Home Health Aide Student Portal

Click on the skills to review procedures discussed in this chapter.

Opening Procedure

Wash hands

Knock on the door

Introduce yourself

Explain the procedure clearly, using eye contact and ensuring understanding

Provide privacy (if needed)

Ensure bed is at proper height for procedure, bed is locked, and side rail is down for good body mechanics

Use gloves on any procedure that might provide exposure to blood or body fluids

Handling Oxygen Safely

When: Oxygen should be handled cautiously at all times to avoid accidents. During a fire, oxygen tanks can be particularly dangerous as oxygen is a flammable substance.

Why: To limit injuries and/or casualties due to oxygen exposure or fire.

How:

Do not allow clients, staff, or visitors to smoke near oxygen tanks.
Keep any flammable liquids away from oxygen tanks and be sure tanks are away from any heat source.
Be sure all areas where oxygen is in use or stored are well ventilated.
Handle oxygen tanks with care. Do not drag, drop, or hit the tanks.
“Oxygen in Use” signage should be used per agency policy.
Empty oxygen tanks must be marked as empty and kept separate from full or partially used tanks. Follow agency policy on where and how to store empty tanks.

Assisting the Client to Dangle

When: After helping the client move from a lying position to sit on the side of the bed and before assisting him to stand, you must let him dangle.

Why: Dangling allows the client time to adjust to the sitting position, stabilizes blood pressure, reduces dizziness, and reduces the risk of falls.

How:

Complete your opening procedure steps.
Verify the client’s level of assistance as listed on the care plan.
If the client is lying under the bed linens, fanfold the top linens to the foot of the bed.
Raise the head of the bed to a Fowler’s position to aid in moving the client into an upright position.
Ask the client to assist you by placing his hands flat on the bed and pushing his body upward during the position change.
Place one arm behind the client’s shoulders and one arm under his thighs.
Instruct the client to assist on the count of three.
On the count of three, raise his shoulders and swing his legs over the edge of the bed so that he is sitting securely upright on the side of the bed, with his feet on the floor.
Stand in front of the client at all times to prevent a fall.
- You may need to continue to support the client’s back if he is unable.
Allow the client to acclimate to the position change.
Ensure that the client is not dizzy prior to making any other position changes.
Proceed with the task or transfer as needed.
Complete your closing procedure steps.

Applying a Gait Belt

Complete your opening procedure steps.
Identify the client’s level of assistance as indicated on the care plan.
Assist the client to an upright sitting position.
The client must have a shirt on to cover her skin under the gait belt. If the client is wearing a hospital gown, wrap the gown around her so that the belt will not touch her skin.
Place the gait belt around the client’s waist.
If the client has a colostomy, urostomy, or gastrostomy tube (G-tube), place the belt above the appliance.
Ensure that the belt is placed beneath the breasts of the female client.
Thread the end of the belt through the teeth of the buckle until the belt is snug around the client’s waist.
Thread the end of the belt through the opposing end of the buckle to secure. Ensure that the belt is snug; adjust as necessary.
Complete the transfer or task.
Complete your closing procedure steps.

Moving the Client From the Bed to the Wheelchair—One Assist

When: When the client requires help to get into the wheelchair in the morning after waking and before meal times, activities, and social outings, or as requested by the client.

Why: The client should be out of bed as much as tolerated or possible to increase his mobility, food and fluid intake, and social interaction.

What: Supplies needed for this skill include

Wheelchair
Shoes or nonskid slipper socks
Gait belt

How:

Complete your opening procedure steps.
Verify the client’s level of assistance as listed on the care plan.
Position the wheelchair parallel to the bed, at the head and against the side of the bed. Always place the wheelchair at the client’s strong or unaffected side.
Lock the brakes on the wheelchair.
If the client is lying under the bed linens, fanfold the top linens to the foot of the bed.
Raise the head of the bed to a Fowler’s position to aid in moving the client into an upright position.
Assist the client to dangle
- Put his shoes or nonskid slipper socks on his feet.
Apply a gait belt.
- Ensure that his feet are flat on the floor.
Stand in front of the client. Place your feet on the outside of the client’s feet, your knees touching the outside of his knees.
- Assume a wide base of support, bending at the knees.
- Place your hands under the client’s arms and grasp the gait belt.
Ask the client to assist you during the transfer by placing his hands at his sides flat on the bed and pushing his body upward off the bed to a standing position on the count of three.
On the count of three, assist the client to a standing position.
Instruct the client to pivot until he can grasp the wheelchair arm farthest from him, and the edge of the wheelchair seat is behind his legs.
Instruct the client to grasp the other arm of the wheelchair and, on the count of three, to lower his body to a seated position.
Ensure that the client’s hips and buttocks are against the back of the wheelchair and that he is properly aligned.
Place the leg rests on the wheelchair, if indicated on the care plan, and position the client’s legs appropriately.
Remove the gait belt.
Complete your closing procedure steps.

Moving the Client From the Wheelchair to the Bed

When: When the client requires help to get into bed in the evening or as requested by the client.

Why: The client should be out of bed as much as tolerated or possible to increase his mobility, food and fluid intake, and social interaction.

What: Supplies needed for this skill include

Wheelchair
Shoes or nonskid slipper socks
Gait belt

How:

Complete your opening procedure steps.
Verify the client’s level of assistance as listed on the care plan.
Position the wheelchair parallel to the bed, at the head and against the side of the bed. Lock the brakes on the wheelchair.
Ensure the client has shoes or nonskid slipper socks on his feet.
Apply a gait belt.
Ask the client to assist you during the transfer by placing his hands at his sides on the wheelchair arms, pushing his body upward off the seat of the wheelchair to a standing position on the count of three.
Stand in front of the client. Ensure that his feet are flat on the floor. Place your feet on the outside of the client’s feet, your knees touching the outside of his knees. Assume a wide base of support, bending at the knees.
Place your hands under the client’s arms and grasp the gait belt. On the count of three, assist the client to a standing position.
Instruct the client to pivot until he can feel the bed behind his legs.
Instruct the client on the count of three to lower his body to a seated position on the bed.
Ensure that the client’s hips and buttocks are fully on the bed and that he is properly aligned.
Remove the gait belt. If the client is stable remove the shoes at this time.
Assist the client to a lying position on the bed. If the client was not stable prior to lying down remove the shoes at this time. Cover and position the client as desired.
Complete your closing procedure steps.

Log Rolling a Client

When: Use the log roll when a client with a suspected or confirmed neck or spinal cord injury must be moved for any intervention, such as incontinence care or transfer onto a back board for transport.

Why: Rolling the client in one fluid motion will limit the risk of further injury to the neck or spinal cord.

What: Supplies needed for this skill include:

One pillow

How:

Complete your opening procedure steps.
The client should be lying in bed, on her back with the bed flat.
One nursing assistant stands at the head of the bed, cradling the client’s head in his hands and maintaining alignment of head and spine at all times.
- This nursing assistant gently removes the pillow from beneath the client’s head, maintaining proper alignment.
Fanfold the linens to the foot of the bed.
Two other nursing assistants positions themselves next to each other on one side of the bed facing the client.
- One nursing assistant stands aligned with the client’s torso. The other nursing assistant stands aligned with the client’s hips.
Place a pillow lengthwise between the client’s legs. Position the client’s arms so that they are slightly in front of her.
Standing at the side of the client, one nursing assistant places one hand on the client’s shoulder and one hand on her lower hip.
The second nursing assistant, standing at the client’s side, places one hand on the client’s hip and one hand on her thigh.
- The arm of the second nursing assistant overlaps that of the first.
One nursing assistant counts to three, and in one fluid motion, the client is rolled toward the two nursing assistants.
Complete the necessary intervention.
On the count of three, in one fluid motion, the nursing assistants return the client to a supine position or to a side-lying position to relieve pressure.
Remove the pillow between the client’s legs. Replace the pillow beneath the client’s head. Adjust the bed linens as necessary to cover the client.
Complete your closing procedure steps.

Placing a Client in a Fowler’s Position

When: The client is placed in a Fowler’s position when eating, to ease breathing, while watching television in bed, or when requested by the client. The client receiving a tube feeding should be placed in a semi-Fowler’s position for the duration of the feeding.

Why: The head of the bed is elevated in Fowler’s position. The client’s risk of choking is reduced when she eats or receives tube feedings in this position. Labored breathing is eased when the client is in this position because pressure on the chest cavity is reduced. The position enables the client to watch television comfortably while in bed.

What: Supplies needed for this skill include

Two to four pillows

How:

Complete your opening procedure steps.
The client should be lying in bed, on her back, a pillow under her head.
- Her head should be approximately 2 inches from the head of the bed.
Raise the head of the bed:
- 35–40 degrees for a semi-Fowler’s position;
- 45–60 degrees for a Fowler’s position; or
- 80–90 degrees for a high-Fowler’s position.
Place a pillow under her knees and calves. The heels should not be touching the bed.
If she prefers, place one pillow under each arm to prevent pressure on her elbows.
The client’s arms can lie at her sides or across her abdomen.
Ensure client comfort.
Adjust the bed linens to cover the client as desired.
Complete your closing procedure steps.

Placing a Client in a Side-Lying (Lateral) Position

When: The client is placed in a lateral position to relieve pressure on the coccyx and sacrum, to receive an over-the-counter enema, or when she requests it for comfort.

Why: Rotating the lateral and supine positions can reduce the client’s risk of developing pressure ulcers. Placing the client in a side-lying position for an over-the-counter enema can reduce the risk of a bowel tear. The lateral position is another one preferred by many clients for comfort and sleeping.

What: Supplies needed for this skill include

Two to four pillows

How:

Complete your opening procedure steps.
The client should be lying in bed, on her back, a pillow under her head.
- Her head should be approximately 2 inches from the head of the bed.
Raise one side rail. Move to the opposite side of the bed where the side rail is not raised.
Ask the client to move her entire body toward you. Assist the client if she is unable.
Ask the client to reach over her body, grab onto the side rail, and roll over. Assist the client if she is unable.
The client should now be in the center of the bed. If not, assist her.
Adjust the pillow beneath the client’s head for comfort. Place a pillow behind her back. Place a pillow lengthwise in between her knees and lower legs to relieve pressure on her lower back, hips, knees, and ankles.
Lower the side rail.
If the client prefers, place a pillow in front of her abdomen and ask her to “hug” the pillow to relieve the pressure on her shoulder.
- Ensure that she is not lying directly on her shoulder if this pillow is not used.
Gently shift the client’s weight to rest on the pillow located behind her back. Ensure that she is not lying directly on her shoulder.
- Ensure that she is lying on the buttocks rather than on the hip bone.
Adjust the bed linens to cover the client as desired.
Complete your closing procedure steps.

Measuring Oral Intake

When: When a client is placed on intake and output.

Why: To help assess the client’s fluid balance.

What: Supplies needed for this skill include

Note pad and pen

How:

Complete your opening procedure steps.
Assist the client as needed with fluid intake.
Calculate how many milliliters (mLs) of fluid the client takes in by mouth through your shift. Keep a running total of how many mLs have been consumed based on the fluid container size.
Include items that are fluid at room temperature such as ice cream and popsicles. Include all fluids from meals, snacks, and bedside fluids.
At the completion of the shift add up the total of all fluid intake and document the results per agency policy.
Complete your closing procedure steps.

Measuring Urine Output From a Collection Bag

When: Empty the collection bag when it becomes too full and at the end of each shift.

Why: Urine must be emptied to prevent a back flow of urine into the bladder. The amount must be recorded and documented at the end of each shift.

What: Supplies needed for this skill include:

Gloves
Alcohol wipes
Graduate or urinal
Paper towels

How:

Complete your opening procedure steps.
Don gloves.
Place paper towels on the floor directly under the urinary drainage bag. Place the graduate or urinal on top of the paper towels.
Wipe the drainage port of the urinary drainage bag with an alcohol wipe. Discard the wipe into the wastebasket.
Open the drainage port and allow all urine to drain from the bag into the graduate or urinal. Make sure that tip of the drainage port does not touch the inside of the graduate or urinal.
Once all urine has been drained, wipe the drainage port with an alcohol wipe. Discard the wipe into the wastebasket. Close the drainage port.
Pick up the graduate or urinal and the paper towels from the floor. Discard the paper towels into the wastebasket.
Place clean paper towels on the bathroom countertop. Place the graduate or urinal on top of the paper towels.
Bend at the knees to measure the urine in the graduate or urinal at eye level. Measure the amount of urine to the closest 25 mL hash line.
Empty the contents of the graduate or urinal into the toilet. Rinse the graduate or urinal and empty the contents into the toilet. Repeat as necessary. Dry the graduate or urinal with paper towels. Discard the paper towels into the wastebasket. Place the graduate or urinal in the designated storage area in the client’s room.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.
Record the amount of urine if indicated on the care plan.

Measuring Urine Output From a Urinal

When: Each time a client uses the urinal if a client is on intake and output.

