift that assists with bearing weight may also be used to place a resident on the toilet. Bedpan Bedpans are used for residents who cannot bear weight or prefer to stay in bed, such as when having to urinate during the night. Residents who require a full body lift to transfer typically require the use of a bedpan, but there are also toileting slings to assist a fully dependent resident to use a toilet or commode. See Figure 5.17 1 for an image of two types of bedpans. The image on the left is a standard bedpan and the image on the right is called a fracture pan. Fracture bedpans are smaller than standard bedpans and have one flat end. They are designed for individuals recovering from a hip fracture or hip replacement. 1. “Bedpan.jpg”, "Fracture Bedpan.jpg", and "Fracture Bedpan View 2.jpg" by Landon Cerny are licensed under CC BY 4.0 230 | 5.8 Assistance With Toileting

Figure 5.17 Bedpan Examples For residents with strong hip mobility who require a bedpan, ask them to bend their knees and push their hips upwards. While they are raised, place a barrier (e.g., a towel, waterproof soaker pad, disposable pad, etc.) under them and then place a standard bedpan underneath their buttocks. Ensure the handle of the fracture pan (or the opening of the rim on a full bedpan) is pointed towards the foot of the bed before they lower themselves onto the bedpan. For residents with limited hip mobility, use their lift sheet to roll them away from you towards a raised side rail. While they are lying on their side and holding the side rail, return the lift sheet on top of the bed and then place a barrier on top of the lift sheet. Place a fracture pan behind the resident’s buttocks and then gently roll both the resident and the fracture pan back to the bed surface, ensuring proper placement of the pan. Please see Skills Checklist for additional information. Commode A commode looks like a toilet, but it is a movable device with a bucket underneath the seat. See Figure 5.18 2 for an image of a commode. Commodes are typically placed near the bed for residents who have limited weightbearing ability, do not want to share a bathroom with another resident, or have urge incontinence. Urge incontinence means that as soon as the person feels the need to empty their bladder, they have very little time before urine escapes. 2. “Bedside Commode” by Landon Cerny is licensed under CC BY 4.0 5.8 Assistance With Toileting | 231

Figure 5.18 Bedside Commode Incontinence Briefs or Pads Incontinence briefs or pads are disposable products used for residents who have little to no control over bladder or bowel function and are worn in, or in place of, their underwear. Please see Skills Checklist for additional information. Urinary Catheter A urinary catheter is a device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag. Urinary catheters are used sparingly due to increased risk of urinary tract infections. Catheters are typically used for clients with urinary retention, have a wound near the perineal area that may become infected due to incontinence, or have a neurological condition that does not allow them to control their bladder function. See Figure 5.19 3 for an illustration of an indwelling urinary catheter attached to a collection bag. Nursing assistants may assist in emptying/ documenting urine output from the collection bag or providing catheter care according to agency policy. Please see 5.25 Skills Checklist for additional information. 3. "Foley Catheter with Collection Bag and Leg Strap" by Landon Cerny is licensed under CC BY 4.0 232 | 5.8 Assistance With Toileting

Figure 5.19 Indwelling Urinary Catheter With a Collection Bag Urostomy A urostomy is placed surgically to collect urine from the ureters when the bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag. See Figure 5.20 4 for an illustration of a urostomy. 4. “Diagram_showing_how_a_urostomy_is_made_(ileal_conduit)_CRUK_124.svg” by Cancer Research UK is licensed under CC BY-SA 4.0 5.8 Assistance With Toileting | 233

Figure 5.20 Urostomy Colostomy A colostomy is placed surgically when colon function is impaired. A piece of the colon is diverted to an artificial opening in the abdominal wall called a stoma, and feces is collected in a pouch. Considerations When Assisting Clients With Toileting Nursing assistants must consider a resident’s privacy and dignity when assisting with toileting just as they do with bathing. Most residents prefer to be alone when urinating or defecating. Privacy can be provided by closing the bathroom door if the resident is able to be left alone. If the resident is not safe to be left alone, close the door as much as possible while keeping the resident within eyesight. Maintain awareness of a resident who is toileting or on the bedpan so they do not need to wait for assistance with perineal care after elimination and will not develop any skin issues from sitting on a hard surface. To maintain dignity, nurse aides should be careful when explaining and providing care related to toileting. For example, a disposable brief should never be referred to as a diaper; acceptable terms include a brief, pad, liner, or disposable underwear. Additionally, a nurse aide should never show 234 | 5.8 Assistance With Toileting

reluctance or appear burdened when providing toileting assistance, no matter how often a resident feels the need to be toileted or requires perineal care due to incontinence. Bladder and Bowel Retraining Clients who are dependent on others for assistance with elimination should be taken to the bathroom or offered toileting options every two hours. Incontinence is a very personal matter and can be embarrassing for clients. Nursing assistants should use therapeutic communication when assisting clients with toileting. When indicated, clients may undergo bladder and bowel retraining to regain control of elimination. There are several strategies used to promote bladder continence. The nurse aide may assist the nurse with one of the strategies called timed voiding. Timed voiding encourages the patient to urinate on a set schedule, such as every hour, whether they feel the urge to urinate or not. The time between bathroom trips is gradually extended with the general goal of achieving four hours between voiding. Timed voiding helps to control urge and overflow incontinence as the brain is trained to be less sensitive to the sensation of the bladder walls expanding as they fill. 5 Bowel retraining involves teaching the body to have a bowel movement at a certain time of the day. This training includes encouraging clients to go to the bathroom when feeling the urge to do so and not ignoring the urge. For some individuals, it is helpful to schedule this consistent time in the morning when the natural urge occurs after drinking warm fluids or eating breakfast. For other people, especially those with a neurological cause, a laxative may be scheduled regularly to stimulate the urge to have a bowel movement on a regular basis and prevent constipation. The nurse should communicate to the 5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 5.8 Assistance With Toileting | 235

nursing assistant when bowel retraining is in place, or a laxative is administered to a client so they are aware of the client’s need to defecate. 6 Urinary Tract Infection (UTI) 7 A urinary tract infection (UTI) is a common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the bladder or kidneys. Infections can affect several parts of the urinary tract, but the most common type is a bladder infection. Kidney infections are more serious than a bladder infection because they can have long-lasting effects on the kidneys. Some people are at higher risk of getting a UTI. UTIs are more common in females because their urethras are shorter and closer to the rectum, which makes it easier for bacteria to enter the urinary tract. Providing improper perineal care is a common cause of a UTI. Nursing assistants must be diligent and assist with perineal hygiene as needed to prevent infections. Other factors that can increase the risk of UTIs include the following: • A previous UTI • Sexual activity, especially with a new sexual partner • Pregnancy • Age (Older adults and young children are at higher risk) • Urinary retention • Low fluid intake • Structural problems in the urinary tract, such as prostate enlargement Symptoms of a UTI should be reported to the nurse immediately and include the following: • Pain or burning while urinating (dysuria) • Frequent urination (frequency) 6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 236 | 5.8 Assistance With Toileting

• Urgency with small amounts of urine • Bloody urine • Pressure or cramping in the groin or lower abdomen • Confusion or altered mental status in older adults Symptoms of a more serious kidney infection (called pyelonephritis) include fever above 101 degrees F (38.3 degrees C), shaking chills, lower back pain or flank pain (i.e., on the sides of the back), and nausea or vomiting. It is important to remember that older adults with a UTI may not exhibit these common symptoms but instead demonstrate an increased level of confusion. Older adults often become weaker when they have a UTI and may fall. If you notice increased weakness or a change in the level of confusion in an older client, report these symptoms to the nurse immediately. If not treated quickly, UTIs can spread to the blood (called septicemia), leading to life-threatening infection called sepsis. When a patient has symptoms related to a possible UTI, the health care provider will order diagnostic tests, such as a urine dip, urinalysis, or urine culture. See the subsection below on “Specimen Collection,” which details how nursing aides assist with these tests. Antibiotics are prescribed for urinary tract infections and are administered by the nurse. Nursing assistants should encourage clients with UTIs to drink extra fluids to help flush bacteria from the urinary tract, and toileting should be offered more frequently with proper perineal care. Observation and Documentation of Urinary Output When assisting residents with urinary elimination, their urine should be observed for the characteristics described in Table 5.8. Terms used to document these characteristics are included. Characteristics of urine can be indicative of a urinary tract infection or dehydration and should be reported to the nurse. Dark urine, minimal urine output, or the infrequent need to void can be signs of dehydration. Characteristics of an infection are described in the previous “Urinary Tract 5.8 Assistance With Toileting | 237

Infection (UTI)” subsection. If noted and reported promptly, fluids can be encouraged to help treat these conditions. Table 5.8 Urine Characteristics Characteristic Normal Observation Abnormal Observation Documentation Terminology Color Amber (like a stoplight) or straw-colored Dark amber or possibly root beer or cola-colored Amber or cola Odor Acidic Noticeably stronger odor than usual Strong Clarity Clear Cloudy Cloudy Sediment None present Particles present Sediment noted Amount Generally 250-350 cc More or less than usual amount Amount in milliliters or cubic centimeters. Minimal amount may be described as scant If a resident is regularly incontinent and uses a brief or disposable pad for elimination, the nursing assistant should document the number of times the resident is incontinent rather than recording the amount. For a continent resident, use a toilet hat to measure urine output as described in the “Specimen Collection” subsection below. If the resident uses a commode or bedpan, place a graduated cylinder on a barrier, carefully pour the urine into the graduated cylinder, and observe and document the characteristics. See Figure 5.21 8 for an image of a graduated cylinder. 8. "Graduated Cylinder" by Landon Cerny is licensed under CC BY 4.0 238 | 5.8 Assistance With Toileting

Figure 5.21 Graduated Cylinder Observation and Documentation of Stool Similar to urine, stool output and characteristics can indicate underlying health concerns. Risk factors to healthy stool elimination will be discussed further in the “Digestive System” section in Chapter 11, but slowing of the digestive system, decreased intake, and lower mobility can all contribute to constipation and even cause bowel obstruction. Documentation and reporting of unusual characteristics can assist nurses in providing interventions that can prevent more serious health concerns. Elimination patterns vary for each individual, but a typical range for bowel elimination is twice daily to once every other day. When regular bowel movements do not occur, stool becomes hardened in the colon, making it difficult to push out, especially for those who are physically declined. Stool should be soft and formed when eliminated to prevent additional problems like hemorrhoids. Stool that is loose or liquid may indicate an infection or other chronic intestinal issues. Nursing assistants should note the size of a client’s bowel movement as “small,” “medium,” or “large” as an estimation. Using agency protocol, the consistency of the stool should also be documented. The Bristol Stool Chart is a common tool used to easily observe and document the consistency of stool. 5.8 Assistance With Toileting | 239