Why: To help assess the client’s fluid balance

What: Supplies needed for this skill include:

Gloves
Urinal
Bed protector
Washcloth, as necessary

How:

Complete your opening procedure steps.
Once the client has finished with the urinal, don gloves, pull back the linens and remove the urinal with your dominant hand, being careful not to spill the contents. If the urinal was lined with a washcloth, remove it with your non-dominant hand and place it in the linen bag. With your non-dominant hand, adjust the bed linens as necessary to cover the client.
Place clean paper towels on the bathroom countertop. Place the graduate on top of the paper towels.
Bend at the knees to measure the urine in the graduate at eye level. Measure the amount of urine to the closest 25 mL hash line. Make a note of the amount for later documentation.
Empty the contents of the urinal into the toilet and rinse it. Empty the rinse water into the toilet. Repeat as necessary until the urinal is clean. Dry the urinal with paper towels and discard them into the wastebasket. Place the urinal in the designated storage area in the client’s room.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Documenting in Military Time

When: Each time you document.

Why: To maintain clear and consistent documentation that aligns with professional health care standards.

What: Supplies needed for this skill include:

Black pen

How:

Complete your opening procedure steps.
Complete the required caregiving for the client.
Complete your closing procedure steps.
Document the caregiving interactions based on the 24 hour military time clock expressed as four digits. For example, if the caregiving occurred at 5:00 pm you would document that as 1700.

Giving the Client a Back Rub

When: After a bath or shower or during am or pm cares as requested by the client.

Why: A back rub eases aches and pains and helps to calm a client.

What: Supplies needed for this skill include

Lotion, if desired by the client

How:

Complete your opening procedure steps.
After the bathing process or as desired by the client expose the back area, being careful to keep the client covered as much as possible for privacy and warmth.
Warm the desired lotion in your hands by rubbing together.
Using long gliding strokes the length of the back apply the lotion to the back.
Rub the back until the lotion has been absorbed by the skin or as desired by the client.
If any excess lotion remains wipe gently with a towel.
Complete your closing procedure steps.

Assisting with Female Perineal Care

When: Complete peri-care with each partial and complete bed bath and each shower. Peri-care is also required with each incontinence episode, but adult wipes can be used in lieu of washcloths and towels for prn incontinence care.

Why: Peri-care keeps individuals fresh in between showers or tub bathing. It is especially important for clients who are incontinent. It keeps clients clean and odor free and maintains healthy skin.

What: Supplies needed for this skill include

Gloves
Basin of warm water
Two washcloths (minimum)
One towel (minimum)
Bath blanket
Bed protector
Soap or peri-cleanser
Barrier creams, if indicated on the care plan

How:

Complete your opening procedure steps.
The client should by lying in bed, on her back with the bed flat. Fanfold the bedspread and blanket down to the foot of the bed.
Cover the client’s upper body with the bath blanket. Fanfold the top sheet down to the client’s thighs, only exposing the perineum.
Raise one side rail. Move to the opposite side of the bed where the side rail is not raised.
Ask the client if the water is a comfortable temperature.
Don gloves.
Place a clean bed protector or towel under her to protect the bed linens from becoming wet.
Ask the client to bend her knees and separate her legs. Assist the client if she is unable.
Wet a washcloth and wring out excess water. Apply and lather a small amount of soap or peri-cleanser into the washcloth.
With your nondominant index finger and thumb, open the labia gently.
Wash the perineal area from front to back at least three times, using a clean area of the washcloth each time. You may need to wash more than three times to clean the area completely.
If using soap, wet the second washcloth in the washbasin and wring out excess water. Rinse the perineal area from front to back at least three times, using a clean area of the washcloth each time. Repeat a minimum of three times, more if needed to remove all soap.
- If using peri-cleanser, you do not need to rinse the perineum. Proceed to Step 16.
Gently pat the perineal area dry with a towel.
While cleansing, check for drainage, or any red, rashy, or open areas of skin on or in the perineum.
- If any drainage or rashy areas are present, place the soiled washcloths and towel in the linen bag.
Ask the client to reach over herself, grab the side rail, and roll over. Assist the client if she is unable. Adjust the bath blanket and top sheet as needed to ensure privacy. Only the buttocks should be exposed.
Rewet the first washcloth, or use a clean washcloth, and wring out excess water.
Apply and lather a small amount of soap or peri-cleanser into the washcloth.
Wash the client’s buttocks. Wash the anal area from front to back at least three times, using a clean area of the washcloth each time. You may need to wash more than three times to clean the area completely. You may need to use several washcloths.
- When done, place the washcloths in the linen bag. Do not place these washcloths back in the washbasin.
If using soap, remove the second washcloth from the washbasin, or use a clean, wet washcloth, and wring out excess water. Rinse the anal area from front to back at least three times, using a clean area of the washcloth each time. Repeat a minimum of three times, more if needed to remove all soap.
- If using peri-cleanser, you do not need to rinse the buttocks and anal area. Proceed to Step 22.
- Place washcloth(s) in the linen bag.
Gently pat the buttocks and anal area dry with a towel.
- Place this towel in the linen bag.
While cleansing, check for drainage, or any red, rashy, or open areas of skin on the buttocks or around the anal area.
Apply barrier creams to the buttocks or anal area as indicated on the care plan. Do not apply any creams to open areas of the skin.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the side rail.
Complete your closing procedure steps.
Report drainage, or any red, rashy, or open areas of skin promptly to the nurse.

Assisting with Male Perineal Care

What: Supplies needed for this skill include

Gloves
Basin of warm water
Two washcloths (minimum)
One towel (minimum)
Bath blanket
Bed protector
Soap or peri-cleanser
Barrier creams, if indicated on the care plan

How:

Complete your opening procedure steps.
The client should be lying in bed, on his back with the bed flat. Fanfold the bedspread and blanket down to the foot of the bed.
Cover the client’s upper body with the bath blanket. Fanfold the top sheet down to the client’s thighs, only exposing the perineum.
Raise one side rail. Move to the opposite side of the bed where the side rail is not raised.
Ask the client if the water is a comfortable temperature.
Don gloves.
Place a clean bed protector or towel under the client to protect the bed linens from becoming wet.
Wet one washcloth and wring out excess water. Apply and lather a small amount of soap or peri-cleanser into the washcloth.
With your nondominant hand, hold the client’s penis upright.
- If the client is not circumcised, pull back the foreskin until the entire head of the penis is exposed. Hold the foreskin back with your nondominant hand.
- If the client is circumcised, simply hold the penis upright with your nondominant hand.
With the washcloth in your dominant hand, wash the penis, starting at the top, moving downward to the base.
With a clean area of the washcloth, or a new wet soapy washcloth, for each wipe, repeat Step 10 at least two more times, or as many times as needed until the entire penis has been washed.
Wash the scrotal area, starting in the front, moving to the back closest to the anal area last.
If using soap, wet the second washcloth in the washbasin and wring out excess water. Rinse the penis and scrotal area from front to back at least three times, using a clean area of the washcloth each time. Repeat a minimum of three times, more if needed to remove all soap.
- If using peri-cleanser, you do not need to rinse the perineum. Proceed to Step 14.
If the client is not circumcised, gently pull the foreskin back into place.
Gently pat the perineum dry with a towel.
While cleansing, check for drainage, or any red, rashy, or open areas of skin on or in the perineum.
- If any drainage or rashy areas are present, place the soiled washcloths and towel in the linen bag.
Ask the client to reach over himself, grab the side rail, and roll over. Assist the client if he is unable. Adjust the bath blanket and top sheet as needed to ensure privacy. Only the buttocks should be exposed.
Rewet the first washcloth, or use a clean washcloth, and wring out excess water.
Apply and lather a small amount of soap or peri-cleanser into the washcloth.
Wash the client’s buttocks. Wash the anal area from front to back at least three times, using a clean area of the washcloth each time. You may need to wash more than three times to clean the area completely. You may need to use several washcloths.
- When done, place these in the linen bag. Do not place these washcloths back in the washbasin.
If using soap, remove the second washcloth from the washbasin, or use a clean, wet washcloth, and wring out excess water. Rinse the anal area from front to back at least three times, using a clean area of the washcloth each time. Repeat a minimum of three times, more if needed to remove all soap.
- If using peri-cleanser, you do not need to rinse the buttocks and anal area. Proceed to Step 23.
- Place washcloth(s) in the linen bag.
Gently pat the buttocks and anal area dry with a towel.
- Place this towel in the linen bag.
While cleansing, check for drainage, or any red, rashy, or open areas of skin on buttocks or the anal area.
Apply barrier creams to the buttocks or anal area as indicated on the care plan. Do not apply any creams to open areas of the skin.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the side rail.
Complete your closing procedure steps.

Assisting with a Partial Bed Bath

When: A partial bed bath is given in the morning when the client gets up and in the evening before she goes to bed. The partial bed bath can be given in bed or while the client is sitting on the toilet, whichever the client prefers.

Why: The partial bed bath is a way to freshen up the client who is only taking a shower one to two times per week. It is an important time to take note of the integrity of the client’s skin.

What: Supplies needed for this skill include

Gloves
Basin of warm water
Two washcloths (minimum)
Two towels (minimum)
Bath blanket (if available)
Soap
Lotion, as desired by the client
Deodorant, as desired by the client

How:

Complete your opening procedure steps.
Offer to assist the client to the bathroom or bedside commode, or offer the bedpan or urinal before bathing.
Remove glasses and hearing aids that the client may be wearing. Store them in a safe place in the room to prevent falls and breakage.
Ask the client if the water is a comfortable temperature.
- Change the water during the bed bath if it becomes too dirty, cold, or soapy.
- Discard all wash water into the toilet.
Don gloves.
Wet one washcloth.
Ask the client if she prefers soap to wash her face.
- If so, apply and lather a small amount of soap into the washcloth.
- If not, just use the wet washcloth. Do not use soap on the face of a client with dementia.
Wring excess water out of the washcloth.
With a clean area of the washcloth, start at the inside corner of one eye and wipe toward the outer corner. Wash the second eye in the same manner with a clean area of the washcloth.
Open the washcloth completely and wash the client’s forehead, cheeks, chin, and neck.
If no soap was used on the client’s face, proceed to Step 13.
Wet the second washcloth in the washbasin. This is used to rinse the client’s face. Repeat Steps 8–10 with the rinse washcloth.
Then gently pat the client’s face and neck dry with a towel.
Uncover the client’s hands. Wash one hand at a time with the soapy washcloth.
Using the rinse washcloth, rinse the soap from the client’s hands, one hand at a time.
Then gently pat the hands dry with a towel.
Assist the client in removing her hospital gown or the pajama top, exposing only her upper body. Cover the top part of her body with a bath blanket, bed blanket, sheet, or towel.
Lift the client’s breasts and, with the soapy washcloth, wash underneath where the skin folds meet. Check for any red, rashy, or open areas of skin.
If there are any rashy areas under the breasts, after washing, rinsing, and drying this area:
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
Using the rinse washcloth, rinse the soap from under the client’s breasts.
Gently pat the area under the breasts dry with a towel.
Lay a dry towel across the client’s chest and breasts.
If the client has any abdominal folds, wash, rinse, and dry these areas as was done while washing under the breasts. If the client does not have any abdominal folds, proceed to Step 24.
Uncover one arm, and assist the client if she is unable to lift it. Wash the axilla.
Uncover the opposite arm and assist the client if she is unable to lift it. Wash the axilla.
Using the rinse washcloth, rinse the soap from under both arms.
Gently pat the area under the arms dry with a towel.
Apply deodorant, as desired by the client.
Cover the client so as to expose only the perineum.
Complete perineal care.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize as appropriate.
Apply lotion as desired by the client prior to assisting her in getting dressed.
Assist the client to put on a clean hospital gown or pajamas, or to dress in street clothes.
Replace glasses and hearing aids.
Don gloves.
Wring out excess water from the used washcloths. Place the soiled washcloths, towels, bath blanket, and hospital gown or pajamas in the linen bag.
Discard the water from the basin into the toilet. Rinse the basin and discard the rinse water into the toilet.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.
Report drainage and any red, rashy, or open areas of skin promptly to the nurse.

Assisting with a Complete Bed Bath

When: A complete bed bath is offered one to two times each week in lieu of the shower or tub bath on the client’s scheduled bath day.

Why: The complete bed bath may be more tolerable for the client who is embarrassed to be seen unclothed, who is in pain or otherwise not feeling well, who cannot physically sit on a shower or bath chair, or who does not like the shower or tub bath.

What: Supplies needed for this skill include

Gloves
Basin of warm water
Four washcloths (minimum)
Three towels (minimum)
Bath blanket (if available)
Soap
Lotion, as desired by the client
Deodorant, as desired by the client

How:

Complete your starting-up steps.
Offer to assist the client to the bathroom or bedside commode, or offer the bedpan or urinal before bathing.
Remove glasses and hearing aids that the client may be wearing. Store them in a safe place in the room to prevent falls and breakage.
Ask the client if the water is a comfortable temperature.
- Change the water during the bed bath if it becomes too dirty, cold, or soapy.
- Discard all wash water into the toilet.
Don gloves.
Wet one washcloth.
Ask the client if she prefers soap to wash her face.
- If so, apply and lather a small amount of soap into the washcloth.
- If not, just use the wet washcloth. Do not use soap on the face of a client with dementia.
Wring excess water out of the washcloth.
With a clean area of the washcloth, start at the inside corner of one eye and wipe toward the outer corner. Wash the second eye in the same manner with a clean area of the washcloth.
Open the washcloth completely and wash the client’s forehead, cheeks, chin, and neck.
If no soap was used on the client’s face, proceed to Step 13.
Wet the second washcloth in the washbasin. It is used to rinse the client’s face. Repeat Steps 8–10 with the rinse washcloth.
Then gently pat the client’s face and neck dry with a towel.
Uncover the client’s hands. Wash one hand at a time with the soapy washcloth.
Using the rinse washcloth, rinse the soap from the client’s hands, one hand at a time.
Then gently pat the hands dry with a towel.
Assist the client in removing her hospital gown or pajama top, exposing only her upper body. Cover the top part of her body with a bath blanket, bed blanket, sheet, or towel.
Working under the blanket, sheet, or towel, wash the client’s chest, breasts, and abdomen, and then rinse with the second washcloth to remove all soap and pat dry.
Be sure to lift the client’s breasts while washing, and, with the soapy washcloth, wash underneath where the skin folds meet. Check for any red, rashy, or open areas of skin.
If there are any rashy areas under the breasts, after washing, rinsing, and drying this area:
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
If the client has any abdominal folds, wash, rinse, and dry these areas as was done while washing under the breasts.
Ask the client to raise her exposed arm; assist her if she is unable to raise it. Place the dry towel lengthwise under the client’s arm to protect the bed linens. Lower the client’s arm to rest on top of the towel.
Rewet the first washcloth and wring out excess water. Apply and lather a small amount of soap.
Starting at her shoulder, wash the client’s entire arm, and then her hand and axilla.
Using the rinse washcloth, rinse the soap from the client’s shoulder, arm, hand, and axilla.
Gently pat the shoulder, arm, hand, and axilla dry with a towel.
Remove the towel from underneath the client’s arm and cover the client. Complete Steps 22–26 on the opposite arm.
Apply deodorant, as desired by the client.
Raise one side rail.
Assist the client in removing her pajama bottoms, if worn.
Expose the client’s back.
Place the dry towel lengthwise close to the client’s back to protect the bed linens.
Rewet the first washcloth and wring out excess water. Apply and lather a small amount of soap.
Starting at the base of her neck, wash the client’s entire back in long gliding strokes down to the upper crest of her hips.
Using the rinse washcloth, rinse the soap from the client’s back.
Gently pat the client’s back dry with a towel.
Apply lotion, as desired by the client.
Ask the client to return to the supine position. Assist the client if she is unable.
Expose one leg from the hip to the foot.
Ask the client to bend her knee and raise her foot. Assist the client if she is unable.
Place a towel lengthwise under the client’s leg to protect the bed linens. Ask the client to lower her leg, keeping it bent and keeping her foot flat on the bed. Assist the client if she is unable.
Starting at the client’s hip, wash the entire leg down to the ankle.
Using the rinse washcloth, rinse the soap from the client’s hip and leg.
Gently pat the hip and leg dry with a towel. Remove the towel from underneath the client’s leg.
Cover the client’s leg with the bath blanket, keeping her foot exposed.
Complete foot care.
If the client is unable to flex her knee to place her foot in a basin and maintain that position, place a towel under her foot.
Wash the entire foot with a soapy washcloth, including between the toes, looking for any areas of skin breakdown.
Rinse the foot with the rinse washcloth. Gently pat it dry with a towel, making sure to dry well between the toes.
If there are any rashy areas on the feet or between the toes, after washing, rinsing, and drying this area:
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
Apply lotion as desired to the client’s leg and foot.
- Do not apply lotion between the client’s toes.
Move to the opposite side of the bed.
Complete Steps 39–51 on the opposite extremity.
Wring out excess water from the used washcloths. Place the soiled washcloths, towels, and hospital gown or pajamas in the linen bag.
Discard the water from the basin into the toilet. Rinse the basin and discard the rinse water into the toilet.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Refill the basin with warm water.
Ask the client if the water is a comfortable temperature.
Don clean gloves.
Complete perineal care.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Assist the client to put on a clean hospital gown or pajamas, or to dress in street clothes.
Replace glasses and hearing aids.
Don gloves.
Wring out excess water from the used washcloths. Place the soiled washcloths, towels, bath blanket, and hospital gown or pajamas in the linen bag.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Complete your finishing-up steps.
Report drainage and any red, excoriated, or open areas of skin promptly to the nurse.

Assisting With a Shower

When: The shower is offered one to two times each week on the client’s scheduled bath day, or as requested by the client in acute care.

Why: The shower provides complete body bathing for the client. It encourages cleanliness and can be refreshing for the client. It is also a time when the nursing assistant can observe all areas of the skin for anything outside normal findings.

What: Supplies needed for this skill include

Gloves
Washbasin (optional)
Shower chair
Child’s potty seat (optional)
Three washcloths (minimum)
Six towels (minimum)
Shampoo
Soap
Conditioner, as desired by the client
Lotion, as desired by the client
Deodorant, as desired by the client
Clean clothes, including socks and shoes or nonskid slipper socks
Comb or brush
Disinfectant

How:

Complete your opening procedure steps.
Offer to assist the client to the bathroom or bedside commode, or offer the bedpan or urinal before bathing.
Transport the client to the shower room.
Remove glasses and hearing aids that the client may be wearing. Store them in a safe place in the room to prevent falls and breakage.
Help your client undress. Place soiled clothes, pajamas, or hospital gown in the linen bag.
Cover the client with a bath blanket. Put nonskid slipper socks on the client’s feet.
Lock the brakes on the shower chair and the wheelchair.
Transfer the client as indicated in the care plan onto the shower chair.
- If the client is very small, choose a small-sized shower chair. If a small shower chair is not available, consider placing a child’s potty seat in the seat of the shower chair, or wrap the shower seat with towels for comfort.
- If the client is very large, ensure that you are using a bariatric-approved shower chair.
Remove the nonskid slipper socks and gait belt if used, and set them aside in a clean place in the room.
- If the client’s legs are dangling, flip a washbasin over and ask the client to place her feet on top of the upside-down basin for comfort.
Turn the shower on, away from the client.
Adjust the water temperature until it is comfortably warm when testing it on the inside of your arm. Verify the water temperature by
- asking the client to hold out her hand while you run the stream of water over it.
- adjusting the water temperature until it is comfortable for the client.
Don gloves.
Cover the client’s breasts with one towel and her genital area with another.
- You can work around and underneath these towels during the entire bathing process.
- Or remove and place them in the linen bag if they make the client cold after getting wet.
Hold the stream of water over the client, covering her with water to keep her warm.
Ask the client if she prefers her hair to be washed. If so, hand the client a washcloth to cover her eyes. If not, proceed to Step 16.
- Saturate the client’s hair with the stream of water.
- Lather the shampoo through the hair, from the roots to the ends.
- Pick up the shower head and rinse all shampoo from the hair completely.
- If the client desires conditioner, lather conditioner into the client’s hair, from the roots to the ends.
- Pick up the shower head and rinse all conditioner from the hair completely.
- Ask the client to remove the washcloth from her eyes, and place it in the soiled linen bag.
Wet a washcloth under the stream of water and wring out excess water.
Ask the client if she would like soap on the washcloth to wash her face. If so, apply and lather a small amount of soap into the washcloth.
Hand the washcloth to the client to wash her face. Assist the client if she is unable.
If the client is able to wash any of the upper part of her body, rewet the washcloth, and apply and lather soap into it. Ask the client to wash.
Wet the second washcloth, apply and lather soap into it, and wash the client’s back.
If the client is unable to wash all or part of her upper body, continue to wash her where needed, starting from her neck and working down to her waist.
Lift the client’s breasts and any abdominal folds and wash well.
If there are any rashy areas under the breasts, after washing, rinsing, and drying this area:
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
Rewet the washcloth and reapply soap as needed throughout the bathing process.
After washing the client’s upper body, wash each leg entirely, starting at the hip and working down to the feet.
Wash the feet, making sure to inspect between the toes, looking for areas of skin breakdown.
- Wring out excess water from each washcloth used to wash the client’s body.
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
Pick up the shower head once more, and test the water temperature. Continue to adjust the water temperature until it is comfortable for the client.
Rinse the client’s body entirely. Make sure to lift the client’s breasts and all abdominal folds to rinse the soap out from under them completely.
Wet the third washcloth under the stream of water, and wring out excess water. Apply soap and lather into the washcloth.
Complete perineal care.
- You may need to use several washcloths for perineal care.
- When done, wring out excess water from each washcloth, and place them in the linen bag.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Don a clean pair of gloves.
Pick up the shower head once more, and test the water temperature. Continue to adjust the water temperature until it is comfortable for the client.
Rinse her perineal area completely.
Turn off the water.
Remove the towels from the client’s breasts and perineal area, if you have not done so already. Wring out excess water. Place the towels in the linen bag.
Place the bath blanket over the client for warmth if so desired.
Wrap the client’s head with a dry towel, gently squeezing her hair from the roots to the ends to wring out excess water, and place this towel in the linen bag.
Then drape a dry towel over the client’s head to help keep her warm.
With a dry towel, gently dry off the client’s body, paying attention to areas where there is skin-on-skin contact, such as under her breasts and abdominal folds, and between the toes.
- Use as many towels as necessary to dry the client completely.
- Place all used towels in the linen bag promptly.
Apply lotion and deodorant, as desired by the client.
Assist your client in dressing the upper part of her body. Put on her underpants and pants up to her thighs, and then her socks and shoes or nonskid slipper socks.
Lock the brakes on the shower chair and on the wheelchair.
When the client stands up from the shower chair, dry her buttocks; then pull up her underpants and pants.
Transfer the client to the wheelchair as indicated by the care plan.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Comb or brush the client’s hair. Apply makeup, if she desires. Replace glasses and hearing aids.
Transport the client to her desired location.
Return the client’s supplies to her room.
Don gloves. Disinfect the shower chair with a facility-approved disinfectant. Rinse thoroughly.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.
Report any drainage and red, excoriated, or open areas of skin promptly to the nurse.

Assisting With a Tub Bath

When: The tub bath is offered one to two times each week on the client’s scheduled bath day, or as requested by the client in acute care.

Why: The tub bath provides complete body bathing for the client. It encourages cleanliness and can be refreshing for the client. It is also a time when the nursing assistant can observe all areas of the skin for anything outside the normal findings.

What: Supplies needed for this skill include

Gloves
Three washcloths (minimum)
Six towels (minimum)
Cup or pitcher
Shampoo
Soap
Conditioner, as desired by the client
Lotion, as desired by the client
Deodorant, as desired by the client
Clean clothes, including socks and shoes or nonskid slipper socks
Comb or brush
Disinfectant

How:

Complete your opening procedure steps.
Offer to assist the client to the bathroom or bedside commode, or offer the bedpan or urinal before bathing.
Transport the client to the tub room.
Remove glasses and hearing aids that the client may be wearing. Store them in a safe place in the room to prevent falls and breakage.
Help your client undress. Place soiled clothes, pajamas, or hospital gown in the linen bag.
Cover the client with a bath blanket. Put nonskid slipper socks on the client’s feet.
Lock the brakes on the wheelchair.
Transfer the client as indicated in the care plan onto the tub chair.
- There are many types of whirlpool tubs; refer to the facility protocol for exact transferring information.
- If the client is very large, ensure that you are using a bariatric-approved tub chair.
Remove the nonskid slipper socks. Set them aside in a clean place in the room.
If using a tub with a hydraulic lift, raise the tub chair and swing the client’s legs over the side of the tub before lowering the client into the tub, or transfer the client into the tub after opening the tub door. The system you use will depend on the type of whirlpool tub the facility uses.
Turn the water on slowly so that it does not splash onto the client.
Adjust the water temperature until it is comfortably warm when testing it on the inside of your arm. Verify the water temperature by
- asking the client to hold out her hand while you run the stream of water over it.
- adjusting the water temperature until it is comfortable for the client.
Then plug and fill the tub and remove the bath blanket from the client.
After the tub is full or the level of the water is higher than the level of the jets, turn on the whirlpool jets.
Don gloves.
Cover the client’s breasts with a towel, if she desires.
- You can work around and underneath these towels during the entire bathing process.
- Or remove and place them in the linen bag if they make the client cold after getting wet.
Ask the client if she prefers her hair to be washed. If so, hand the client a washcloth to cover her eyes. If not, proceed to Step 18.
- Submerge the cup or pitcher under water to fill it. Pour the water over the client’s head to completely wet her hair, starting at the roots.
- Lather the shampoo through the hair, from the roots to the ends.
- Pour water over the client’s hair to remove all shampoo from the hair completely. Continue as many times as necessary until the hair is completely rinsed.
- If the client desires conditioner, lather the conditioner into the client’s hair, from the roots to the ends.
- Pour the water over the client’s hair to remove all conditioner from the hair completely. Continue as many times as necessary until the hair is completely rinsed.
- Ask the client to remove the washcloth from her eyes, and place it in the soiled linen bag.
Wet a washcloth and wring out excess water.
Ask the client if she would like soap on the washcloth to wash her face. If so, apply and lather a small amount of soap into the washcloth.
Hand the washcloth to the client to wash her face. Assist the client if she is unable.
If the client is able to wash any of the upper part of her body, rewet the washcloth, and apply and lather soap into it. Ask the client to wash.
Wet the second washcloth, apply and lather soap into it, and wash the client’s back.
If the client is unable to wash all or part of her upper body, continue to wash her where needed, starting from her neck and working down to her waist.
Lift the client’s breasts and any abdominal folds and wash well.
If there are any rashy areas under the breasts, after washing, rinsing, and drying this area:
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
Rewet the washcloth and reapply soap as needed throughout the bathing process.
After washing the client’s upper body, wash each leg entirely, starting at the hip and working down to the feet.
Wash the feet, making sure to inspect between the toes, looking for areas of skin breakdown.
- Wring out excess water from each washcloth used to wash the client’s body.
- Place the washcloths and towel in the linen bag.
- Remove gloves and discard into the wastebasket.
- Hand wash or hand sanitize.
- Don clean gloves.
Wring out excess water from each washcloth used to wash the client’s body. Place them in the linen bag.
Submerge the cup or pitcher to fill it, and pour the water over the client to rinse the soap from her upper body.
Lift the client’s breasts and all abdominal folds to rinse the soap out from under them completely.
Wet the third washcloth and wring out excess water. Apply and lather soap into the washcloth.
Wash the client’s genital area by submerging your hands and arms into the water.
You will not be able to wash the rectal area; the whirlpool action of the tub is designed to cleanse this area. Be sure to inspect the skin of the perineal area once the tub has been drained.
Wring out excess water from each washcloth and place these in the linen bag.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Don a clean pair of gloves.
Remove the towels from the client’s breasts, if you have not done so already. Wring out excess water. Place the towels in the linen bag.
Place the bath blanket over the client for warmth if so desired.
Unplug the tub and let it drain completely.
Wrap the client’s head with a dry towel, gently squeezing her hair from the roots to the ends to wring out excess water, and place this towel in the linen bag. Then drape a dry towel over the client’s head to help keep her warm.
With a dry towel, gently dry off the client’s body, paying attention to areas where there is skin-on-skin contact, such as under her breasts and abdominal folds, and between the toes.
- Use as many towels as necessary to dry the client completely.
- Place all used towels in the linen bag promptly.
Remove the client from the tub either by using the hydraulic lift or by opening the tub door.
Apply lotion and deodorant, as desired by the client.
Assist your client in dressing the upper part of her body. Put on her underpants and pants up to her thighs, and then her socks and shoes or nonskid slipper socks.
Lock the brakes on the tub chair and on the wheelchair.
When the client stands up from the shower chair, dry her buttocks and then pull up the underpants and pants.
Transfer the client to the wheelchair as indicated by the care plan.
Remove gloves and discard into the wastebasket.
Hand wash or hand sanitize, as appropriate.
Comb or brush the client’s hair. Apply makeup, if she desires. Replace glasses and hearing aids. Transport the client to her desired location. Return the client’s supplies to her room.
Don gloves. Disinfect the tub chair with a facility-approved disinfectant. Rinse thoroughly.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.
Report any drainage and red, excoriated, or open areas of skin promptly to the nurse.