See Figure 5.22 9 for an image of the Bristol Stool Chart. Additionally, if any blood or dark tarry stool is observed, this should be reported immediately to the nurse. Figure 5.22 Bristol Stool Chart Specimen Collection 10 Urinary Samples Urinary samples may need to be collected to detect infection. When needed, obtain a toilet hat (see Figure 5.23“Toilet Hat” and “Commode with Toilet Hat” by Landon Cerny are licensed under CC BY 4.0[/footnote]. Ask the nurse to label a specimen cup before collecting urine (see Figure 5.24 11 ). When assisting in collecting a urine specimen, place the cup and toilet hat on a barrier to prevent contamination with bacteria from the environment. Apply 9. “Bristol_stool_chart.svg” by Cabot Health, Bristol Stool Chart is licensed under CC BY-SA 3.0 10. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 11. “Sterile Specimen Container" by Landon Cerny are licensed under CC BY 4.0 240 | 5.8 Assistance With Toileting

gloves and assist the client when needed to clean around the urethra to remove any external pathogens. If able, ask the resident to void a small amount of urine into the toilet. Place the toilet hat in the front of the toilet and instruct the resident to void into the hat. Do not put toilet paper or any other products into the toilet hat. After urination, assist the resident in completing perineal care and transferring from the toilet. Remove dirty gloves, perform hand hygiene, and apply new gloves to prevent contamination of the urine with bacteria from the perineal area. Pour the urine sample from the toilet hat into the specimen cup and tightly put on its cover. Remove gloves and perform hand hygiene before writing the time of collection on the label. Immediately bring the urine sample to the nurse. Figure 5.23 Toilet Hat 5.8 Assistance With Toileting | 241

Figure 5.24 Specimen Cup Stool Samples Stool samples are collected from patients to test for cancer, parasites, or for occult blood (i.e., hidden blood). The Guaiac-Based Fecal Occult Blood Test (gFOBT) is a commonly used test to find hidden blood in the stool that is not visibly apparent. As a screening test for colon cancer, it is typically obtained by the patient in their home using samples from three different bowel movements. Nursing assistants may collect gFOBT specimens for clients. Before the test, the nurse should verify that the client has avoided red meat for three days and has not taken aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for seven days prior to the test. (Blood from the meat can cause a false positive test, and aspirin and NSAIDS can cause bleeding, also leading to a false positive result.) Vitamin C (more than 250 mg a day) from supplements, citrus fruits, or citrus juices should be avoided for 3 to 7 days before testing because it can affect the chemicals in the test and make the result negative, even if blood is present. To perform a gFOBT in an inpatient setting, perform the following steps. • Verify with the nurse that the client has met dietary and medication requirements. • Explain the procedure to the client. Assist the resident to a clean, dry commode and instruct them not to put any toilet paper in the commode, 242 | 5.8 Assistance With Toileting

as this may alter the test result. Request they use the call light when they have had a bowel movement. • Review the manufacturer’s instructions with the nurse. • Label the card with the patient’s name and medical information per agency policy. Open the flap of the guaiac test card. • Apply nonsterile gloves. Use the applicator stick to apply a thin smear of the stool specimen to one of the squares of filter paper on the card. Obtain a second specimen from a different part of the stool and apply it to the second square of filter paper on the card. (Occult blood isn’t typically equally dispersed throughout the stool.) • Place the labeled test card in a transport bag. • Remove gloves and perform hand hygiene. • Give the transport bag to the nurse to send to the laboratory for analysis. 5.8 Assistance With Toileting | 243

5.9 Skills Checklist: Partial Bath 1. Gather Supplies: Wash basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, clean clothes or gown, and linen bag or hamper. See Figure 5.25 1 at the end of this checklist for an image of a wash basin. 2. Routine Pre-Procedure Steps: ◦ Knock on the client’s door. ◦ Perform hand hygiene. ◦ Introduce yourself and identify the resident. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Provide for privacy. ◦ Explain the procedure to the client. 3. Procedure Steps: ◦ Put on gloves. ◦ Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Raise the bed height to a working height. ◦ Keep the resident covered as much as possible using a bath blanket or bed linens. ◦ Wash the resident’s face using water only. ◦ Pat dry the face. ◦ Remove the gown from one arm, keeping the rest of the body covered. ◦ Place a towel under one arm, only exposing the arm. ◦ Wet a washcloth, put soap on the washcloth, and wash the arm with soap. 1. "Wash Basin" by Landon Cerny is licensed under CC BY 4.0 244 | 5.9 Skills Checklist: Partial Bath

◦ Wash the hand with soap. ◦ Wash the underarm with soap. Place the washcloth containing soap on the edge of the basin or barrier. ◦ Rinse the arm with the second washcloth. ◦ Rinse the hand. ◦ Rinse the underarm. ◦ Pat dry the arm. ◦ Pat dry the hand. ◦ Pat dry the underarm. ◦ Move to the other side of the bed and repeat actions on the other side of the body. ◦ Dispose of the gown into a linen bag or laundry hamper. ◦ Ask the resident if they would like lotion. When applying lotion, wear gloves. ◦ Assist the resident to put on a clean gown or clothes. ◦ While wearing gloves, empty the equipment. ◦ Rinse the equipment. ◦ Dry the basin. ◦ Return the equipment to storage. ◦ Dispose of soiled linen in the designated laundry hamper. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and if anything else is needed. ◦ Be sure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. 5.9 Skills Checklist: Partial Bath | 245

Figure 5.25 Wash Basin View a YouTube video 2 of an instructor demonstrating a partial bath: 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=284#oembed-1 2. Chippewa Valley Technical College. (2022, December 3). Partial Bath. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/iR1r-_SKVpc 246 | 5.9 Skills Checklist: Partial Bath

5.10 Skills Checklist: Full Bed Bath 1. Gather Supplies: Basin, warm water, soap, shampoo and conditioner if used, lotion, six washcloths, two towels, barrier, gloves, clean clothes or gown, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the client’s door. ◦ Perform hand hygiene. ◦ Introduce yourself and identify the resident. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Provide for privacy. ◦ Explain the procedure to the client. 3. Procedure Steps: ◦ Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Place a towel under one leg, keeping the rest of the body covered with the bath blanket. ◦ Wash the leg with soap, only exposing the leg. ◦ Wash the feet with soap. ◦ Rinse the leg and feet. ◦ Pat the leg and feet dry. ◦ Repeat on the other leg. ◦ Raise the side rail on one side of the bed. ◦ Move to the opposite side of the bed and assist the resident to roll on their side using a lift sheet or other supportive device. ◦ Wash the back while keeping the rest of the body covered. ◦ Rinse the back. ◦ Pat the back dry. ◦ Dispose of the gown and used linens into the linen bag or laundry 5.10 Skills Checklist: Full Bed Bath | 247

hamper. ◦ Ask the resident if they would like lotion. If applying lotion, wear gloves. ◦ Perform perineal care using clean linens according to Chapters 5.18 & 5.19 “Perineal Care Skills Checklists.” ◦ Assist the resident to put on a clean gown or clothes and apply an incontinence product if needed. ◦ While wearing gloves, empty the equipment. ◦ Rinse the equipment. ◦ Dry the basin. ◦ Return the equipment to storage. ◦ Dispose of soiled linen in the designated laundry hamper. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and if anything else is needed. ◦ Be sure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. Note: Shampooing can be done before washing face, after washing back, or after perineal care per resident preference. See “Shampoo Skills Checklist” for specific steps. 248 | 5.10 Skills Checklist: Full Bed Bath

View a YouTube video 1 of an instructor demonstrating a full bed bath: 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=286#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Full Bed Bath . [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/j5GYMOvjjtk 5.10 Skills Checklist: Full Bed Bath | 249

5.11 Skills Checklist: Shower 1. Gather Supplies: Soap, shampoo and conditioner if used, lotion, two washcloths, several towels, barrier, gloves, clean clothes or gown, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Assist the resident to the shower per facility protocol. See the “Considerations During Bathing” subsection in this chapter and implement comfort measures. Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Repeatedly check the water temperature throughout the shower. ◦ Put on gloves. ◦ Wet a washcloth and wash the face without soap. ◦ Put soap on the washcloth and wash the resident, starting with their upper body and then their legs. ◦ Lift any skin-on-skin areas and wash gently with soap. ◦ Wash the front of the perineal area. ◦ Reach through the bottom of the shower chair and wash the rectal area from front to back. ◦ Remove the gloves, turning them inside out. ◦ Perform hand hygiene. ◦ Put on clean gloves. ◦ Rinse the resident starting with the upper body, followed by the legs, 250 | 5.11 Skills Checklist: Shower

front perineal area, and rectal area. ◦ Change the gloves and perform hand hygiene if the perineal area was touched during rinsing. ◦ Turn off the water and place warm towels to cover the resident ◦ Pat dry. ◦ Ask the resident if they would like lotion. If applying lotion, wear gloves. ◦ Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair and avoiding getting the gown or clothes wet. ◦ Place nonskid footwear on the client. ◦ Assist the resident to stand per their care plan. ◦ Dry the back of their legs ◦ Dry the perineal area from front to back ◦ Finish putting on clothes. ◦ Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the resident is safely seated. ◦ Place all linens and soiled gown or clothing in a linen bag or designated hamper. ◦ Sanitize the shower chair per facility policy. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Be sure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. 5.11 Skills Checklist: Shower | 251

5.12 Skills Checklist: Tub Bath 1. Gather Supplies: Soap, shampoo and conditioner if used, lotion, four washcloths, four towels, barrier, gloves, clean clothes or gown, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Assist the resident to the tub per facility protocol. See the subsection in this chapter called “Considerations During Bathing” for comfort measures. Repeatedly check the water temperature throughout the bath. ◦ Put on gloves. ◦ Wash the client’s face with a washcloth and no soap. ◦ Put soap on the washcloth and wash the resident starting with their upper body and then their legs. ◦ Lift any skin-on-skin areas and wash gently with soap. ◦ Perineal care can be performed in the bed prior to the bath. See Skills Checklists 5.18 and 5.19 for perineal care specifics. ◦ Wash the client’s hair. See the “Shampoo” checklist for specific steps. ◦ Drain the tub per facility protocol and rinse the resident. ◦ Place warm towels to cover the resident. ◦ Pat dry. ◦ Ask the resident if they would like lotion. If applying lotion, wear gloves. 252 | 5.12 Skills Checklist: Tub Bath

◦ Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair to prevent getting the gown or clothes wet. ◦ Place nonskid footwear on the client. ◦ Assist the resident to stand per their care plan. ◦ Dry the back of their legs. ◦ Dry the perineal area from front to back. ◦ Finish putting on clothes. ◦ Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the resident is safely seated. ◦ Place all linens and soiled gown or clothing in a linen bag or designated hamper. ◦ Sanitize the bath chair per facility policy. ◦ Remove the gloves by turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Be sure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. 5.12 Skills Checklist: Tub Bath | 253