Dressing and Undressing the Client

When: Dress clients in the morning as part of morning care to prepare them for the day. Clients

who have had a stroke or a traumatic brain injury may have one-sided weakness or paralysis. Undress the client at the end of the day as part of the evening care to prepare the client for bed.

Why: Dress and undress clients with an affected side in the proper order to prevent injury and pain. Use the technique listed in this skill for those that have an affected weak side. If the client does not have a weak side use these guidelines without need to address which side of the body is dressed or undressed first.

What: Supplies needed for this skill include

Client’s clothes and socks and shoes or nonskid slipper socks
Incontinence garment, as needed
Supplies for peri-care, as needed

How:

Shirt—Dressing

Complete your opening procedure steps.
Offer at least two choices of clothing to your client.
The client should be lying in bed, on her back. Identify which of the client’s sides is affected or weak.
Raise one side rail. Stand on the side of the bed where the side rail is not raised.
Don gloves if the client is incontinent.
Lower the top bed linens to the client’s waist.
First, remove the pajama top or hospital gown from the client’s arm on her unaffected side.
Then, remove the pajama top or hospital gown from the arm on her affected side. Be sure to support the joints of the affected arm during the process.
Guide the client’s affected arm through the bra strap, taking care to support the joints of the affected arm during the process. Then, guide her unaffected arm through the other bra strap.
Position the bra straps as high up on the client’s shoulder as possible. Tuck the bra under the client’s side that is closest to the raised side rail.
Ask the client to reach over herself, grab on to the side rail, and roll over. Assist her if she is unable.
Pull both ends of the back of the bra toward each other and fasten the bra on a hook that is comfortable for the client.
Ask the client to roll back to a supine position. Assist her if she is unable.
Position her breasts in the bra cups.

Shirt—Undressing

To undress the client perform these steps in the opposite order, starting with removing the bra. If the client has an affected or weak arm start with the unaffected side first and move towards the affected side for each layer of clothing.

Pullover

Guide the client’s hand on her affected side through the sleeve of the shirt that she has chosen to wear.
Bring the sleeve up the client’s arm as close to her shoulder as possible. Be sure to support the joints of the affected arm during the process.
Guide the client’s head through the neck of the shirt.
Guide her hand and arm on her unaffected side through the other shirt sleeve.
Pull the shirt down to cover as much of her upper body as possible.
Ask the client to reach across herself and grab on to the side rail and roll over. Assist her if she is unable. Pull the shirt down in back.
Ask the client to roll back to a supine position and then roll toward you. Assist her if she is unable. Pull the shirt down in back.
Ask the client to roll back to a supine position. Assist her if she is unable.
Pull the shirt down in front and straighten it as necessary.

Button Down

If the client has chosen a shirt that buttons, guide the affected hand through the sleeve of the shirt.
Bring the shirt sleeve up the client’s arm as close to her head as possible. Be sure to support the joints of the affected arm during the process.
Ask the client to reach over herself, grab on to the side rail, and roll over. Assist her if she is unable.
Pull the shirt up and over the client’s shoulder and cover as much of her back as possible. Tuck the other side of the shirt under the client.
Ask the client to roll back to a supine position and then roll toward you. Assist her if she is unable. Pull the shirt out from beneath her.
Ask the client to roll back to a supine position. Assist her if she is unable.
Assist the client to move her unaffected hand and arm through the shirt sleeve.
Button the shirt and straighten it as necessary.

Pants—Dressing

Remove the client’s pajama bottoms, if worn, by asking the client to reach over herself, grab on to the side rail, and roll over. Assist her if she is unable. Pull at the waistband to bring the pajama bottom down below the buttock.
Ask the client to roll back to a supine position and then roll toward you. Assist her if she is unable. Pull at the waistband to bring the opposite-side pajama bottom down below the other buttock.
Ask the client to roll back to a supine position. Assist her if she is unable.
Pull the pajama bottoms down the client’s legs and remove them.
Place the pajama bottoms at the foot of the bed or directly into the linen bag.
If the client is incontinent, remove and change the soiled bed protector or disposable underpad.
1. Discard the disposable underpad into the wastebasket immediately. If a bed protector is used, place the soiled bed protector in the linen bag. Place a clean bed protector or underpad under the client.
2. Complete perineal care.
3. Put a clean incontinence garment on the client.
4. Remove gloves and discard into the wastebasket.
5. Hand wash or hand sanitize, as appropriate.
If the client is continent, guide her feet through the leg openings of the underwear.
Pull the underwear as high up on her thighs as possible. Be sure to support the joints of the affected leg during the process.
Gather the pants that the client has chosen to wear together at the leg openings and the waistband. Pull the pants up on the client’s thighs as high as possible. Be sure to support the joints of the affected leg during the process.
Ask the client to reach over herself, grab on to the side rail, and roll over. Assist her if she is unable. Pull one side of the underwear and pants up over the client’s hip to her waist.
While you are holding the waist of the underwear and pants in proper position, ask the client to roll back to a supine position and then toward you. Assist her if she is unable. Pull the other side of the underwear and pants up over the client’s hip to her waist.
Ask the client to roll to the supine position. Assist her if she is unable.
Straighten, zip, and button the pants, if necessary.
Put the client’s socks and shoes or nonskid slipper socks on her feet.
Don gloves.
Place the soiled linens and hospital gown or pajamas into the linen bag.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Pants—Undressing

To undress the client perform these steps in the opposite order. If the client has an affected or weak leg start with the unaffected side first and move towards the affected side for each layer of clothing.

Dressing a Client With an IV

When: A client with an IV is dressed when desired by the client, or when the client requires a hospital gown change.

Why: The IV must not be disturbed when dressing a client or changing the client’s hospital gown that does not have snaps on the shoulders.

What: Supplies needed for this skill include:

A clean hospital gown or the client’s clothes, socks and shoes, or nonskid slipper socks

How:

Refer as necessary to the skill: Dressing and Undressing the Resident (above).
Complete your opening procedure steps.
Ask the client if he will be dressing in a hospital gown or pajamas or in his street clothes. If he will be dressing in street clothes, offer him at least two choices of clothing.
First, remove the pajama top or hospital gown or shirt from the client’s arm that does not have the IV inserted into it.
If the client is wearing a pullover, pull it over and then off of the client’s head and off of his unaffected arm.
Remove the IV from the IV pole.
Slide the sleeve from the client’s arm with your dominant hand while holding onto the IV bag with your nondominant hand.
Following the client’s arm, thread the IV bag and tubing through the sleeve. Ensure that there is no tugging or pulling on the IV tubing or insertion site.
Next, thread the IV bag and tubing through the clean hospital gown or shirt sleeve, then bring through the client’s hand and arm. Ensure that there is no tugging or pulling on the IV tubing or insertion site.
Replace the IV bag onto the IV pole.
Continue dressing the client’s opposite arm.
- If he is wearing a pullover, guide the client’s head through the neck of the shirt last.
- If the client is wearing street clothes, continue to assist him in dressing in his underwear, pants, socks, and shoes, or nonskid slipper socks.
Place the soiled hospital gown, pajamas, or clothing into a linen bag.
Complete your closing procedure steps.

Providing Oral Care for a Client With Natural Teeth

When: Oral care for clients should be provided every day in the morning upon waking, in the evening prior to going to bed, and after meals, if the client requests.

Why: Good oral hygiene promotes overall well-being, maintains the health of natural teeth, and is important for self-image.

What: Supplies needed for this skill:

Gloves
Emesis basin
Clothing protector, towel, or washcloth
Toothbrush
Toothpaste
Floss
Cup of tap water
Cup of mouthwash
Lip balm, as desired by the client

How:

Complete your opening procedure steps.
Raise the head of the bed until the client is in a high-Fowler’s position.
Don gloves.
Drape a clothing protector, towel, or washcloth across the client’s chest to protect his clothing.
- Some types of mouthwash are used prior to brushing. In that case, follow the labeled directions and start oral care with the mouthwash prior to brushing.
- If your client is cognitively challenged, do not offer mouthwash.
Wet the toothbrush, and apply a pea-size amount of toothpaste on the toothbrush.
Hold the toothbrush at a 45-degree angle to the gums.
Starting on the upper teeth at the back, brush the outer surface of each tooth, using a circular motion.
- Repeat for the lower teeth.
- Allow your client to spit toothpaste into the emesis basin, as necessary.
Use the tip of the brush.
Starting on the upper teeth at the back, brush the inner surface of each tooth, using a circular motion.
- Repeat for the lower teeth.
- Allow your client to spit toothpaste into the emesis basin, as necessary.
Use the flat surface of the toothbrush.
Starting on the upper teeth at the back, brush the chewing surface of each tooth.
Next, ask your client to stick out his tongue, and brush the surface of the tongue in a back-to-front motion.
Ask your client to spit out the excess toothpaste and saliva into the emesis basin.
Offer your client a cup of water to swish and spit into the emesis basin.
- You may need to wipe your client’s mouth with a paper towel after he has finished.
If your client is cognitively intact, you may offer a swish and spit of mouthwash at this time.
- If your client is cognitively challenged, do not offer mouthwash.
Pull out 18–24 inches of dental floss.
Wrap the floss around each of your index fingers until you have approximately 1 inch of floss between your two fingers.
Use the floss on the inside and in between each tooth.
Once you meet the gum line, make a “C” with the floss to follow the base of each tooth.
If the gums bleed, you may want to offer the client a swish and spit of water.
- You may need to wipe your client’s mouth with a paper towel after he has finished.
Empty, rinse, and dry the emesis basin. Rinse the toothbrush and place it in the emesis basin, along with the toothpaste and dental floss.
Apply lip balm, as your client desires.
Remove the soiled clothing protector, towel, or washcloth from the client’s chest and place it in the linen bag.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the head of the bed.
Complete your closing procedure steps.

Oral Care for an Unconscious Client

When: Provide oral care for an unconscious client in the morning and in the evening with am and hs cares.

Why: Good oral hygiene promotes overall well-being, maintains the health of natural teeth, and removes slough from the unconscious client’s mouth.

What: Supplies needed for this skill:

Gloves
Clothing protector, towel, or washcloth
A cup of tap water or mouthwash
Oral swabs
Lip balm

How:

Complete your opening procedure steps.
Position the client on his side, with the head of the bed slightly elevated.
Don gloves.
Place a clothing protector, towel, or washcloth alongside the client’s face and under the client’s chin.
Wet the oral swabs in the cup of mouthwash or water until just moistened. If needed, squeeze swab to remove excess fluid before placing in client’s mouth. Swab all surfaces of the mouth including the tongue, cheeks, and teeth.
- After each swab use, immediately discard the swab into the wastebasket. You may use a tongue depressor wrapped with gauze to open the mouth if needed; never place your fingers between the client’s teeth to open the mouth.
- Gently slide the gauze-wrapped tongue depressor between the client’s teeth, and slowly turn it sideways to slightly open the mouth for cleansing.
- Remove the tongue depressor and discard into the wastebasket after the inside surfaces of the mouth are clean.
Repeat Step 5 as many times as necessary until the oral swab no longer has particulate on it upon removal from the client’s mouth.
You may need to wipe your client’s mouth and face with the clothing protector, towel, or washcloth.
Apply lip balm.
Remove the soiled clothing protector, towel, or washcloth and place it in the linen bag.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Oral Care for a Client With Dentures

When: In the morning upon waking, in the evening prior to going to bed every day, and after meals, if the client requests.

Why: Good oral hygiene promotes overall well-being, maintains the cleanliness and integrity of the dentures, and is important for self-image.

What: Supplies needed for this skill:

Gloves
Emesis basin
Clothing protector, towel, or washcloth
Denture toothbrush
Toothpaste
Denture cup
Cup of tap water
Cup of mouthwash
Oral swabs, as necessary
Lip balm, as desired by the client

How:

Complete your opening procedure steps.
Raise the head of the bed to a high-Fowler’s position.
Don gloves.
Drape a clothing protector, towel, or washcloth across the client’s chest to protect his clothing.
Rinse out the denture cup.
Ask the client to remove his dentures. Assist him if he is unable. Remove the bottom plate first, then the top plate.
- To remove the top plate, slide your index finger along the gum line all the way to the back.
- Hook the tip of your finger on the back of the plate, and pull downward to break the suction.
- You may need to wipe your client’s mouth with a paper towel after removal.
Place the dentures in the emesis basin. Take the emesis basin to the sink in the bathroom.
Place a barrier in the bathroom sink such as a washcloth or towel, or plug the drain and fill the sink with warm water.
Apply a pea-size amount of toothpaste on the denture toothbrush.
Brush one plate at a time, making sure to brush all surfaces. Rinse the plate and place in the rinsed denture cup. Rinse the toothbrush.
Complete Steps 9–10 for the second plate.
Return to your client while he is still endentulous, or without teeth, and offer a swish and spit of mouthwash. You may need to wipe your client’s mouth with a paper towel after he has finished spitting.
- If your client is cognitively challenged, offer only water.
- You may also use a moistened oral swab in lieu of the swish and spit for cognitively challenged clients. Discard the used oral swab in the wastebasket.
Next, ask your client to stick out his tongue. Brush the surface of the tongue in a back-to-front motion with either a toothbrush or a moistened oral swab. Discard the used oral swab in the wastebasket. Offer a swish and spit of water as needed.
If the client is replacing the dentures immediately, bring the dentures back to him in the denture cup. Offer the top plate first, then the bottom plate. Assist him if he is unable.
If the client will not be placing the dentures back in his mouth immediately, you may store the dentures in the rinsed cup full of water, or a half water/half mouthwash solution.
Apply lip balm, as your client desires.
Rinse and dry the emesis basin. Rinse the toothbrush and place it in the emesis basin along with the toothpaste.
Remove the soiled clothing protector, towel, or washcloth from the client’s chest and place in the linen bag.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the head of the bed.
Complete your closing procedure steps.

Shampooing Hair in Bed

When: The client should have the hair washed at least one time each week, or more often when requested. Shampooing is done on the scheduled bath day.

Why: To keep hair clean, healthy, and manageable.

What: Supplies needed for this skill include:

Gloves
Basin of warm water
Bucket
Washcloth
Four towels (minimum)
Bed protector
Shampoo trough
Cup or pitcher
Shampoo
Conditioner, as desired by the client
Comb or brush

How:

Complete your opening procedure steps.
The client should be lying in bed on her back, with the bed flat.
Remove glasses and hearing aids that the client may be wearing. Store them in a safe place in the room to prevent falls and breakage.
Ask the client if the water is a comfortable temperature.
Don gloves.
Remove the pillow from under the client’s head and place it on a clean surface, such as the chair.
Ask the client to lift her head. Assist her if she is unable.
Place a bed protector under the client’s head, with the bed protector slightly hanging over the side of the bed where you will place the bucket.
Position the shampoo trough on top of the bed protector, under the client’s head. The spout should be hanging over the same side of the bed as the bed protector. Position a bucket on the floor next to the bed, directly underneath the spout of the trough.
Place a towel folded lengthwise under the client’s neck on top of the trough.
Ask the client to lay her head back so that her neck is resting on the towel. Assist her if she is unable.
Place a washcloth folded lengthwise over the client’s eyes. Ask the client to hold it in place if she can.
Submerge the cup or pitcher in the basin of water to fill it. Pour the water over the client’s head to completely wet her hair, starting at the roots.
Place a small amount of shampoo in the palm of your hand, and then rub your hands together to evenly distribute the shampoo before rubbing it into the hair. Lather the shampoo through the hair, from the roots to the ends.
- Note any red, open, or scabbed areas on the scalp or behind the ears.
With the second towel, wipe the excess lather from your hands.
Submerge the cup or pitcher in the basin of water to fill it. Pour the water from the cup or pitcher over the client’s hair to remove all shampoo, starting at the roots.
If the client desires conditioner, place a small amount in the palm of your hand, and then rub your hands together to evenly distribute the conditioner before rubbing it into the hair. Lather the conditioner into the hair, from the roots to the ends.
- If the client does not want conditioner, proceed to Step 20.
With the second towel, wipe the excess conditioner from your hands. Place this towel in the linen bag.
Pour the water from the cup or pitcher over the client’s head to remove all conditioner from her hair, starting at the roots.
Gently squeeze the client’s hair from the roots to the ends to wring out excess water.
Remove the washcloth from the client’s eyes and place it in the linen bag.
Ask the client to lift her head. Assist her if she is unable.
Remove the trough from the bed, leaving the bed protector in place. Place the trough on the overbed table. Remove the towel from under the client’s neck and place it in the linen bag.
Wrap the client’s head with the third dry towel, gently squeezing her hair from the roots to the ends to wring out excess water. Lay the client’s head on the bed protector.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Raise the head of the bed to a Fowler’s position.
Ask the client to lift her head. Assist her if she is unable.
Remove the bed protector from behind the client’s head and place it in the linen bag.
Place the pillow behind the client’s head. Cover the pillow with the fourth towel.
Remove the third towel from the client’s head, and towel dry her hair as needed with this towel, and then place it in the linen bag. Remove the towel from the pillow and place it in the linen bag.
Comb or brush the client’s hair. Replace glasses and hearing aids.
Complete your closing procedure steps.
Report any red, open, or scabbed areas promptly to the nurse.

Combing the Client’s Hair

When: After the client’s hair has been washed or when the client requests.

Why: To meet the grooming needs as well as to preserve the client’s right of dignity by looking presentable prior to leaving the room.

What: Supplies needed for this skill:

Comb or brush, hair product as desired by the client

How:

Complete your opening procedure steps.
Ask the client how she prefers her hair to be styled.
Using the preferred comb or brush gently comb or brush the client’s hair as desired without pulling or tugging. The client may prefer you wet the comb or brush prior to combing or brushing the hair. Be mindful of glasses or hearing aids that might be bumped during combing or brushing.
Use any styling product that the client desires as per manufacturer’s directives.
Once styled ensure the client is pleased with the way the hair looks, then return the comb or brush.
Complete your closing procedure steps.

Fingernail and Hand Care

When: Provide fingernail and hand care every bath day and as needed.

Why: To trim long nails, prevent nails from ripping and cracking, prevent scratches, and cleanse the hands.

What: Supplies needed for this skill:

Gloves
Basin of warm water
Two washcloths
Towels
Soap
Nail clipper
Alcohol wipes
Emery board
Orange sticks
Lotion
Nail polish remover, as needed
Cotton balls, as needed
Nail polish, as desired by the client

How:

Complete your opening procedure steps.
Verify with the care plan, or nurse that the client is not diabetic. Nursing assistants cannot clip the fingernails of a diabetic client. If the client is diabetic, omit Step 11 and report to the nurse that the nails need clipping.
Cover the overbed table with a towel or paper towels and place your assembled supplies on it, including the basin of warm water. Raise the head of the bed up to a high-Fowler’s position.
Don gloves.
Ask the client if the water is a comfortable temperature. Change the water in the basin as often as necessary if it becomes too cold, dirty, or soapy.
Place one of the client’s hands in the basin of water and allow it to soak for 2–5 minutes.
Wet one washcloth in the basin and squeeze out the excess water. Lather soap on the wet washcloth. Gently lift the client’s hand out of the water and wash the entire hand, including between the fingers.
Hang the soapy washcloth on the side of the basin.
Wet the rinse washcloth in the basin, remove it, and squeeze the excess water over the top of the client’s hand to rinse off the soap. Repeat as necessary.
Dry the hand with a clean towel. Remove the basin of water.
Clip each nail as necessary along its natural curve to a comfortable length for the client. Leave approximately 1/4 inch of nail beyond the skin.
- Clippings can be placed on the towel or directly in the wastebasket.
Use the emery board to file the edges of the nail. File in one direction only. Do not “saw” the emery board back and forth, since that motion may cause the nail to become rough or cracked.
Use the flat end of the orange stick to remove dirt from underneath the nail. Swipe one time with the orange stick and wipe residue on the towel. Continue this process until each nail is clean, using as many orange sticks as necessary.
Repeat Steps 6–13 on the opposite hand.
Apply lotion to her hands and polish to her nails, as desired by your client. If necessary, remove any old polish first with fingernail polish remover and cotton balls prior to applying new polish.
Lower the head of the bed, if the client is in bed. Position to comfort.
Empty, rinse, and dry the basin. Discard the emery board and the orange sticks in the wastebasket. Clean the nail clipper with the alcohol wipes.
If your client is cognitively challenged, do not leave the nail clipper in her room. Return it to the nurse or place it in the designated area.
Place soiled washcloths and towels in the linen bag. If nail clippings were placed on the towel, gently shake the towel over the wastebasket prior to placing it in the linen bag.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Providing Foot Care

When: Provide foot care every bath day and as needed.

Why: To trim long nails, prevent nails from ripping and cracking, and cleanse the feet.

What: Supplies needed for this skill:

Gloves
Basin of warm water
Bed protector or disposable incontinence pad
Bath blanket
Two washcloths
Towels
Soap
Nail clipper, preferably a toenail clipper
Emery board
Lotion
Alcohol wipes

How:

Complete your opening procedure steps.
Verify with the care plan, or nurse that the client is not diabetic. Nursing assistants cannot clip the toenails of a diabetic client. If the client is diabetic, omit Step 15 and report to the nurse that the nails need clipping.
Raise the head of the bed to a semi-Fowler’s position. If the client is lying under the bed linens, fanfold the top linens to the foot of the bed. Place the bed protector on top of the fitted sheet near the foot of the bed. Cover the top half of the client with a bath blanket.
Don gloves.
Ask the client if the water is a comfortable temperature.
Remove the client’s sock and roll her pant leg up above her ankle. Expose only one foot at a time. Flex the client’s knee to a 45-degree angle so that her foot rests flat on the pad. Place the basin of warm water on top of the bed protector.
Ask the client to lift her exposed foot and lower it into the basin of water. Assist her if she is unable.
Allow the client’s foot to soak for 2–5 minutes.
Wet one washcloth in the basin and squeeze out the excess water. Lather soap on the wet washcloth. Gently lift the client’s foot out of the water, and wash the entire foot, including in between the toes.
Place the foot back into the basin.
Hang the soapy washcloth on the side of the basin.
Wet the rinse washcloth in the basin. Gently raise the foot again and squeeze the excess water out of the second washcloth over the top of the client’s foot to rinse off the soap. Repeat as necessary.
Dry the foot with a clean towel, including in between the toes to prevent infection.
Remove the basin of water, and gently set the client’s foot on the bed protector.
Clip the nail along the natural curve of the nail to a comfortable length for the client. Do not get too close to the skin. If the nail is too thick to cut, notify the nurse.
Use the emery board to file the edges of the nail as needed. File in one direction only. Do not “saw” it back and forth, since that motion may cause the nail to become rough or cracked.
Empty the washbasin and refill it with clean water. Ask the client if the water is a comfortable temperature.
Complete Steps 6–16 for the opposite foot.
Warm a small amount of lotion in your hands and apply to her feet, as desired by the client. Do not put lotion in between the toes. Wipe off excess lotion with a clean towel.
Lower the pant legs, replace bed linens, lower the head of the bed, and position to comfort.
Empty, rinse, and dry the basin. Discard the emery board in the wastebasket. Clean the nail clipper with the alcohol wipes.
Place the soiled bed protector, washcloths, and towels in the linen bag. If nail clippings were placed on the towel or bed protector, gently shake linens over the wastebasket prior to placing it in the linen bag.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.
Report any red, open, or excoriated areas of skin promptly to the nurse.

Shaving a Face With an Electric Razor

When: Shave male clients each morning after bathing, or as needed. Female clients may also request to be shaved, usually on an as-needed basis.

Why: Preserve client dignity by ensuring the client looks presentable prior to leaving the room.