5.13 Skills Checklist: Shampoo 1. Gather Supplies: Shampoo basin if in bed, shampoo, conditioner if used, two washcloths or small towels, one large towel, gloves, and linen bag 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Place a basin underneath the client’s head and neck if they are in bed and place the drain over the garbage can located on the floor. ◦ Give the client a dry washcloth or towel to cover their face if desired. ◦ Check the water temperature for safety and comfort. Have the resident check the water temperature by placing their hand in the water in the basin or putting a wet washcloth on the back of their hand. Ask the resident if the temperature is comfortable to them. ◦ Wet their hair with a wet washcloth or by gently pouring water over their hair. ◦ Apply shampoo and lather while massaging scalp gently. ◦ Rinse their hair. ◦ Apply conditioner if used, massaging the scalp gently. ◦ Rinse their hair. ◦ Dry their hair gently and style it per the resident’s preference. ◦ While wearing gloves, empty the equipment. ◦ Rinse the equipment. ◦ Dry the basin. ◦ Return the equipment to storage. 254 | 5.13 Skills Checklist: Shampoo

◦ Dispose of soiled linen in a designated laundry hamper. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin or scalp issues or changes noted with the resident. 5.13 Skills Checklist: Shampoo | 255

5.14 Skills Checklist: Foot Care 1. Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Fill a foot basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Remove their socks. ◦ Immerse their feet in warm water for 5 to 20 minutes. ◦ Use water and a soapy washcloth. ◦ Wash each foot and between the toes. ◦ Rinse the entire foot with the wet washcloth, including between the toes. ◦ Dry the foot thoroughly, including between the toes. ◦ Ask the resident if they would like lotion. If applying lotion, wear gloves. ◦ Massage the lotion over the foot but avoid applying any lotion between the toes. ◦ Wipe off any excess lotion with a dry towel. ◦ Replace the socks or preferred footwear. ◦ While wearing gloves, empty the equipment. 256 | 5.14 Skills Checklist: Foot Care

◦ Rinse the equipment. ◦ Dry the basin. ◦ Return the equipment to storage. ◦ Dispose of soiled linen in a designated laundry hamper. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin or nail issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating foot care: 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=297#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Foot Care. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/gQekzAPHKGY 5.14 Skills Checklist: Foot Care | 257

5.15 Skills Checklist: Nail Care NOTE: Nail care for clients with diabetes should be performed by a Registered Nurse (RN). 1. Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, manicure stick, emery board, nail clipper, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Have the resident perform hand hygiene with sanitizer. ◦ Immerse the client’s hands in warm water for 5 to 20 minutes. ◦ Place their hand on a barrier. ◦ Using a manicure stick, clean underneath each nail, wiping any debris on the barrier after each nail. ◦ If necessary, trim nails using a clipper. Sanitize the clipper prior to and after use. ◦ Using an emery board, file each nail from the outside of the nail towards the middle of the nail. ◦ Check each nail for snags and file until smooth. 258 | 5.15 Skills Checklist: Nail Care

◦ Rinse the hand in water, return to the barrier, and dry. ◦ Repeat the procedure for the second hand. ◦ Offer lotion. If applying lotion, wear gloves. ◦ Rub the lotion gently into the skin if requested. ◦ Wipe off any excess lotion with a dry towel. ◦ While wearing gloves, empty the equipment. ◦ Rinse the equipment. ◦ Dry the basin. ◦ Return the equipment to storage. ◦ Dispose of soiled linen in a designated laundry hamper. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene ◦ Document and report any skin or nail issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating nail care: 1. Chippewa Valley Technical College. (2022, December 3). Nail Care. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/T32Csl2Rx0s 5.15 Skills Checklist: Nail Care | 259

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=299#oembed-1 260 | 5.15 Skills Checklist: Nail Care

5.16 Skills Checklist: Skin Care 1. Gather Supplies: Gloves and lotion 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene and put on gloves. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Position the resident as needed and only expose the skin that will be moisturized. ◦ Put on gloves. ◦ Place a quarter-sized circle of lotion on one palm. ◦ Rub the hands together to warm the lotion. ◦ Apply the lotion to dry skin but avoid getting lotion between the toes. ◦ Use additional lotion, warming between your hands as needed, until all dry skin has been moisturized. ◦ Wipe off any excess lotion gently with a dry towel. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the 5.16 Skills Checklist: Skin Care | 261

resident. It is important to properly clean the wash basin and other supplies after performing any type of skin care to prevent the spread of infection. View a YouTube video 1 of an instructor demonstrating cleaning supplies after performing skin care: 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=302#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Post Skin Care Procedure. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/yZ_VfxFxUho 262 | 5.16 Skills Checklist: Skin Care

5.17 Skills Checklist: Back Rub 1. Gather Supplies: Gloves and lotion 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Raise the side rail on one side of the bed. ◦ Move to the opposite side of the bed and assist the resident to roll towards the raised side rail. ◦ Only expose the resident’s back from the shoulders to the top of the hips. ◦ Place a quarter-sized circle of lotion on one palm. ◦ Rub the hands together to warm the lotion. ◦ Begin with long, gentle strokes starting at the top of hips and moving to the top of the shoulders. Repeat about five times. ◦ Throughout the back rub, ask the resident if there is any pain or discomfort. If pain is present, stop the procedure and report it to the nurse. ◦ Apply more lotion to gloved hands as needed to reduce friction on the resident’s skin. ◦ Make large circles with both hands from the top of hips to the top of shoulders. Repeat about five times. ◦ Apply additional lotion to gloved hands as needed to reduce friction on resident’s skin. ◦ Make small circles with both hands from the top of the hips to the top 5.17 Skills Checklist: Back Rub | 263

of the shoulders. Repeat about five times. ◦ Apply additional lotion to gloved hands if needed to reduce friction on resident skin. ◦ End with long, gentle strokes starting at the top of hips and moving to the top of shoulders. Repeat about five times. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Cover the resident completely per resident preference. ◦ Assist the resident to their preferred position. ◦ Lower the side rail that was raised. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating a backrub: 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=304#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Back Rub. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/CqFgIrLaQ4M 264 | 5.17 Skills Checklist: Back Rub

5.18 Skills Checklist: Perineal Care (Female) 1. Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Raise one side rail of the bed after checking the resident’s mobility and their preferred side to lie on. ◦ Put on gloves. ◦ Raise the bed height if needed. ◦ Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Turn the resident or raise their hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their buttocks. ◦ Expose their perineum only. ◦ Separate the labia. ◦ Use water and a soapy washcloth. ◦ Clean one side of the labia from top to bottom. ◦ Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom. ◦ Using a clean portion of the first washcloth, clean the vaginal area from top to bottom. ◦ Put the first washcloth in the linen bag. 266 | 5.18 Skills Checklist: Perineal Care (Female)

◦ Using the second clean washcloth, rinse one side of the labia from top to bottom. ◦ Using a clean portion of the second washcloth, rinse the other side of the labia from top to bottom. ◦ Using a clean portion of the second washcloth, rinse the vaginal area from top to bottom. ◦ Put the second washcloth in the linen bag. ◦ Avoid overexposure throughout the procedure. ◦ Pat dry. ◦ Cover the exposed area with the bath blanket. ◦ Assist the resident to turn onto their side facing away from you and ask the resident to hold onto the raised side rail. ◦ Using the third clean washcloth, apply water and soap. ◦ Using a clean portion of the third washcloth, clean one side of the buttock, wiping away from vagina. ◦ Using a clean portion of the third washcloth, clean the other side of the buttock, wiping away from the vagina. ◦ Using a clean portion of the third washcloth, clean the rectal area wiping away from the vagina. ◦ Put the third washcloth in the linen bag. ◦ Using the fourth washcloth, rinse one side of the buttock wiping away from the vagina. ◦ Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the vagina. ◦ Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from vagina. ◦ Put the fourth washcloth in the linen bag. ◦ Pat dry. ◦ Safely remove the waterproof pad from under the buttocks. ◦ Remove the gloves, turning them inside out. ◦ Perform hand hygiene. ◦ Position the resident on her back. ◦ Put on clean gloves. ◦ Dispose of soiled linen in the designated laundry hamper. 5.18 Skills Checklist: Perineal Care (Female) | 267

◦ Empty the equipment. ◦ Rinse the equipment. ◦ Dry the equipment. ◦ Return the equipment to storage. ◦ Remove the gloves, turning them inside out. ◦ Dispose of the gloves in an appropriate container. 4. Post- Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating female perineal care: 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=307#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Perineal Care (Female). [Video]. YouTube. Video licensed underCC BY 4.0. https://youtu.be/6Xu2Sgk1y80 268 | 5.18 Skills Checklist: Perineal Care (Female)

5.19 Skills Checklist: Perineal Care (Male) 1. Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Raise one side rail of the bed. Check the resident’s mobility and their preferred side to lie on. ◦ Put on gloves. ◦ Raise the bed height if needed. ◦ Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Turn the resident or raise the hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their buttocks. ◦ Expose the perineum only. ◦ Use water and a soapy washcloth. ◦ If the resident is not circumcised, gently move the foreskin away from their urethra toward the base of the penis. ▪ Using a clean portion of the first washcloth, start from the urethra and clean in a circular motion toward their scrotum. ▪ Using a clean portion of the first washcloth, clean one groin fold and the scrotum. 5.19 Skills Checklist: Perineal Care (Male) | 269

▪ Using a clean portion of the first washcloth, clean the other groin fold and the other side of scrotum. ▪ Put the first washcloth in a linen bag. ▪ Using the second clean washcloth, rinse from the urethra in a circular motion toward the scrotum. ▪ Using a clean portion of the second washcloth, rinse one groin fold and the scrotum. ▪ Using a clean portion of the second washcloth, rinse the other groin fold and the other side of the scrotum. ▪ Put the second washcloth in the linen bag. ▪ Avoid overexposure throughout the procedure. ▪ Pat dry. ◦ If uncircumcised, gently return the foreskin toward the urethra. ▪ Cover the exposed area with the bath blanket. ▪ Assist the resident to turn onto their side away from you and ask the resident to hold onto the raised side rail. ▪ Using the third clean washcloth, apply water and soap. ▪ Using a clean portion of the third washcloth, clean one side of the buttock wiping away from the urethra. ▪ Using a clean portion of the third washcloth, clean the other side of the buttock wiping away from the urethra. ▪ Using a clean portion of the third washcloth, clean the rectal area wiping away from the urethra. ▪ Put the third washcloth in the linen bag. ▪ Using the fourth washcloth, rinse one side of the buttock wiping away from the urethra. ▪ Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the urethra. ▪ Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from the urethra. ▪ Put the fourth washcloth in the linen bag. ▪ Pat dry. ◦ Safely remove the waterproof pad from under the buttocks. ◦ Remove the gloves, turning them inside out. 270 | 5.19 Skills Checklist: Perineal Care (Male)

◦ Perform hand hygiene. ◦ Position the resident on his back. ◦ Put on clean gloves. ◦ Dispose of soiled linen in the designated laundry hamper. ◦ Empty the equipment. ◦ Rinse the equipment. ◦ Dry the equipment. ◦ Return the equipment to storage. ◦ Remove the gloves, turning them inside out. ◦ Dispose of gloves in an appropriate container. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating male perineal care: 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=309#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Perineal Care (Male). [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/n3Ed36YSz9w 5.19 Skills Checklist: Perineal Care (Male) | 271

5.20 Skills Checklist: Oral Care 1. Gather Supplies: Gloves, toothbrush, toothpaste, emesis/oral basin, cup of water, clothing protector (towel), barrier (paper towel), and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Place all supplies on a barrier. ◦ Put on gloves. ◦ If the resident is in bed, elevate the head of the bed if it is permissible per the care plan. ◦ Cover the resident’s chest with a towel to keep their clothing or gown clean. ◦ Wet the toothbrush in the sink or in a cup of water. ◦ Apply a small amount of toothpaste to the toothbrush. ◦ Brush the resident’s teeth, including the inner, outer, and chewing surfaces of all upper and lower teeth. ◦ After each quadrant of the mouth (i.e., lower right, lower left, upper right, or upper left), allow the resident to rinse with water and spit into an emesis basin if needed. ◦ Clean the resident’s tongue being careful not to cause the resident to gag. ◦ Assist the resident in rinsing their mouth. ◦ Wipe the resident’s mouth with the towel on their chest. ◦ Remove the towel and place it in a linen bag. 5.20 Skills Checklist: Oral Care | 273

◦ Empty the emesis basin. ◦ Rinse the emesis basin. ◦ Dry the emesis basin. ◦ Rinse the toothbrush. ◦ Return the equipment to storage. ◦ Remove the gloves, turning them inside out. ◦ Dispose of the gloves in an appropriate container. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any oral issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating oral care: 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=311#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Oral Care. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/SQEjgHODEz0 274 | 5.20 Skills Checklist: Oral Care

5.21 Skills Checklist: Denture Care 1. Gather Supplies: Gloves, denture brush, denture toothpaste if available, dentures, denture cup, denture cleansing tablet if desired, emesis/oral basin, oral swab, cup of water, clothing protector (towel), barrier (paper towel), sink liner (paper towel or washcloth), and linen bag or hamper. See Figure 5.26 1 at the end of this checklist for an image of an oral swab. 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Place all supplies on a barrier. ◦ Place a clothing protector on the resident. ◦ Line the sink with a washcloth or paper towel. ◦ Remove dentures from the cup or remove them from the resident’s mouth and place them in the denture cup or emesis basin. ◦ Handle the dentures carefully to avoid damage or contamination. ◦ Wet the denture brush and apply denture toothpaste if available. Water alone is acceptable to clean dentures if toothpaste is not available. ◦ Thoroughly brush the inner, outer, and chewing surfaces of each denture. ◦ Rinse the dentures using clean, cool water and place them on a clean 1. "Oral Swab" by Landon Cerny is licensed under CC BY 4.0 5.21 Skills Checklist: Denture Care | 275

barrier or in an emesis basin. ◦ Rinse the denture cup. ◦ Place the dentures in a rinsed cup. ◦ Wet an oral swab and gently clean all surfaces of the resident’s gums and tongue. ◦ Allow the resident to rinse and spit into the emesis basin. ◦ Place the dentures in the resident’s mouth if desired. ◦ Wipe the resident’s mouth and remove the clothing protector, placing it in an appropriate container. ◦ In the evening, place the dentures in the denture cup and add cool, clean water to the denture cup to cover the dentures. ◦ Put a denture cleansing tablet in the cup, if desired. ◦ Rinse the equipment (denture brush and emesis basin). ◦ Return the equipment to storage. ◦ Discard the protective lining in an appropriate container. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any oral issues or changes noted with the resident. 276 | 5.21 Skills Checklist: Denture Care

Figure 5.26 Oral Swab View a YouTube video 2 of an instructor demonstrating denture care: 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=313#oembed-1 2. Chippewa Valley Technical College. (2022, December 3). Denture Care. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/kDWlh3lRGnk 5.21 Skills Checklist: Denture Care | 277

5.22 Skills Checklist: Preparing Clients for Meals and Assisting With Feeding 1. Gather Supplies: Clothing protector, meal, diet card, eating utensils, sanitizer or soapy and wet washcloths 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door unless they are in the dining room. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Verify the name on the diet card matches the resident. ◦ Verify the diet, diet texture, and liquid consistency matches the diet card. ◦ Position the resident in an upright position, at least 45 degrees. ◦ Place a clothing protector on the resident if desired (e.g., a paper or cloth towel or a large napkin). ◦ Ask the resident if they would like oral care before eating. ◦ Assist the resident to clean their hands before feeding using sanitizer or soapy and wet washcloths. ◦ Position yourself at eye level facing the resident. ◦ Describe the foods and fluids being offered to the resident. ◦ Offer small amounts of food at a reasonable rate. ◦ Offer fluids frequently. ◦ Allow the resident time to chew and swallow. ◦ Wipe the resident’s face whenever necessary. ◦ Continue to alternate foods and fluids until the resident indicates they are full. ◦ Clean the resident’s face and hands. ◦ Ask the resident if they would like oral care. 278 | 5.22 Skills Checklist: Preparing Clients for Meals and Assisting With Feeding

◦ Leave the resident with their head elevated at least 30 degrees. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Record the intake as a percentage of total solid food eaten. ◦ Record the sum of estimated fluid intakes in mL or cc. ◦ Check for resident comfort and ask if anything else is needed. ◦ If in the resident’s room, ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any feeding issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating preparing clients for meals and assistance with feeding: 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=316#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Preparing Clients for Meals and Assistance With Feeding. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/Yt3EelUdy60 5.22 Skills Checklist: Preparing Clients for Meals and Assisting With Feeding | 279

5.23 Skills Checklist: Choking Maneuver 1. Call out for help or tell another staff member to get the nurse if you think a resident is choking. If no nurse is available, direct someone to call 911 while proceeding with the following steps. 2. Until help arrives, stand behind the victim with one leg forward between the victim’s legs. 3. For a child, move down to their level and keep your head to one side. 4. Reach around their abdomen and locate the navel. 5. Place the thumb side of your fist against their abdomen just above the navel. 6. Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks. 7. For a responsive pregnant victim, any victim you cannot get your arms around, or for anyone in whom abdominal thrusts are not effective, give chest thrusts while standing behind them. Avoid squeezing the ribs with your arms. 8. Continue thrusts until the victim expels the object or becomes unresponsive. 9. If the person becomes unconscious, notify the nurse. If no nurse is available, call 911. View a YouTube video 1 of an instructor demonstrating the choking maneuver: 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=318#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Choking Maneuver. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/HMtwmw5Vaoo 280 | 5.23 Skills Checklist: Choking Maneuver

5.24 Skills Checklist: Catheter Care 1. Gather Supplies: Basin, warm water, soap, two washcloths, one towel, barrier, gloves, and linen bag or hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand. ◦ Raise the bed height to a working height. ◦ Expose only the urethra and catheter. ◦ Follow the tubing from the resident toward the drainage bag, ensuring that the tubing is at a lower level as it goes toward the bag. Be sure no kinks or elevation can cause backflow to the bladder. ◦ Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, or disposable pad) under their buttocks. ◦ Use the first washcloth with soap and water to carefully wash around the catheter where it exits the urethra. ◦ Hold the catheter where it exits the urethra with one hand. ◦ While holding the catheter, clean 3-4 inches down the catheter tube. ◦ Clean with strokes moving away from the urethra. ◦ Use a clean portion of washcloth for each stroke. ◦ Put the soiled first washcloth in the linen bag. 282 | 5.24 Skills Checklist: Catheter Care

◦ Wet the second washcloth and rinse, using strokes only away from the urethra while continuing to hold the catheter where it exits the urethra. ◦ Rinse using a clean portion of washcloth for each stroke. ◦ Put the soiled second washcloth in the linen bag. ◦ Pat dry with a towel. ◦ Do not allow the tube to be pulled at any time during the procedure. ◦ Replace the gown over the resident’s perineal area. ◦ While wearing gloves, empty the basin. ◦ Rinse the basin. ◦ Dry the basin. ◦ Return the equipment to storage. ◦ Dispose of soiled linen in a designated laundry hamper. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating catheter care: 1. Chippewa Valley Technical College. (2022, December 3). Catheter Care. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/pIM5rRt9s-w 5.24 Skills Checklist: Catheter Care | 283

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=320#oembed-1 284 | 5.24 Skills Checklist: Catheter Care

5.25 Skills Checklist: Emptying Catheter Drainage Bag 1. Gather Supplies: Gloves, two barriers, graduated cylinder, and alcohol swab 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Place a barrier (e.g., paper towel or disposable pad) on the floor under the drainage bag. ◦ Place the graduated cylinder on the barrier. ◦ Open the drain to allow the urine to flow into the graduated cylinder. ◦ Avoid touching the tip of the tubing to the sides of the graduated cylinder. ◦ Close the drain. ◦ Wipe the drain with an alcohol wipe. ◦ Wipe the drain holder, if present, with an alcohol wipe. ◦ Replace the drain into the holder. ◦ Place a clean barrier on a level, flat surface. ◦ Place the graduated cylinder on the barrier. ◦ With the graduated cylinder at eye level, read the amount of output. ◦ Note the characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine. ◦ Empty the urine in the graduated cylinder into the toilet. ◦ Rinse the graduated cylinder and empty it into the toilet. ◦ Return the equipment to storage. 5.25 Skills Checklist: Emptying Catheter Drainage Bag | 285

◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document urinary output in mL and report any issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating emptying catheter drainage bag: 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=322#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Emptying Catheter Drainage Bag. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/V2Xq4GWcfow 286 | 5.25 Skills Checklist: Emptying Catheter Drainage Bag

5.26 Skills Checklist: Assisting With a Bedpan 1. Gather Supplies: Gloves, bedpan, barrier, and toilet tissue 2. Routine Pre-Procedure Steps: ◦ Knock on the client’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the client. 3. Procedure Steps: ◦ Put on gloves. ◦ Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, disposable pad) under their buttocks. ◦ Position the resident on the bedpan/fracture pan correctly. The deeper portion of the bedpan should be directed toward their toes, and the resident should be centered on the bedpan. For fracture bedpans, the handle should be directed toward their toes. ◦ Raise the head of the bed to a comfortable level. ◦ Cover the resident with linens or a bath blanket. ◦ Leave toilet tissue within reach of the resident. ◦ Leave the call light within reach of the resident. ◦ Wait nearby allowing for resident privacy. ◦ When the resident signals, return and assist the resident to perform hand hygiene. ◦ Discard the soiled linen in the designated laundry hamper. ◦ Gently remove the bedpan/fracture pan. ◦ Assist with perineal care. ◦ Empty the bedpan into the toilet or into a graduated cylinder if output is being recorded. Note the amount and characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine. Empty the urine 5.26 Skills Checklist: Assisting With a Bedpan | 287

from the graduated cylinder used into the toilet. ◦ Rinse the equipment used and empty the rinse water into the toilet. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document urinary output in mL and report any issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating assisting with a bedpan: 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=324#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Assisting with a Bedpan. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/WCg57s4HGhc 288 | 5.26 Skills Checklist: Assisting With a Bedpan