What: Supplies needed for this skill:

Two pairs of gloves
Electric razor
Razor brush/cleaning tool
Aftershave or lotion, as desired by the client

How:

Complete your opening procedure steps.
Raise the head of the bed to a high-Fowler’s position.
Don gloves.
Gently pull the skin taut over the area to be shaved.
If the razor has three rotating heads, move across the entire area to be shaved in small, rotating circles.
If the razor has a flat head, shave the area in the direction of the hair growth.
- Shave the cheeks in a downward motion.
- Ask the client to tuck in his lips, and shave the upper lip and chin area in a downward motion.
- Ask the client to look at the ceiling, and shave the neck using upward strokes to the chin and jaw line.
Apply aftershave or lotion, as your client desires.
Place the soiled washcloths and towels in the linen bag.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the head of the bed.
Don a clean pair of gloves.
Remove the head of the razor. Using the manufacturer’s cleaning brush, brush out hair and dead skin cells onto a dry paper towel placed on a flat surface or directly into a wastebasket. Discard paper towel into the wastebasket.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Plug in the razor to recharge the battery.
Complete your closing procedure steps.

Shaving a Face With a Disposable Razor

When: Shave male clients each morning after bathing, or as needed. Female clients may also request to be shaved, usually on an as-needed basis.

Why: Preserve client dignity by ensuring the client looks presentable prior to leaving the room.

What: Supplies needed for this skill include:

Gloves
Basin of warm water
Washcloth
Two towels
Shaving cream or soap
Disposable razor
Aftershave or lotion, as desired by the client
Sharps container as needed

How:

Complete your opening procedure steps.
Verify with the care plan, or nurse that shaving with a disposable razor is not contraindicated (i.e., if the client is on blood thinners).
Raise the head of the bed to a high-Fowler’s position. Drape a towel across the client’s chest and shoulders to protect his clothing.
Don gloves.
Wet the washcloth. Offer the client the warm wet washcloth to soften his hair follicles. Assist him if he is unable.
Apply shaving cream or soap to all areas that are to be shaved. Use a towel to wipe excess shaving cream from your hands.
Remove the cover from the disposable razor. If the razor blade is dull, dispose of the razor in the sharps container and replace it with a new one.
Gently, pull the skin taut.
Using short downward motions, shave the cheeks.
Rinse the razor in the water basin between each stroke. Change the water in the basin as necessary.
Ask the client to tuck in his lips to make the skin taut around the upper lip and chin. You may gently pull the skin taut to facilitate this.
In a downward motion, shave the upper lip and chin area.
Ask the client to look up at the ceiling.
Using short upward strokes, shave the neck to the chin and jaw line.
When shaving is complete, wipe off excess shaving cream or soap with the washcloth, dry the client’s face and neck with a towel, and apply aftershave or lotion, as your client desires.
Remove the towel from the client’s chest and shoulders. Place the soiled washcloths and towels in the linen bag.
Empty, rinse, and dry the wash basin.
Remove gloves and discard in the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the head of the bed.
Complete your closing procedure steps.

Changing an Incontinence Garment

When: An incontinence garment should be changed every 2 hours or more frequently when soiled.

Why: An incontinence garment is changed to maintain the integrity of the skin and to keep the client clean, dry, and odor free. Peri-care is to be performed with each incontinent garment change.

What: Supplies needed for this skill include

Gloves
Bed protector, as needed
Supplies for performing peri-care
Barrier creams, as needed
Incontinence garment

How:

Complete your opening procedure steps.
The client should be lying in bed, on his back with the bed flat. Fanfold the bed linens to the client’s knees.
Raise one side rail. Move to the opposite side of the bed where the side rail is not raised.
Don gloves.
If the client is wearing a hospital gown, pull it up slightly to expose the perineum. If the client is wearing pajama bottoms, lower them to his knees (refer to skill: Dressing and Undressing the Client).
If the bed protector under the client is soiled, remove and replace it with a clean one. Place the soiled bed protector in the linen bag. If there is no bed protector under the client, place one under him to protect the bed linens from becoming soiled.
If the client was incontinent, complete perineal care (refer to skills: Assisting With Female Perineal Care and Assisting with Male Perineal Care). Apply barrier cream as indicated on the care plan. Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Don a clean pair of gloves.
Ask the client to reach over himself, grab onto the side rail, and roll over. Assist him if he is unable.
Open the incontinence brief. Position the brief on the bed so that the back side of the brief will be under and aligned with the client’s buttocks. The back side of the brief has the fastening tabs attached to it.
Tuck one side of the incontinence brief under the hip that the client is lying on.
Ask the client to roll back to the supine position. Assist him if he is unable.
Roll him slightly toward you to free the side of the brief from under the hip. Pull free the side of the brief that you tucked under the client.
With the client lying on his back with the bed flat, pull the incontinence brief up and over the perineal area. Ensure that the brief is even on both sides, providing complete coverage over the perineal area. Fasten the tabs on each side of the brief.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Continue to dress the client (refer to skill: Dressing and Undressing the Client).
Complete your closing procedure steps.

Assisting the Client to the Commode or Toilet

When: Assist the client to the commode or toilet every two hours or as requested by the client.

Why: To empty the bowel and/or bladder.

What: Supplies needed for this skill include

Toilet paper
Adult wipes

How:

Complete your opening procedure steps.
Verify the client’s level of assistance as listed on the care plan.
Position the wheelchair perpendicular to the toilet so the client can grasp the grab bars next to the toilet. Lock the brakes on the wheelchair.
Ensure the client has shoes or non-skid slipper socks on his feet.
Apply a gait belt if indicated on the care plan. Ask the client to assist you during the transfer by grasping the grab bars or pushing his body upward off the arms of the wheelchair to a standing position on the count of three.
Stand on the side of the client. Ensure that his feet are flat on the floor. Assume a wide base of support, bending at the knees.
Grasp the gait belt if used. On the count of three, assist the client to a standing position.
Instruct the client to pivot until the edge of the toilet seat is behind his legs. Lower pants and undergarments.
On the count of three, lower his body to a seated position onto the toilet.
Ensure that the client’s hips and buttocks are towards the back of the toilet seat and that he is properly aligned.
Allow the client time to use the toilet.
Once complete assist the client with cleaning the peri area as needed. Complete hand hygiene as needed.
Ask the client to grasp the grab bars and on the count of three to stand. Reposition undergarments and pants.
Instruct the client to pivot until the edge of the wheelchair is behind his legs.
Ask the client, on the count of three, to lower his body to a seated position into the wheelchair.
Ensure that the client’s hips and buttocks are towards the back of the wheelchair and that he is properly aligned.
Complete your closing procedure steps.

Assisting the Client With a Urinal

When: The nursing assistant assists the client to use a urinal when the client requests.

Why: A urinal is used by the male client who prefers it to using a bedpan, commode, or toilet.

What: Supplies needed for this skill include:

Gloves
Urinal
Bed protector
Washcloth, as necessary

How:

Complete your opening procedure steps.
Cover the chest of drawers with a towel or paper towels and place your assembled supplies on it. Do not place the urinal on the overbed table.
The client should be lying in bed, on his back with the bed flat. Fanfold the bed linens to the client’s knees. The client may want to sit on the side of the bed or stand; assist as needed following the client’s care plan.
Don gloves.
If the client is wearing a hospital gown, pull it up slightly to expose the perineum. If the client is wearing pajama bottoms, lower them to his knees (refer to skill: Dressing and Undressing the Client).
If the bed protector under the client is soiled, remove and replace it with a clean one. Place the soiled bed protector in the linen bag. If there is no bed protector under the client, place one under him to protect the bed linens from becoming soiled.
Line the opening of the urinal with the washcloth if it is uncomfortable for the client or if he has fragile skin.
Ask the client to position the urinal. If he is unable, place his penis inside of the urinal between his thighs. Adjust the bed linens as necessary to cover the client.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Raise the head of the bed to a semi-Fowler’s position.
Provide privacy for the client. Hand him the call light and ask him to use it when done using the urinal.
Once the client has finished with the urinal, don gloves, pull back the linens, and remove the urinal with your dominant hand, being careful not to spill the contents. If the urinal was lined with a washcloth, remove it with your nondominant hand and place it in the linen bag. With your nondominant hand, adjust the bed linens as necessary to cover the client.
Empty the contents of the urinal into the toilet and rinse it. Measure the urine output if the client is on intake and output, as indicated on the care plan (refer to skill: Measuring Urine Output From a Urinal).
Empty the rinse water into the toilet and rinse. Repeat as necessary until the urinal is clean. Dry the urinal with paper towels and discard them into the wastebasket. Place the urinal in the designated storage area in the client’s room.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Assisting the Client With a Bedpan

When: The nursing assistant assists the client to use a bedpan when the client requests.

Why: A bedpan is used for the client who is bed bound, who cannot physically sit on a toilet or commode, whose transferring equipment does not fit in the bathroom, or who prefers to not walk to the toilet or use a commode during the night.

What: Supplies needed for this skill include

Gloves
Bedpan, traditional or fracture as indicated on the care plan
Adult wipes or toilet paper
Bed protector

How:

Complete your opening procedure steps.
Cover the chest of drawers or a nearby chair with a towel or paper towels and place your assembled supplies on it. Do not place the bedpan on the overbed table.
The client should be lying in bed, on his back with the bed flat.
Raise one side rail. Move to the opposite side of the bed where the side rail is not raised.
Don gloves.
If the bed protector under the client is soiled, remove and replace it with a clean one. Place the soiled bed protector in the linen bag. If there is no bed protector under the client, place one under him to protect the bed linens from becoming soiled.
Ask the client to reach over himself, grab onto the side rail, and roll over. Assist him if he is unable.
Adjust the bed linens as necessary to ensure privacy as the client rolls over, but be sure not to let the linens come between the bedpan and the client when he rolls back.
Place the bedpan against the client’s buttocks, with the deepest part of the well closer to his feet. Remember “deep to feet.”
- If using a traditional bedpan, it should look like the client is sitting on a toilet seat.
- If using a fracture bedpan, the thinnest part of the pan should be against the client’s sacrum.
Holding the bedpan in place so that it does not shift, ask the client to roll back to the supine position.
- Release the bedpan once the client is lying securely on top of it.
- Look between the client’s legs to ensure proper placement of the bedpan.
- Adjust the bed linens as necessary to cover the client.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Lower the side rail.
Raise the head of the bed to a semi-Fowler’s position.
Provide privacy for the client. Hand him the call light, and ask him to use it when done using the bedpan.
Once the client has finished with the bedpan, lower the head of the bed until he is lying flat in bed.
Raise the side rail. Move to the opposite side of the bed where the side rail is not raised.
Don gloves.
Hold the bedpan in place against the bed protector.
Ask the client to reach over himself, grab onto the side rail, and roll over. Assist the client if he is unable by keeping hold of the bedpan with your dominant hand and assisting him to roll with your nondominant hand.
Remove the bedpan and place it on the corner of the bed protector.
Wipe the client with adult wipes until he is clean. Discard the wipes into the wastebasket.
With your dominant hand, take the bedpan off the bed protector. Ask the client to roll back to the supine position. Assist him if he is unable.
With your nondominant hand, adjust the bed linens as necessary to cover the client.
Empty the contents of the bedpan into the toilet and rinse it. Empty the rinse water into the toilet. Repeat as necessary until the bedpan is clean. Dry the bedpan with paper towels and discard them into the wastebasket. Place the bedpan in the designated storage area in the client’s room.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Bowel and Bladder Retraining

When: When a client has an overactive bladder, possibly combined with incontinence.

Why: To help the client regain bladder and bowel control and extend the amount of time in between bathroom trips.

What: Supplies needed for this skill include

None

How:

Complete your opening procedure steps.
Identify the time in between use of the toilet for the client. This will be found in the client’s care plan.
Remind the client of instructions from the nurse if bathroom trips are requested in between the time frames listed on the care plan. Support the client’s self esteem.
Care for any incontinent episodes that may occur by supporting cleansing of the area and change of clothing as needed.
Document voiding times. Report any distress to the nurse.
Complete your closing procedure steps after each client interaction.

Care of the Client With Tubing (IV, Nasogastric, Gastrostomy)

When: Caregiving for the client can occur during the morning or evening care times, or as needed or requested by the client throughout the day.

Why: It is important for the nursing assistant to be mindful of all tubing during caregiving so as to not injure the client or disrupt the purpose of the tubing.

What: Supplies needed for this skill include

None

How:

Complete your opening procedure steps.
Identify based on the client’s care plan if tubing is in place and if so, which type.
When caregiving be mindful to maintain slack on the tubing at all times. Always avoid any tugging or pulling.
For IV tubing:
- Look at the IV insertion site. If it is red, swollen or painful report this to the nurse immediately.
- Dress the client by first removing the IV bag from the IV pole and inserting the IV bag into the sleeve of the shirt followed by the hand and arm. Promptly place the IV bag back on the IV pole. Then assist the client in placing the opposite arm into the second sleeve.
For nasogastric tubing:
- Ensure the adhesive tape is in good repair and fully adhered across the client’s nose.
- Keep the nasogastric bag of contents on the IV pole when in use.
- To dress the client in a pullover top when the nasogastric tube is in use, take the nasogastric bag of contents on the IV pole and feed through the head opening of the top followed by placing the top over the client’s head and down to the shoulders. Replace the nasogastric bag of contents on the IV pole and proceed to assist the client with getting the arms through the top.
- If the nasogastric tubing is not in use delivering contents from the bag, ensure the tubing is properly secured to prevent any pulling or tugging.
For gastrostomy tubing:
- Ensure the adhesive tape is in good repair and fully adhered on the client’s stomach and the tube is attached to this when not in use.
- Keep the gastrostomy bag of contents on the IV pole when in use.
- When dressing a client be sure the pants do not rub against the gastrostomy tube insertion site or pinch the tubing in any way.
Complete the caregiving needs.
Complete your closing procedure steps.