5.27 Skills Checklist: Assisting With a Urinal 1. Gather Supplies: Gloves, urinal, and barrier 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Assist the resident to their preferred position of comfort and mobility status (e.g., seated on the side of the bed, lying in bed, or standing). ◦ Place the urinal with the shaft of the penis well within the opening. Keep the urinal level to prevent urine spillage while the resident is urinating. If the resident has discomfort, a washcloth can be placed around the rim of the urinal to prevent skin issues. ◦ Provide privacy while the resident voids. ◦ Place a barrier on a flat surface. ◦ Place the urinal on the barrier. ◦ With the urinal at eye level, read the amount of urine and note its characteristics (i.e., color, clarity, sediment, or unusual odor). ◦ Empty the urinal into the toilet. ◦ Rinse the urinal and empty the rinse water into the toilet. ◦ Return the urinal to storage. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. 5.27 Skills Checklist: Assisting With a Urinal | 289

◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document urinary output in mL and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating assisting with a urinal: 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=326#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Assisting with a Urinal. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/bLtm0TLEAFk 290 | 5.27 Skills Checklist: Assisting With a Urinal

5.28 Skills Checklist: Changing Incontinence Brief 1. Gather Supplies: Gloves and brief 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ If the resident is in bed, raise one side rail. ◦ Moving to the opposite side of bed, assist the resident to raise their hips or turn towards the side rail. Remove the soiled brief. ◦ Remove the gloves, turning them inside out. ◦ Perform hand hygiene. ◦ Put on gloves. ◦ Assist with perineal care. ◦ Remove the gloves, turning them inside out. ◦ Perform hand hygiene. ◦ Put on gloves. ◦ Place a new brief under the resident’s buttocks and center the brief. Gently tuck the tabs under the resident. ◦ Assist the resident to roll onto their back. ◦ Position the brief over the front of the resident and secure the brief with tabs. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: 5.28 Skills Checklist: Changing Incontinence Brief | 291

◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document output from the soiled brief and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating changing incontinence brief: 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=329#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Changing Incontinence Brief. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/1Ue22ysFyqQ 292 | 5.28 Skills Checklist: Changing Incontinence Brief

5.29 Skills Checklist: Dressing A Client Who Needs Total Assistance 1. Gather Supplies: Resident clothing, socks and footwear, and hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Raise the bed height. ◦ Keep the resident covered while removing their gown. ◦ Remove the gown from the unaffected (most mobile) side first. ◦ Place the used gown in a designated laundry hamper. ◦ Ask the resident their preferences for desired clothing. ◦ Start dressing them on their affected (least mobile) side first. Insert their hand through the sleeve of their shirt and grasp the hand of the resident to guide it through the sleeve. ◦ Put pants on both legs, starting with the affected (least mobile) side first. If the resident is able, assist them to raise their buttocks. If they are unable to raise their hips, put the side rail on their unaffected (most mobile) side up. Assist the resident to turn towards the side rail. Pull the pants over their buttocks and up to their waist. ◦ While still on the unaffected (most mobile) side, tuck the resident’s shirt underneath their unaffected side. ◦ Assist the resident onto their back. ◦ Raise the side rail if the resident is unable to lift their hips. ◦ Move to the unaffected side of the resident. ◦ Place their unaffected arm in the shirt sleeve, grasping the hand of 5.29 Skills Checklist: Dressing A Client Who Needs Total Assistance | 293

the resident. Finish putting on their shirt by buttoning and zipping closures. ◦ Assist the resident to turn onto their affected side and pull their pants up to their waist. ◦ Return the resident to lying on their back. ◦ Put on the resident’s socks. Draw the socks up the resident’s foot until they are smooth. ◦ Put on the resident’s nonskid footwear by slipping each nonskid footwear on the resident’s feet. ◦ Leave only when the resident is properly dressed. 4. Post-Procedure Steps: ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. ◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating dressing a client who needs total assistance: 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=331#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Dressing a Client Who Needs Total Assistance. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/StcnLjYQBtY 294 | 5.29 Skills Checklist: Dressing A Client Who Needs Total Assistance

5.30 Skills Checklist: Shaving With an Electric Razor 1. Gather Supplies: Gloves, clothing protector (towel), razor, and hamper 2. Routine Pre-Procedure Steps: ◦ Knock on the resident’s door. ◦ Perform hand hygiene. ◦ Maintain respectful, courteous, and professional communication at all times. ◦ Introduce yourself and identify the resident. ◦ Provide for privacy. ◦ Explain the procedure to the resident. 3. Procedure Steps: ◦ Put on gloves. ◦ Sit the resident upright and place a clothing protector over their chest. ◦ Hold the shaver at a right angle to the resident’s face, using your free hand to pull their skin taught as you shave. This will minimize snagging and the risk of cutting the resident. ◦ Shave all areas of the face and neck per resident preference. ◦ Gather the clothing protector so their whiskers do not fall onto their clothing. ◦ Place the clothing protector in the designated hamper. ◦ Clean the razor per facility guidelines and charge or plug it in. ◦ Remove the gloves, turning them inside out. 4. Post-Procedure Steps: ◦ Perform hand hygiene. ◦ Check for resident comfort and ask if anything else is needed. ◦ Ensure the bed is low and locked. Check the brakes. ◦ Place the call light or signaling device within reach of the resident. ◦ Open the door and privacy curtain. 296 | 5.30 Skills Checklist: Shaving With an Electric Razor

◦ Perform hand hygiene. ◦ Document and report any skin issues or changes noted with the resident. View a YouTube video 1 of an instructor demonstrating shaving with an electric razor: 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=333#oembed-1 1. Chippewa Valley Technical College. (2022, December 3). Shaving with an Electric Razor. [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/ShawTlxf1o8 5.30 Skills Checklist: Shaving With an Electric Razor | 297

5.31 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=344#h5p-28 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=344#h5p-39 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=344#h5p-41 298 | 5.31 Learning Activities

V Glossary Activities of daily living (ADLs): Hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs of clients. A.M. care: Personal care performed in the morning. Aspiration: Inadvertently breathing fluid or food into the airway instead of swallowing it. Clock method: A method used with clients with visual impairments to describe where the food on their plate is located. For example, state, “Your mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your plate.” CLOWD: An acronym to consider after providing personal care but before leaving the room that stands for Comfort; Light, Lock and Low; Open; Wash; and Document. Colostomy: A surgically placed opening when a client’s colon function is impaired. A piece of the colon is diverted to an artificial opening in the abdominal wall called a stoma, and feces is collected in a pouch. Commode: A movable device with a bucket underneath the seat that is used for elimination when the client has difficulty getting to the bathroom. Complete bed bath: A bath provided in bed for clients who have difficulty getting out of bed, are experiencing excessive pain, or have other physical or cognitive issues that make other types of bathing less tolerable. Grooming: Maintaining a resident’s appearance through shaving, hair, and nail care. Hygiene: Keeping the body clean and reducing pathogens by performing tasks such as bathing and oral care. Impaired skin integrity: Skin that is damaged or not healing normally. An V Glossary | 299

example of impaired skin integrity is a pressure injury (also called a bedsore or pressure ulcer) with damage to the skin and surrounding tissue. Incontinence briefs or pads: Disposable products used for clients with little to no control over bladder or bowel function. Partial bath: Washing the face, underarms, arms, hands, and perineal area. Partial baths are given daily to maintain hygiene. They preserve skin integrity by not drying out skin with excessive soap and water use. Perineal: The genital and anal area. Personal care: Care that a client needs to maintain hygiene, well-being, selfesteem, and dignity. Person-centered care: A care approach that considers the whole person, not just their physical and medical needs. It also refers to a person’ autonomy to make decisions about their care, as well as participate in their own care. P.M. care: Personal care performed in the evening. Pureed diet: A diet order indicating all food is blended to smooth consistency. Routine cares: Personal cares provided to every resident every day, such as assisting them in getting dressed for breakfast. Sepsis: Life-threatening infection that has spread throughout the body. SKWIPE: An acronym to consider before providing cares to clients that stands for Supplies, Knock, Wash, Introduce, Privacy, and Explain. Timed voiding: Encourages the patient to urinate on a set schedule. Urge incontinence: A condition where as soon as the person feels the need to empty their bladder they have very little time before urine escapes. Urinary catheter: A device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag. 300 | V Glossary

Urinary tract infection (UTI): A common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the bladder or kidneys. Urostomy: A surgically placed opening to collect urine from a person’s ureters when their bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag. Wet voice: Vocalization with sounds as if food or fluids remain in the mouth or throat. V Glossary | 301

6.1 Introduction to Provide for Basic Nursing Care Needs Learning Objectives • Carry out the basic nursing skills required for the nursing assistant • Adapt care to meet the physical needs of the aging client • Apply heat and cold applications • Administer nonprescription (OTC) medications • Define the principles of nutrition and fluid needs • Provide client comfort measures • Assist with end-of-life care for the dying client • Assist with postmortem care • Recognize the general effects of prescribed routine medications The general scope of practice for nursing assistants (NAs) relates to helping individuals with their activities of daily living (ADLs), including facilitating fluid and nutritional intake. NAs also complete actions that provide comfort and increase clients’ quality of life. Quality of life refers to the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events. Nurses may delegate actions to nursing assistants that provide comfort to residents, such as application of nonprescription, topical medications or heat and cold treatments. Nursing assistants may also provide care to residents in special situations, such as end-of-life care or postmortem care. End-of-life care is a term used to describe care provided when death is imminent and life expectancy is limited to a short number of hours or days. Postmortem care refers to care provided after death has occurred through transfer to a morgue 6.1 Introduction to Provide for Basic Nursing Care Needs | 305

6.2 Nutrition and Fluid Needs Nursing assistants (NAs) help clients meet their nutritional and fluid needs as they assist them with their activities of daily living. Let’s begin by reviewing the anatomy and physiology of the gastrointestinal system. Anatomy and Physiology of the Gastrointestinal System The gastrointestinal system (also referred to as the digestive system) is responsible for several functions, including digestion, absorption, and immune response. Digestion begins at the mouth, where chewing of food occurs. This is called mechanical digestion. If food is not broken down mechanically by the teeth, it is very difficult to digest, and it also increases the risk of choking. If there are any concerns with missing or broken teeth, dentures that don’t fit well, or any pain or open areas in the mouth, the NA should report these concerns to the nurse immediately. After food is chewed and swallowed, it goes into the stomach via the esophagus. Involuntary movement, called peristalsis, allows the food to enter the stomach to mix with acidic gastric juices. The breaking down of food with these acids is called chemical digestion. From the stomach, the liquid food (called chyme) passes through the small and large intestine where nutrients and water are absorbed into the bloodstream. Waste products are condensed into feces and excreted through the anus. 1 , 2 More information on the structure and function of the digestive system will be covered in Chapter 11. Appropriate food and fluid intake are essential to good health, so anything that potentially decreases a client’s appetite must be addressed. For example, all five senses decline in functioning to some extent in older adults. It is important for the NA to provide accommodations that address these declines in sensory function that can impact food intake and overall health. Enhancing 1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 2. This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 6.2 Nutrition and Fluid Needs | 307

food intake in older adults with altered sensory function includes the following accommodations: • Vision ◦ If the resident is known to wear glasses, ensure they are wearing them, and the lenses are clean. Seeing food often stimulates the desire to eat. ◦ Explain what is on the meal tray if the client has significant visual impairment. It is helpful to use the “clock method,” such as, “On your plate, your peas are at 3 o’clock, your roast beef is at 6 o’clock, and your mashed potatoes are at 9 o’clock.” ◦ If a resident has a pureed diet order, review their menu so you can describe each type of food in an appealing manner. ◦ Make meals look as attractive as possible. Take food off trays and avoid using plastic utensils and disposable cups whenever possible so the resident feels as if they are having a meal at home. • Hearing ◦ If the resident has hearing aids, ensure they are in place, charged, and functioning so they can hear you describe the food. ◦ Ask if music is preferred during mealtime. ◦ When seating residents in a public eating area, ensure they are seated with others with similar cognitive status so they may enjoy conversation while eating. • Touch ◦ Encourage the resident to eat as independently as possible by using adaptive silverware or other meal aids. Occupational therapists can assess the needs of the resident and provide adaptive equipment. ◦ If utensils can’t be held by the resident, try using finger foods such as fruit, bread, or crackers. • Smell 308 | 6.2 Nutrition and Fluid Needs

◦ If possible, dietary staff should prepare meals near resident rooms because the aroma of cooking food may increase hunger. ◦ If a client is eating a meal in their room, clear the room of unpleasant odors or sights. For example, empty the trash can if it has soiled incontinence products, and empty urinals that may be sitting on side tables. • Taste ◦ Check the diet order. If the order permits, ask residents if they prefer seasoning or condiments. ◦ Ensure hot foods are served hot and cold foods are served cold. Judge the temperature of the food by placing your hand above the food to sense heat, but do not touch the food directly with your hand. Rewarm hot foods that have cooled. ◦ If the resident does not like the meal choice, find an alternative food that appeals to them. Refer to the “Assisting With Nutrition and Fluid Needs” section and the checklist “Preparing Clients for Meals and Assisting With Feeding” in Chapter 5 for specific steps and additional insight on feeding a dependent client. Macronutrients In hospitals and long-term care facilities, the dietician assesses clients periodically to ensure that their nutritional and fluid needs are met. However, when providing care in a group home, assisted living, or home health, NAs are often responsible for creating meals. It is important to understand basic nutritional concepts so you can address your clients’ nutritional needs. Macronutrients make up most of a person’s diet and provide energy, as well as essential nutrient intake. Macronutrients include carbohydrates, proteins, and fats. However, too many macronutrients without associated physical activity cause excess nutrition that can lead to obesity, cardiovascular disease, 6.2 Nutrition and Fluid Needs | 309

diabetes mellitus, kidney disease, and other chronic diseases. Conversely, too few macronutrients contribute to nutrient deficiencies and malnourishment. 3 Carbohydrates are sugars and starches and are an important energy source. Each gram of carbohydrates provides four calories. Carbohydrates break down into glucose and raise blood sugar levels. Diabetics should limit carbohydrate intake to maintain blood sugar levels in a healthy range. Proteins are peptides and amino acids that provide four calories per gram. Proteins are necessary for tissue repair and function, growth, energy, fluid balance, clotting, and the production of white blood cells. Fats consist of fatty acids and glycerol and are essential for tissue growth, insulation, energy, energy storage, and hormone production. Each gram of fat provides nine calories. While some fat intake is necessary for energy and the absorption of fat-soluble vitamins, excess fat intake contributes to heart disease and obesity. Due to its high-calorie content, a little fat goes a long way. 4 Fats are classified as saturated, unsaturated, and trans fatty acids. Saturated fats come from animal products, such as butter and red meat (e.g., steak). Saturated fats are solid at room temperature. Recommended intake of saturated fats is less than 10% of daily calories because saturated fat raises cholesterol and contributes to heart disease. 5 Unsaturated fats come from oils and plants, although chicken and fish also contain some unsaturated fats. Unsaturated fats are healthier than saturated fats. Examples of unsaturated fats include olive oil, canola oil, avocados, almonds, and pumpkin seeds. Fats containing omega-3 fatty acids are 3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 4. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 310 | 6.2 Nutrition and Fluid Needs

considered polyunsaturated fats and help lower cholesterol levels. Fish and other seafood are excellent sources of omega-3 fatty acids. 6 Trans fats are fats that have been altered through a hydrogenation process, so they are not in their natural state. During the hydrogenation process, fat is changed to make it harder at room temperature and have a longer shelf life. Trans fats are found in processed foods, such as chips, crackers, and cookies, as well as in some margarines and salad dressings. Minimal trans-fat intake is recommended because it increases cholesterol and contributes to heart disease. 7 Choosing Food Groups to Meet Macronutrient Needs Good resources for healthy nutritional choices are the USDA’s “My Plate” guidelines. 8 By using a plate as a visual, sections on the plate illustrate general amounts of the different types of food groups that should be eaten every meal, including fruits and vegetables, grains, protein, and dairy. See Figure 6.1 9 for an image of the USDA’s “My Plate” guidelines. 6. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 8. MyPlate.gov. (n.d.). What is MyPlate? U.S. Department of Agriculture. https://www.myplate.gov/eat-healthy/what-ismyplate 9. “MyPlate_blue.png” by USDA is licensed under CC0 6.2 Nutrition and Fluid Needs | 311

Figure 6.1 My Plate About half the plate should be fruits and vegetables that provide many nutrients, as well as fiber for healthy bowel elimination. Fruits and vegetables are low in fat and calories and have no cholesterol. Fresh fruits and vegetables are the best choice, but frozen options have similar nutritional value. Frozen produce can also be more cost-effective because it doesn’t spoil and can save time as the food is already cleaned and chopped. A variety of colors of fruits and vegetables not only makes the plate visually appealing, but also provides the greatest array of nutrients. About 25% of the plate should be grains. Pasta, cereal, and bread are sources of grains. Types of grains include wheat, corn, rice, oats, barley, and quinoa. Grains are low in fat and cholesterol but have high carbohydrate and fiber content. The fiber content in grains can be helpful in preventing constipation and lowering cholesterol. Due to the high carbohydrate content of grains, they may need to be limited for clients with diabetes. The remaining 25% of the plate should contain protein sources. Common proteins include soy, quinoa, eggs, fish, meat, nuts and seeds, legumes (beans), and dairy products. Just as with the other food groups, a variety of protein selections provides the most nutrients. Red meat can contain a lot of fat and cholesterol, so lean cuts are preferred for heart health. Fish, especially salmon, has healthy fat and should be consumed twice weekly. Nuts, seeds, 312 | 6.2 Nutrition and Fluid Needs

and legumes are low in saturated fat and high in fiber, which also make them a good choice for protein. Dairy choices are important for calcium intake that aids in bone health. Calcium intake is important for older adults because they naturally retain less calcium and are at higher risk for bone fractures. Dairy products include milk, lactose-free milk, soy milk, buttermilk, cheese, yogurt, and kefir. Sour cream and cream cheese are not considered dairy items in terms of nutritional benefits. Adults should consume about three cups of dairy per day. Choosing whole foods that are unprocessed, or as close to their original form as possible, is important to feeling full and stabilizing blood sugar because it takes longer to digest unprocessed foods. Think about eating an apple as compared to drinking apple juice. The whole apple will take a long time to chew and chemically break down to chyme, whereas the juice is ready to move through the digestive tract immediately. Eating whole foods can also reduce salt, fat, and sugar intake because they have no additives and can keep blood pressure, blood sugar, and cholesterol levels lower. Read additional information about My Plate guidelines at https://www.myplate.gov/. Fluid Intake Fluid intake comes from both liquids and foods. For example, most fruits and vegetables contain a lot of water, so they contribute to fluid intake. See Table 6.2 10 for water content in various foods. Table 6.2 Water Content in Foods 10. This image is a derivative of “Table 3.1 Water Content in Foods” by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program and is licensed under CC BY-NC-SA 4.0 6.2 Nutrition and Fluid Needs | 313

Percentage Food Items 90-99 Nonfat milk, cantaloupe, strawberries, watermelon, lettuce, cabbage, celery, spinach, squash 80-89 Fruit juice, yogurt, apples, grapes, oranges, carrots, broccoli, pears, pineapple 70-79 Bananas, avocados, cottage cheese, ricotta cheese, baked potato, shrimp 60-69 Pasta, legumes, salmon, chicken breast 50-59 Ground beef, hot dogs, steak, feta cheese 40-49 Pizza 30-39 Cheddar cheese, bagels, bread 20-29 Pepperoni, cake, biscuits 10-19 Butter, margarine, raisins 1-9 Walnuts, dry-roasted peanuts, crackers, cereals, pretzels, peanut butter 0 Oils, sugars The average fluid intake in adults per day is 1.5 liters of fluids with additional 700 milliliters (mL) of water gained from solid foods. About 2.5 liters of fluid are excreted daily in adults in urine, feces, respiration, and other body fluids like sweat and saliva. 11 There is some debate over the amount of water required to maintain health. There is no consistent scientific evidence proving that drinking a particular amount of water improves health or reduces the risk of disease. Additionally, the amount of fluids a person consumes daily is variable and based on their climate, age, physical activity level, and kidney function. 12 11. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 12. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 314 | 6.2 Nutrition and Fluid Needs

Our bodies are constantly trying to balance our fluid volume using the physiological mechanisms of thirst and urine output. The “thirst center” is contained within the hypothalamus, a portion of the brain that lies just above the brain stem. As people age, their thirst mechanism becomes less responsive, causing a higher risk of dehydration. See Figure 6.2 13 for an illustration of the thirst response. Thirst occurs in the following sequence of physiological events: • Receptors in the kidney, heart, and hypothalamus detect decreased fluid volume or increased sodium concentration in the blood. • Hormonal and neural messages are relayed to the brain’s thirst center in the hypothalamus. • The hypothalamus sends neural signals stimulating the conscious thought to drink. • Fluids are consumed. • Receptors in the mouth and stomach detect mechanical movements involved with fluid ingestion. • Neural signals are sent to the brain and the thirst mechanism is shut off. 14 13. “Regulating-Water-intake-.jpg” by Allison Calabrese is licensed under CC BY 4.0. Access for free at https://pressbooks.oer.hawaii.edu/humannutrition/chapter/regulation-of-water-balance/ 14. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 6.2 Nutrition and Fluid Needs | 315