Care of an Indwelling Catheter

When: Complete catheter care while performing peri-care, after washing the genital area, and before washing the anal area.

Why: An indwelling catheter is used when the catheter has to stay in the bladder for a long period of time. Keeping the catheter clean decreases the likelihood of a urinary tract infection developing.

What: Supplies needed for this skill include

Gloves
Basin of warm water
Soap or peri-cleanser
Bath blanket
Two washcloths
One towel
Bed protector

How:

Complete your opening procedure steps.
The client should be lying in bed, on her back with the bed flat. Fanfold the bedspread and blanket to the foot of the bed. Cover the client’s upper body with the bath blanket. Pull down the top sheet to the client’s thighs so that only the perineal area is exposed. Ensure that there is a bed protector under the client; if not place one under her prior to washing.
Ask the client if the water is a comfortable temperature.
Don gloves.
Disconnect the catheter tubing from the catheter holder.
Wet the washcloth and wring out excess water. Apply and lather a small amount of soap or peri-cleanser.
Ask the client to bend her knees and separate her legs. Assist the client to separate her legs if she is unable to bend her knees.
Hold onto the catheter closest to the client’s body with the thumb and index finger of your nondominant hand.
With your dominant hand, wash the catheter, starting closest to the body and moving downward approximately 4 inches.
Repeat Steps 8 and 9 at least three times, or until the catheter is clean. Use a clean area of the washcloth with each wipe.
If using soap, wet the second washcloth and wring out excess water. Repeat Steps 8 and 10 with the rinse washcloth until all soap is removed. Use a clean area of the washcloth with each wipe.
Continuing to hold onto the catheter closest to the client’s body, pat the entire catheter dry with a towel.
Reconnect the catheter tubing to the catheter holder.
Pull the top sheet over the client’s upper body. Remove the bath blanket. Adjust the bed linens as necessary to cover the client and position her as desired.
Place the soiled linens in the linen bag.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Changing a Collection Bag to a Leg Bag

When: Change the indwelling catheter bag to a leg bag when the ambulatory client gets up, usually in the morning, and after naps. Change the leg bag back to the indwelling catheter bag before the client lies down to rest and goes to bed at night.

Why: Use a leg bag to encourage the client to ambulate and be independent without embarrassment. Use the indwelling bag when the client is lying down to decrease the risk of urine back flow into the bladder, potentially causing a urinary tract infection.

What: Supplies needed for this skill include:

Gloves
Bath blanket
Clamp
Leg bag
Leg bag fasteners
Alcohol wipes
Bed protector

How:

Complete your opening procedure steps.
The client should be lying in bed, on her back, with the bed flat. Fanfold the bedspread and blanket to the foot of the bed. Cover the client’s upper body with the bath blanket. Pull down the top sheet to the client’s thighs so that only the perineal area is exposed. Ensure that there is a bed protector under the client; if not, place one under her prior to washing.
Ask the client if the water is a comfortable temperature.
Don gloves.
Disconnect the catheter tubing from the catheter holder.
Clamp the catheter just below the junction of the two ports.
Remove the cap from the leg bag.
Remove the urinary drainage bag tubing from the catheter port. Place the cap from the leg bag on the end of the urinary drainage bag tubing. Set aside.
Open two alcohol wipes. Wipe the open port of the catheter with one and the opening of the leg bag with the other. Discard the wipes into the wastebasket.
Insert the leg bag into the urinary catheter port until it meets resistance.
Unclamp the catheter.
Fasten the leg bag to the client’s thigh with the manufacturer’s straps. Offer to place a washcloth under leg bag where it lies against skin for comfort.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Replace client’s clothing, and assist the client to a seated position.
Don gloves.
Empty and clean the urinary drainage bag per your facility’s policy. Measure urinary output. Place the clamp and urinary drainage bag in the designated storage area in the client’s room.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.

Assisting With the Delivery of Oxygen via Nasal Cannula

When: Oxygen is delivered when ordered by the physician for chronic or acute respiratory disorders. The task is delegated by the nurse with each use.

Why: To ensure the efficiency and effectiveness of machine operations.

What: Supplies needed for this skill include:

Oxygen nasal cannula
Oxygen tubing
Oxygen source

How:

Complete your opening procedure steps.
Verify that the oxygen supply is on and is flowing at the rate indicated in the care plan.
Verify that the oxygen tubing is securely fastened to the oxygen source and is free of obstructions and kinks.
Position the bottom of the loop of the nasal cannula tubing in front of the client.
Align the nasal prongs with the client’s nostrils so that the curve of the prongs is facing toward the client.
Insert the cannula, with one prong in each nostril.
Place one side of the tubing loop over the top of the client’s ear. Place the other side of the tubing loop over the top of the opposite ear.
- Verify that the skin is intact and not reddened behind the ear while placing the tubing.
- If the skin is red or open, report this to the nurse.
Bring the sliding connector on the loop up toward the client’s chin until there is a comfortable fit for the client.
Complete your closing procedure steps.

Assisting With the Delivery of Oxygen via Mask

When: Oxygen is delivered when ordered by the physician for chronic or acute respiratory disorders. The task is delegated by the nurse.

Why: Supplemental oxygen increases oxygen saturation levels and decreases shortness of breath and other respiratory distress symptoms.

What: Supplies needed for this skill include:

Oxygen mask
Oxygen tubing
Oxygen source

How:

Complete your opening procedure steps.
Verify that the oxygen supply is on and is flowing at the rate indicated in the care plan.
Verify that the oxygen tubing is securely fastened to the oxygen source and is free of obstructions and kinks.
Verify that the tubing is securely fastened to the oxygen mask.
Place the mask over the client’s nose and mouth.
Place the elastic strap over the top of the client’s head and position it above the ears. Adjust the strap so that it is tight enough to keep the mask in place, yet comfortable for the client. Pinch the metal nose piece across the bridge of the client’s nose to help secure the mask in position.
Complete your closing procedure steps.

Use of an Oxygen Concentrator

When: An oxygen concentrator is used for clients requiring supplemental oxygen. The concentrator is used when the client is in her room.

Why: Delivery of oxygen via a concentrator is more cost effective than delivery via portable tanks.

What: Supplies needed for this skill include:

Oxygen concentrator
Nipple adapter or humidification bottle
Oxygen tubing

How:

Complete your opening procedure steps.
Plug in the oxygen concentrator.
Screw on the nipple adapter or the humidification bottle to the oxygen port as indicated in the care plan.
Turn the concentrator on.
Verify that the concentrator is at the flow rate indicated in the care plan.
- If it is not, ask the nurse to adjust to the flow rate as prescribed.
Verify that the oxygen tubing is securely fastened to the nipple adapter or humidification bottle and is free of obstructions and kinks.
- If a humidification bottle is being used, the water inside should be bubbling from the force of the oxygen moving through. If it is not bubbling, the oxygen is not flowing properly, and you must troubleshoot the problem.
Place the nasal cannula or face mask on the client.
Complete your closing procedure steps.

Routine Maintenance of an Oxygen Concentrator

To keep the oxygen concentrator working properly and to keep your clients safe, follow the following guidelines:

Keep the oxygen concentrator at least 12 inches way from the wall.
Keep the oxygen concentrator at least 5 feet away from heat sources, such as heaters and radiators.
Remove the filter from the back of the concentrator and rinse it under cool tap water. Pat it dry with paper towels and replace it prior to using the machine.
Only use distilled water in the humidification bottles.
Service the concentrator when a red light appears or an alarm sounds.
Do not smoke when the concentrator is in use.

Emptying a Collection Bag and Measuring Urine Output

When: Empty the collection bag when it becomes too full and at the end of each shift.

Why: Urine must be emptied to prevent a back flow of urine into the bladder. The amount must be recorded and documented at the end of each shift.

What: Supplies needed for this skill include

Gloves
Alcohol wipes
Graduate or urinal
Paper towels

How:

Complete your opening procedure steps.
Don gloves.
Place paper towels on the floor directly under the urinary drainage bag. Place the graduate or urinal on top of the paper towels.
Wipe the drainage port of the urinary drainage bag with an alcohol wipe. Discard the wipe into the wastebasket.
Open the drainage port and allow all urine to drain from the bag into the graduate or urinal. Make sure that the tip of the drainage port does not touch the inside of the graduate or urinal.
Once all urine has been drained, wipe the drainage port with an alcohol wipe. Discard the wipe into the wastebasket. Close the drainage port.
Pick up the graduate or urinal and the paper towels from the floor. Discard the paper towels into the wastebasket.
Place clean paper towels on the bathroom countertop. Place the graduate or urinal on top of the paper towels.
Bend at the knees to measure the urine in the graduate or urinal at eye level. Measure the amount of urine to the closest 25 mL hash line.
Empty the contents of the graduate or urinal into the toilet. Rinse the graduate or urinal and empty the contents into the toilet. Repeat as necessary. Dry the graduate or urinal with paper towels. Discard the paper towels into the wastebasket. Place the graduate or urinal in the designated storage area in the client’s room.
Remove gloves and discard into the wastebasket. Hand wash or hand sanitize, as appropriate.
Complete your closing procedure steps.
Record the amount of urine if indicated on the care plan.

Applying Anti-Embolism Stockings

When: Anti-embolism stockings are applied to clients following surgery, or are applied to immobile clients at risk for developing blood clots. Apply in the morning before the client gets out of bed.

Why: Anti-embolism stockings help reduce the risk of developing blood clots.

What: Supplies needed for this skill include:

Anti-embolism stockings

How:

Complete your opening procedure steps.
The client should be lying in bed, on her back.
Adjust the bed linens as necessary to expose one leg up to the knee.
Hold the stocking up in front of yourself and locate the heel.
Place your dominant hand into the stocking and grasp the heel with your fingertips. Pull the stocking inside out down to the heel. The leg of the stocking will then be inside out covering the foot of the stocking.
Your dominant hand should be holding the stocking by the heel with pursed fingers and positioned so that you are looking at the tips of the fingers on your dominant hand. Reach the fingers of your nondominant hand into the foot of the stocking, and at the same time, slide the fingers of your dominant hand around to the opposite side of the foot of the stocking. Both thumbs are on the outside of the stocking.
Holding on to the stocking with both hands, slide the foot of the stocking over the client’s toes, foot, and heel. Pull the stocking up to the client’s knee.
Eliminate any wrinkles in the stocking. Ensure that the stocking is in the correct position by verifying that the heel of the stocking is over the client’s heel. If it is not in the correct position, remove the stocking and start over.
Adjust the bed linens as necessary to cover the client’s leg.
Move to the opposite side of the bed and repeat Steps 3–9 on the opposite leg.
Complete your closing procedure steps.

Taking an Oral Temperature With a Digital Thermometer

When: Take a client’s temperature on the scheduled bath day, per the facility’s routine, or during an episodic illness when delegated by the nurse.

Why: A temperature outside the normal range can indicate illness.

What: Supplies needed for this skill include

Digital thermometer
Sheath, if available
Alcohol wipes

How:

Complete your opening procedure steps.
Ensure that your client does not have any gum or food in his mouth, has not had frozen food or hot liquids, and has not smoked within the last few minutes. If so, wait approximately 15–20 minutes before taking the temperature.
If plastic sheaths are not used with the thermometer, clean the stem of the thermometer (the end that is inserted into the client’s mouth) with an alcohol wipe. Then, discard the alcohol wipe into the wastebasket. If plastic sheaths are used with the thermometer, cover the thermometer with the sheath.
Turn on the thermometer by pressing the colored button on its top. Verify that the thermometer is on. The thermometer screen will read “low,” or display the ambient temperature.
Ask the client to open his mouth and raise his tongue. Place the thermometer along one side underneath the tongue, with the tip midway back toward the posterior aspect of the tongue. Ask the client to lower his tongue and close his mouth around the thermometer.
Ask the client to hold the thermometer in place until it beeps. When the thermometer beeps, remove it from the client’s mouth. Obtain the temperature from the thermometer’s screen.
If the client’s temperature is out of normal limits, retake it by repeating Steps 3–6.
- You must turn off the thermometer and then turn it back on to clear the original reading.
- If you feel the temperature reading was in error due to client noncompliance with placement, you may want to use a different method of taking the temperature, such as axillary.
If the temperature is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
If a sheath was used, remove and discard it into the wastebasket. Clean the stem of the thermometer with an alcohol wipe, and discard the wipe into the wastebasket.
Record the results.
Complete your closing procedure steps.

Taking an Axillary Temperature With a Digital Thermometer

When: Take a client’s temperature on the scheduled bath day, per the facility’s routine, or during an episodic illness when delegated by the nurse.

Why: A temperature outside the normal range can indicate illness.