Figure 6.2 Thirst Response Thirst is a subconscious physiological mechanism to stimulate water intake. However, actual fluid intake is controlled by conscious eating and drinking habits that are influenced by cognitive, social, and cultural factors. For example, some individuals have a habit of drinking a glass of orange juice, coffee, or milk every morning before going to school or work. Conversely, older adults often have decreased fluid intake due to physical or cognitive challenges in obtaining or drinking fluids. For this reason, older adults often require assistance to maintain a healthy intake of fluids. Due to the decreased thirst response in older adults, it is important to prevent dehydration by encouraging fluid intake even when they don’t feel thirsty. Dehydration can lead to confusion, falls, and bladder infections. Signs of dehydration include the following 15 : 15. Human Nutrition by University of Hawai‘i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 316 | 6.2 Nutrition and Fluid Needs

• Dry mouth or other mucous membranes • Dry skin or skin that does not return to normal shape when gently pinched • Dark urine or urine amounts smaller than 200-300 mL • Headache • Dizziness • Rapid heart rate • Low blood pressure If signs or symptoms of dehydration are noted, these concerns should be reported to the supervising nurse, and fluid intake should be encouraged as tolerated. In hospitals and long-term care facilities, dieticians often determine the amount of daily fluid intake for clients. Fluid restrictions may be prescribed by the health care provider based on the client’s medical condition. Fluid restrictions are further discussed in the following “Modified Diets” subsection. Cultural and Religious Considerations With Nutritional Intake Cultural and religious beliefs often influence a client’s food selection and food intake. Dieticians and nurses assess a client’s cultural and religious preferences on admission to a facility, but NAs should continually ask clients about their food and fluid preferences. A particular diet should never be assumed based on a client’s stated culture or religion. Cultural beliefs may affect the types of food eaten, as well as when they are eaten. Some foods may be restricted due to cultural beliefs or religious rituals, whereas other foods may be viewed as part of the healing process. For example, some individuals choose not to eat pork because of cultural or religious beliefs that consider pork unclean. Other individuals choose to eat “kosher” food because its method of preparation fits with their religious guidelines. Additionally, some individuals avoid eating during certain times. For example, some clients’ religious beliefs encourage fasting on religious 6.2 Nutrition and Fluid Needs | 317

holidays from sunrise to sunset, whereas other individuals avoid eating meat during their religious season of Lent. 16 Modified Diets Some individuals require limitations of certain foods or fluids due to medical circumstances, illnesses, or chronic diseases. For these reasons, the provider may order a modified diet, also referred to as a “therapeutic diet,” based on recommendations from a dietician. A modified diet is any diet altered to include or exclude certain components. For example, a client may have a modified diet order due to an upcoming test or procedure, a specific medical condition like diabetes, an allergy like a gluten allergy, or to lose weight. As previously discussed in Chapter 5, it is critical for the NA to verify the diet orders for every client and then verify the food and fluids on their meal trays are correct based on the diet order. Here are some of the most common diet orders: • Low-Sodium: Salt intake is commonly restricted for individuals with high blood pressure, heart failure, and kidney disease. Salt substitutes may be offered and high sodium condiments, such as ketchup, soy, barbecue and steak sauces, are avoided. This diet is commonly abbreviated as Low NA (sodium) or NAS (No added salt/sodium). • Low-Fat: A low-fat diet is commonly prescribed for individuals with high cholesterol, heart disease, or arterial circulation problems. High-fat dairy and meat products, fried foods, desserts, and baked goods are avoided. However, healthy fats can be consumed from plant-based sources such as olive oil, nuts, avocados, and salmon. • Low-Residue or Low-Fiber: Low-residue or low-fiber diets are commonly prescribed for individuals with bowel disorders. Fiber is found in grains, seeds, fruits, and vegetables, so these food choices are typically avoided. • Diabetic or Carb-Controlled: Carb-controlled diets are typically 16. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 318 | 6.2 Nutrition and Fluid Needs

prescribed for individuals with diabetes to help keep their blood sugar in a healthy range. This diet includes reduced intake of carbohydrates, especially from processed sources such as juices, starches such as potatoes and bread, and cereal or pasta that is not whole grain. Good carbohydrate sources include whole fruits and vegetables. Fat intake may also be restricted because it can elevate blood sugar levels. This diet is commonly abbreviated as CHO or CCHO. Many clients with diabetes have orders for a bedside blood glucose test before eating; ensure this test is completed and/or reported to the nurse. • Gluten-Free: The gluten-free diet is typically prescribed for people with gastrointestinal conditions such as celiac disease or irritable bowel syndrome because their symptoms are aggravated by gluten. Gluten is found in wheat, rye, and barley, so rice, oats, and quinoa are good substitutes. There are many gluten-free pasta, cereal, and bread products available. • Lactose-Free: Lactose is removed from the diet for individuals who are lactose intolerant. Lactose is found in milk and dairy products. Soy, almond, or rice milk are good substitutes that provide calcium. • Fluid Restriction: Fluid restriction orders may be temporary, such as several hours before surgery, or permanent, such as for clients with kidney failure or heart failure. The provider prescribes the amount of fluid a person should consume in one day. In a hospital or facility, this amount is typically split across shifts based on meal and snack times while also taking into consideration fluids consumed with medications. Clients on fluid restrictions will also have their fluid intake and output tracked and documented daily as previously discussed in Chapter 5. • NPO: NPO is a common medical abbreviation referring to “nothing by mouth.” NPO may be a temporary order, such as 8-12 hours before surgery, or a permanent order, such as for an individual with a permanent feeding tube due to dysphagia. Dysphagia refers to difficulty swallowing that can cause aspiration of liquids and food into one’s lungs and lead to life-threatening pneumonia. Individuals with severe dysphagia may never be able to eat or drink anything without risking pneumonia. Their nutrition is typically given through a permanent tube placed directly into 6.2 Nutrition and Fluid Needs | 319

their stomach (i.e., a PEG tube), or if it is a temporary condition, a tube is inserted through their nose into the stomach (i.e., an NG tube). Residents who are NPO do not typically desire to go to the dining room during meals because they can’t eat a regular diet, but be sure to ask their preference. Diet Texture In addition to modified diet orders regarding the content of the food choices, the texture of the food may also be modified based on the chewing and swallowing ability of the resident. Common orders for diet textures for residents include regular, mechanical soft, or pureed: Regular Diet: Regular diets include any texture of food. Mechanical Soft: Mechanical soft diets include food that is soft or easily mashed with a utensil. Meat is ground to make chewing easier. Fruits and vegetables are boiled to soften any skin, and sometimes it is removed. See Figure 6.3 17 for an image of a mechanical soft diet. Figure 6.3 Example of a Mechanically-Soft Meal. Used with permission. 17. “dysphagia-meat-and-potatoes-1w03r35.jpg” by Savannah Greiner is used with permission. Access for free at https://sites.udel.edu/chs-udfoodlab/2017/04/10/learning-about-dysphagia/ 320 | 6.2 Nutrition and Fluid Needs

Pureed: Pureed diets include food that is blended to the consistency of a thick paste. See Figure 6.4 18 for an image of a pureed diet. Figure 6.4 Example of Pureed Food. Used with permission. Liquid Consistency Clients may require a specific type of liquid consistency if they have dysphagia and increased risk for aspiration. The flap that covers the trachea and prevents liquids from entering the lungs when swallowing is called the epiglottis. If the epiglottis loses muscle tone, liquid can seep around it into the lungs and cause aspiration pneumonia. Signs of possible dysphagia are when a client continually coughs or clears their throat while eating or drinking. These signs should be reported immediately to the nurse because it can indicate early stages of dysphagia. Clients with dysphagia typically have orders for thickened liquids. Thickened liquids are easier for the epiglottis to prevent from entering the lungs. Here are common types of liquid consistencies ordered: Regular or Thin Liquids: No modifications for liquid consistency are required. 18. “dysphagia-pureed-breakfast-1kl60uo.jpg” by Savannah Greiner is used with permission. Access for free at https://sites.udel.edu/chs-udfoodlab/2017/04/10/learning-about-dysphagia/ 6.2 Nutrition and Fluid Needs | 321

Nectar Thick (NT): Fluids are modified to have the consistency of thicker juices like a creamy soup. Honey Thick (HT): Fluids are modified to have the consistency of honey or syrup that pour very slowly and may be consumed with a spoon. Pudding Thick (PT): Fluids are modified to have semi-solid consistency like pudding. A spoon stands up in pudding-thick liquid. See Figure 6.5 19 for an illustration comparing liquid consistency. Figure 6.5 Liquid Consistencies for Regular (Thin), Honey Thick, and Pudding-Thick Liquids Liquids can be thickened using thickening powder. Pre-thickened liquids from manufacturers typically have a smoother consistency than prepared liquids. See Figure 6.6 20 for an image of a commercial thickening powder in use. Thickening liquid with powder requires exact attention to measurements to ensure the resident receives the correct liquid consistency and does not aspirate the fluid. Ice cubes should not be added to thickened liquids because as they melt, the liquid will become thinner. See Figure 6.7 21 for an image of thickening water. 19. “Honey Thick Liquid,” “Pudding Thick,” and “Thin Liquid” by Open RN Project are licensed under CC BY 4.0 20. “Powdered Thickener" and "Adding Thickener to Water" by Landon Cerny are licensed under CC BY 4.0 21. “Thickened Water” by Landon Cerny is licensed under CC BY 4.0 322 | 6.2 Nutrition and Fluid Needs

Figure 6.6 Pre-thickened Water Figure 6.7 Thickened Water Read additional information on modified diets and liquid consistencies in the Virginia Department of Behavioral Health and Developmental Services PDF. 6.2 Nutrition and Fluid Needs | 323

6.3 Pain Pain is traditionally defined in health care as, “Whatever the patient says it is, experienced whenever they say they are experiencing it.” 1 In 2020 the International Association for the Study of Pain released a revised definition of pain as, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” along with these additional notes: • Pain is always a personal experience that is influenced to varying degrees by the body’s ability to function, how the brain perceives pain, and even how pain has been reacted to or cared for by others in the past. • Individuals learn the concept of pain throughout all stages of their life. • A person’s report of an experience of pain should be respected. • Although pain usually serves an adaptive role to protect oneself, it can have adverse effects on function, socialization, and psychological wellbeing. • Verbal description is only one of several behaviors that express pain. The inability to communicate does not negate the possibility that a person is experiencing pain. 2 • Be aware that cultural beliefs and generational norms affect how an individual expresses their pain. Pain motivates the individual to withdraw from dangerous stimuli, like touching a hot stove. It reminds the body to protect an injured part while it heals, such as not walking on a sprained ankle. Most pain resolves after the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body. 1. Pasero, C., & MacCaffery, M. (2010). Pain assessment and pharmacological management (1st ed.). Mosby. 2. International Association for the Study of Pain. (2017, December 14). Terminology. https://www.iasp-pain.org/ Education/Content.aspx?ItemNumber=1698 6.3 Pain | 325

Pain can also occur in the absence of any detectable stimulus, damage, or disease. 3 , 4 Factors Affecting Pain There are many factors that affect how a person perceives pain, how they will act while they are in pain, and how they communicate their pain to others. See Table 6.3a for common factors that influence pain. 5 Table 6.3a Factors Affecting Pain 6 3. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 4. This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 5. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 6. Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 326 | 6.3 Pain

Biological Factors Psychological Factors Social Factors • Nociception • Brain function • Source of pain • Illness • Medical diagnosis • Age • Injury, past or present • Genetic sensitivity • Hormones • Inflammation • Obesity • Cognitive function • Mood/affect • Fatigue • Stress • Coping • Trauma • Sleep • Fear • Anxiety • Developmental stage • Meaning of pain • Memory • Attitude • Beliefs • Emotional status • Expectations • Culture • Values • Economic • Environment • Social support • Coping mechanisms • Spirituality • Ethnicity • Education There are endless sources of pain. For example, as people age, osteoarthritis is a common cause of pain. Osteoarthritis is a type of arthritis causing inflammation or swelling of the joints due to daily wear and tear on the body. The extent of a person’s arthritis can be affected by repeatedly performing physically demanding tasks such as those found in jobs such as health care, construction, and manufacturing. Topical medications and treatments such as arthritis cream, ice, or heat can be very effective in managing arthritis pain. Acute Versus Chronic Pain The duration of a person’s pain can be classified as either acute or chronic. Acute pain has limited duration and is associated with a specific cause. It is often attributed to a specific event, such as a fracture, childbirth, or surgery, 6.3 Pain | 327

and should lessen as the body heals. Acute pain usually causes observable physiological responses such as increased pulse, respirations, and blood pressure. The person may also have excessive sweating called diaphoresis. 7 Chronic pain is ongoing and persistent for longer than six months. It typically does not cause a change in vital signs or diaphoresis. Chronic pain can affect an individual’s psychological, social, and behavioral responses and impact daily functioning. Chronic medical problems, such as osteoarthritis, spinal conditions, fibromyalgia, and peripheral neuropathy, are common causes of chronic pain. Chronic pain can continue even after the original injury or illness that caused it has healed or resolved. Some people suffer chronic pain even when there is no past injury or apparent body damage, and it may not be located in a specific area of the body. 8 People experiencing chronic pain often have other physical effects that are stressful on the body such as tense muscles, limited ability to move around, lack of energy, and appetite or sleep changes. Emotional effects of chronic pain include depression, anger, anxiety, and fear of reinjury. These effects can limit a person’s ability to return to their regular work or leisure activities. 9 , 10 Objective and Subjective Signs of Pain The concepts of objective and subjective data were previously discussed in the Chapter 1, “Guidelines for Reporting” subsection. Subjective signs of pain are what the person reports to you, such as “My stomach hurts” or “My knees ache when I walk.” Objective data is observable, such as the change in vital signs that can occur when an individual is experiencing acute pain. Signs of pain can also include nonverbal responses such as grimacing, guarding the 7. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 8. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 9. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 10. Cleveland Clinic. (2020, December 8). Acute vs. chronic pain. https://my.clevelandclinic.org/health/articles/ 12051-acute-vs-chronic-pain 328 | 6.3 Pain

injured body part, rocking, rubbing the area, or moaning. See Figure 6.8 11 for an image of observable signs of pain. Figure 6.8 Observable Signs of Pain When an individual is unable to communicate pain due to cognitive deficits, recognizing objective signs of pain is vital for providing comfort measures and improving their quality of life. The Pain Assessment in Advanced Dementia (PAINAD) is an example of a tool that nurses and NAs use to identify the presence of pain in individuals who are unable to verbally report it. 12 See the PAINAD scale in Table 6.3b. A number is identified for each row and the total number is their pain rating. Table 6.3b PAINAD Scale 13 11. “238074231_2485ed053b_o” by Erik Ogan is licensed under CC BY-SA 2.0 12. Warden, V., Hurley, A., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15. https://doi.org/ 10.1097/01.JAM.0000043422.31640.F7 13. Warden, V., Hurley, A., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in 6.3 Pain | 329

Item 0 1 2 Breathing independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation. Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations. Negative vocalization None Occasional moan or groan. Low-level speech with a negative or disapproving quality. Repeated trouble calling out. Loud moaning or groaning. Crying. Facial Expression Smiling or inexpressive Sad. Frightened. Frowning. Facial grimacing. Body language Relaxed Tense. Distressed pacing. Fidgeting. Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out. Consoling No need to console Distracted or reassured by voice or touch. Unable to console, distract, or reassure. advanced dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15. https://doi.org/ 10.1097/01.JAM.0000043422.31640.F7 330 | 6.3 Pain

6.4 Comfort Measures Nursing assistants (NAs) should report subjective and objective signs of clients’ pain to the nurse for further assessment. After assessing the client, the nurse may choose to administer medication with provider order and/or provide other nonpharmacological treatments. The nurse may delegate tasks to the NA such as the application of over-the-counter topical medications, ice, or heat. The NA may also assist with repositioning and massage. Topical Medications Topical medications are applied to the skin and are typically over-the-counter (OTC) medications, meaning no prescription is needed to obtain them. Topical analgesics may come as a cream, gel, spray, or patch. An example of a topical analgesic is “Icy-Hot” cream. There are also other types of topical medications an NA may be delegated to apply, such as antifungal medications (e.g., Nystatin in powder or cream form) or barrier creams to reduce the risk of skin breakdown or assist in healing of opened areas. When applying topical medications, it is important to use diligent infection control measures to prevent the medication from becoming contaminated. See the “Topical Medications” Skills Checklist for steps on how to properly apply topical medications. Ice and Heat Applications Applying ice and heat can also be delegated from the registered nurse to the NA. To safely apply ice or heat, first place a thin barrier on the skin, such as a towel or washcloth, to avoid damaging the tissue. Ice may be placed in a plastic bag, or cold therapy may be available in a disposable package. In some situations, a reusable gel pack may be placed in the freezer between uses. Heat applications may include using an electrical heating pad or a reusable microwavable pack. The NA should discuss the setting for the heating pad or the time the pack should be warmed in the microwave with the delegating 6.4 Comfort Measures | 331

nurse. The NA should feel the pack’s temperature before placing it on the resident. Ice or heat applications are typically left on for 15-20 minutes. If the resident is unable to communicate, the NA should lift the pack, check the skin temperature, and look for any redness every five minutes to prevent damage to the skin. If the ice or heat applications are not disposable, ensure they are sanitized according to agency policy before providing them to the resident. Positioning and Massage Pain may arise when a client remains in one position too long or is placed in a position that causes pressure on a sensitive area such as a joint, tendon, or muscle. Residents who are unable to move on their own should be repositioned at least every two hours, and some may require more frequent repositioning due to pain or skin issues. Clients can be maintained in a position of comfort by placing pillows to prevent discomfort between joints and bony prominences or to support the body and prevent them from rolling out of the position. For information on proper positioning, see Chapter 8. Massage provides relaxation by reducing soreness and tension in muscles. It also increases circulation by promoting blood flow. However, a massage should never be provided over red or swollen areas. A massage given to a resident for pain relief should last about 3-5 minutes. For specifics on giving a massage, see the 5.17 “Back Rub” Skills Checklist in Chapter 5. Other Comfort Measures In addition to the previously described interventions to reduce pain, NAs can further help reduce clients’ pain by offering distractions, such as talking with the resident about pleasant or interesting things that the resident enjoys, looking at photos or magazines, playing board games, or listening to music. Deep breathing, mindfulness techniques, aromatherapy, and light range of motion (ROM) activities can also help calm the resident and ease their pain. 332 | 6.4 Comfort Measures

Read more about providing ROM activities in Chapter 9. See Figure 6.9 1 for images of nonpharmacological treatments for pain. Figure 6.9 Nonpharmacological Treatments for Pain Read more about pain management for older adults from the University of Iowa. 1. “Massage-hand-4.jpg” by Lubyanka is licensed under CC BY-SA 3.0, “Biofeedback_training_program_for_posttraumatic_stress_symptoms.jpg” by Army Medicine is licensed under CC BY 2.0, “Tai_Chi1.jpg” by Craig Nagy is licensed under CC BY-SA 2.0, “Musicoterapia_lmidiman_flickr.jpg” by Midiman is licensed under CC BY 2.0, “Cold_Hot_Pack.jpg” by Mamun2a is licensed under CC BY-SA 4.0, “pexels-photo-1188511.jpeg” by Mareefe is licensed under CC0, “STOTT-PILATES-reformer-class.jpg” by MHandF is licensed under CC BY-SA 3.0, “prayer-2544994_960_720.jpg” by Himsan is licensed under CC0, and “gaming-2259191_960_720.jpg” by JESHOOTScom is licensed under CC0 6.4 Comfort Measures | 333

6.5 Effects of Prescribed Routine Medications NAs may not be aware of all the medications a client is receiving, but the nurse should inform the NA of potential harmful side effects to report when a new medication has been prescribed. The NA should be vigilant for possible side effects, especially if it is known that a new medication has been prescribed. Common side effects to report to the nurse are as follows: • Dizziness • Drowsiness • Change in cognition (i.e., new confusion) • Constipation; diarrhea; or dark, bloody or tarry stools • Nausea or vomiting • Dry mouth • Ringing in the ears • Itchy skin or rash • Increased urination or discolored urine • Muscle aches • Bleeding gums • Increased bruising 334 | 6.5 Effects of Prescribed Routine Medications

6.6 End-of-Life Care There are many circumstances and medical diagnoses that may cause an individual to approach the end of their life. The natural aging process and chronic conditions such as heart failure (HF), chronic obstructive pulmonary disease (COPD), cancer, and advanced dementia may lead to end-of-life care. All nursing care should be provided in a holistic, person-centered approach, but during end-of-life care, all caregivers must be fully attuned to the needs and wishes of the person. Caregivers often have a long-standing relationship with the dying person, but it is critical to not assume their client’s preferences. Communication must be more frequent and intentional during end-of-life care because a patient’s needs can change quickly. Additionally, attitudes and mental outlooks often fluctuate for the patient and their loved ones during this difficult time when many decisions need to be made. It is essential for caregivers to find an appropriate balance of interventions and space for the dying person and their loved ones. Use techniques discussed in Chapter 1 for therapeutic communication and making observations of facial expressions and body language to guide your interactions with the resident and their loved ones. As discussed in Chapter 2.6, “Health Care Settings,” hospice care is a choice offered to individuals approaching end of life. Hospice care is offered to patients who are terminally ill and expected to live less than six months. Hospice provides comfort to the client and supports the family, but curative medical treatments are stopped. It is based on the idea that dying is part of the normal life cycle. Hospice care does not hasten death but focuses on providing comfort. 1 For example, a cancer patient may choose to no longer receive chemotherapy due to its severe side effects but will continue to take medications to manage pain and nausea. While nutritional intake is still important, food choices center around those that are pleasurable to the client rather than meeting their daily requirement of nutrients. 1. This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 6.6 End-of-Life Care | 335