What: Supplies needed for this skill include

Digital thermometer
Sheath, if available
Alcohol wipes

How:

Complete your opening procedure steps.
If plastic sheaths are not used with the thermometer, clean the stem of the thermometer (the end that is inserted in the client’s axilla) with an alcohol wipe. Discard the alcohol wipe into the wastebasket. If plastic sheaths are used with the thermometer, cover the thermometer with the sheath.
Turn on the thermometer by pressing the colored button on its top. Verify that the thermometer is on. The thermometer screen will read “low,” or display the ambient temperature.
Assist the client in removing one arm from his sleeve to easily access the axilla. Ask the client to raise his arm; assist if he is unable. Place the thermometer tip directly in the center, deepest fold of the axilla, and ask the client to lower his arm around the thermometer.
Hold the thermometer in place until it beeps. When the thermometer beeps, remove it from the client’s axilla. Obtain the temperature from the thermometer’s screen.
If the client’s temperature is out of normal limits, retake it by repeating Steps 3–5.
1. You must turn off the thermometer and then turn it back on to clear the original reading.
2. If you feel the temperature reading was in error due to client noncompliance with placement, you may want to use a different method of taking the temperature, such as using the temporal artery scanner.
If the temperature is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
If a sheath was used, remove and discard it into the wastebasket. Clean the stem of the thermometer with an alcohol wipe and discard the wipe into the wastebasket.
Record the results.
Complete your closing procedure steps.

Taking a Tympanic Temperature

When: Take a client’s temperature on the scheduled bath day, per the facility’s routine, or during an episodic illness when delegated by the nurse.

Why: A temperature outside the normal range can indicate illness.

What: Supplies needed for this skill include

Tympanic thermometer
Thermometer probe sheaths (covers)

How:

Complete your opening procedure steps.
Ensure that the client does not have hearing aids in his ears. If the client does have hearing aids in place, remove one and put it in a safe place.
Remove the thermometer from its holder, if applicable. Place a thermometer sheath over the tip of the thermometer according to directions.
If taking a child’s temperature, pull the ear back and slightly downward. If taking an adult’s temperature, pull the ear back and slightly upward. Insert the tip of the thermometer into the client’s ear until you have a snug fit.
Turn on the thermometer by pressing the colored button on the top. Keep the button depressed and thermometer in place until the thermometer beeps, or for the manufacturer’s recommended amount of time.
Release the button and remove the thermometer from the client’s ear. Obtain the temperature from the thermometer’s screen.
If the temperature is out of normal limits, retake the temperature by repeating Steps 3–6. You must remove and discard the thermometer cover, and then replace it with a new cover to clear the original reading.
If the temperature is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
Remove the thermometer cover and discard it into the wastebasket. Return the thermometer to its holder, if applicable. Place the client’s hearing aids back in his ears, if applicable.
Record the results.
Complete your closing procedure steps.

Counting Heart Rate—Radial Pulse

When: Take a client’s pulse on the scheduled bath day, per the facility’s routine, during an episodic illness, or when delegated by the nurse.

Why: A heart rate outside the normal range can indicate illness or injury.

What: Supplies needed for this skill include

Watch with a second hand

How:

Complete your opening procedure steps.
Get close to the client, preferably in a seated position in a chair next to the client.
The client should be supine or seated.
Ask the client to get into a comfortable position and to try to move as little as possible during this procedure.
Assist the client in moving his hand so that it is resting comfortably on the bed or the chair, the wrist perpendicular to the bed or the chair.
Using your index and middle fingers, locate the pulse found on the thumb side of the client’s wrist. Press hard enough to feel the pulse, but not so hard as to occlude it. Once you have located the pulse, note the time on your watch.
Count each beat felt for a total of 60 seconds. If you lose the pulse for any period of time, stop and restart from Step 4.
The total number of beats felt in the 60-second time frame is the heart rate. If the client’s heart rate is out of normal limits, retake it by repeating Steps 4–7.
If the heart rate is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
Record the results.
Complete your closing procedure steps.

Counting Heart Rate—Apical Pulse

When: Take a client’s pulse on the scheduled bath day, per the facility’s routine, during an episodic illness, or when delegated by the nurse.

Why: A heart rate outside the normal range can indicate illness or injury.

What: Supplies needed for this skill include

Stethoscope
Alcohol wipes

How:

Complete your opening procedure steps.
Locate the apical pulse. This is found under the left breast area. Provide for privacy.
Place a cleaned and warm stethoscope over the apical pulse.
Ask the client to be still and not speak during this measurement.
Count the pulse for one minute. Each “lub-dub” is one beat. If the heart rate is regular you may count for 30 seconds and then multiply by two for your beats per minute.
Complete your closing procedure steps.

Counting Respirations

When: Take a client’s respirations on the scheduled bath day, per the facility’s routine, during an episodic illness, or when delegated by the nurse.

Why: A respiratory rate outside the normal range can indicate illness or injury.

What: Supplies needed for this skill include

Watch with a second hand

How:

Complete your opening procedure steps.
Get close to the client, preferably in a seated position in a chair next to the bed.
The client should be supine, and may have the head of the bed elevated for comfort.
Ask the client to get into a comfortable position and to try to move as little as possible during this procedure.
Assist the client in moving his hand so that it is resting comfortably on the bed, the wrist perpendicular to the bed.
Do not tell the client you are counting respirations.
Using your index and middle fingers, locate the pulse on the thumb side of the client’s wrist.
While holding on to the client’s wrist, observe the client’s chest and abdomen. If the client is a “chest breather,” observe the rise and fall of his chest. If the client is a “stomach breather,” observe the rise and fall of his abdomen. Each rise and fall of the chest or abdomen indicates one respiration. Once you have determined the breathing pattern, note the time on your watch.
Count all respirations for a total of 60 seconds. If you lose count of the respirations for any period of time, stop and restart from Step 4. The total number of respirations in the 60-second time frame is the respiratory rate. If the client’s respiratory rate is out of normal limits, recount it by repeating Steps 4–9.
If the respiratory rate is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
Record the results.
Complete your closing procedure steps.

Taking Blood Pressure With a Stethoscope and a Sphygmomanometer

When: Take a client’s blood pressure on the scheduled bath day, per the facility’s routine, during an episodic illness, or when delegated by the nurse.

Why: A blood pressure outside the normal range can indicate illness or cardiac events.

What: Supplies needed for this skill include

Stethoscope
Sphygmomanometer
Alcohol wipes

How:

Complete your opening procedure steps.
Select an appropriate size sphygmomanometer for your client.
Clean the stethoscope bell, diaphragm, ear pieces, and tubing with alcohol wipes. Clean the tubes of the blood pressure cuff and the gauge with alcohol wipes. Discard the wipes into the wastebasket.
Ask the client to sit with his legs and ankles uncrossed. If the client is in bed, raise the head of the bed to a high-Fowler’s position.
Remove the client’s arm from his sleeve to expose the antecubital and upper arm area. If the client is wearing a short-sleeve shirt, push the sleeve up to his shoulder.
Support the client’s arm so that the upper arm is resting at the level of his heart. This can be done by physically holding the arm with your nondominant hand, positioning with pillows, or placing the arm on the overbed table.
Position the client’s arm so that his palm is facing upward. Wrap the blood pressure cuff around the top portion of the client’s arm, with the tubes of the sphygmomanometer toward his hand.
Fasten the Velcro so that the cuff is snug on the client’s arm. You should be able to fit at least one finger between the cuff and the client’s arm. The bottom edge of the cuff should be approximately 1 inch above the bend of his arm. The colored mark on the bottom edge of the cuff should be over the brachial artery.
With your dominant index and middle fingers, palpate the brachial artery, which is found in the inner aspect of the antecubital area, or palpate the radial artery. Place the gauge on a hard surface where the face is easy to see. The needle of the gauge should be on zero. If not, replace the sphygmomanometer.
Place your index and middle fingers over the brachial or radial artery and inflate the cuff until the pulse is no longer felt. Deflate the cuff and let the client’s arm rest for a minimum of 1 to 2 minutes. Note the measurement where the last pulse was felt.
Look at the stethoscope to determine the correct positioning before placement. The stethoscope ear pieces should be pointing away from your face, in the direction that your nose points. Place the ear pieces in your ears and adjust for comfort.
Test to ensure the diaphragm is open by gently tapping the diaphragm with your finger. If it is muted, twist the diaphragm and bell clockwise half of a rotation until it locks into place. Retest by gently tapping the diaphragm with your finger. The noise will be markedly louder when the diaphragm is open.
Instruct the client not to move or talk during the measurement.
Place the open diaphragm of the stethoscope over the brachial artery; keep it in place with your nondominant hand. Ensure the valve on the sphygmomanometer is closed. To close the valve, turn the knob clockwise until it stops turning.
Inflate the cuff 30 mmHg higher than the measurement of the last brachial pulse felt. Open the valve slowly to start deflating the cuff. When blood starts to flow into the artery, you will hear the first beat, or Korotkoff sound. The first beat heard is the systolic pressure. Remember this number.
Deflate the cuff slowly, listening for each beat until the last is heard. Note the measurement of the last sound heard; this is the diastolic pressure.
Completely open the valve to release the rest of the air. Remove the sphygmomanometer from the client’s arm.
If the blood pressure is out of normal limits, allow the client to rest for approximately 5 minutes; then repeat Steps 13–17.
If the blood pressure is still out of normal limits, update the nurse and complete any special directives from the nurse such as other vital signs or delegated comfort interventions.
Lower the head of the bed, if applicable.
Clean the stethoscope bell, diaphragm, ear pieces, and tubing with alcohol wipes. Clean the tubes of the blood pressure cuff and the gauge with alcohol wipes. Discard the used alcohol wipes into the wastebasket.
Record the results.
Complete your closing procedure steps.

Ambulating a Client With a Cane or Walker—One Assist and a Gait Belt

When: The client is ambulated to and from the bathroom, into and out of the dining room, and for daily exercise for the distance indicated on the care plan.

Why: Ambulation helps maintain muscle mass, mobility, activity tolerance, and even self-esteem. Ambulation also helps decrease the risk of constipation, pressure sores, and other problems due to immobility. Always use a gait belt when ambulating a client who is a one-assist transfer, as indicated on the care plan.

What: Supplies needed for this skill include

Gait belt
Wheelchair

How:

Complete your opening procedure steps.
The client should already have on socks and shoes, or nonskid slipper socks.
Lock the brakes on the wheelchair.
- Remove the wheelchair leg rests, if in use.
- Ensure that the client’s feet are not twisted and are flat on the floor.
- Remove reminder devices or restraints, and deactivate any alarms.
Place the gait belt around the client and fasten.
If the client has an affected or weak side, stand on that side and hold the gait belt on that side. Remain on that side for ambulation.
With an underhand grasp, take hold of the gait belt over the client’s hip so that you are slightly behind and slightly to the side of the client.
Ask the client to place his hands on the wheelchair armrests and push his body upward to a standing position, on the count of three.
On the count of three, assist the client to a standing position.
- Unlock the brakes on the wheelchair.
- Continue to hold the gait belt in an underhand grasp.
- With the other hand, grasp the arm rest of the wheelchair.
If using a walker, place the walker in front of the client and ask the client to grasp with each hand. If using a cane, offer the cane to the client’s strong or unaffected side. Ensure the client has a firm grasp of either the cane or the walker. Allow the client time to find her balance before beginning ambulation.
Ask the client to begin ambulating. Follow slightly behind and slightly to the side of the client, pulling the wheelchair during the ambulation to use if the client becomes unsteady, faint, or dizzy.
- If another nursing assistant is available, ask him to push the wheelchair behind the client.
- Encourage the client to ambulate as far as he can tolerate, allowing for rest periods, sitting in the wheelchair when necessary.
When the client is finished ambulating, place the wheelchair directly behind him so that the edge of the wheelchair seat is behind and touching his legs.
- Lock the brakes on the wheelchair.
- Instruct the client to grasp the arms of the wheelchair and, on the count of three, to lower his body to a seated position.
On the count of three, assist the client to a seated position, holding the gait belt.
Ensure that the client’s hips and buttocks are against the back of the wheelchair and that he is properly aligned.
Place the leg rests on the wheelchair, if indicated by the care plan, and position the client’s legs appropriately.
Remove the gait belt.
Replace reminder devices or restraints, and reactivate any alarms, as indicated by the care plan.
Unlock the brakes on the wheelchair.
Complete your closing procedure steps.

Range-of-Motion Exercises

When: Complete range-of-motion exercises with am and pm cares, or as directed by the care plan.

Why: To prevent contractures, and to maintain strength and mobility.

What: Supplies needed for this skill:

None

How:

Complete your opening procedure steps.
Check the care plan to identify which joints require range-of-motion exercises and which specific exercises.
Ask the client to assist in the range-of-motion exercises as much as possible if performing active range-of-motion exercises.
Perform each exercise a minimum of three times. Check the care plan for special directives.
Tell the client that if at any time it is painful or uncomfortable to alert you, and that you will stop the exercises.
Support the joints by holding the joint with one cupped hand and use your opposite hand to complete the exercise.
Move the joints smoothly and slowly until resistance is met. Never force the joint(s) past the point of resistance.
Complete your closing procedure steps.

Report Appropriate Information to Charge Nurse

When: When anything out of the normal limits in the client’s condition occurs.

Why: To promptly communicate any important information to the nurse so further assessment can be completed.

What: Supplies needed for this skill include

None

How:

Complete your opening procedure steps.
Complete caregiving for the client as per the care plan.
If any vital sign, behavior, functioning, level of care required, or skin integrity outside of the normal limits are noted, report both subjective and objective information to the nurse promptly.
Complete your closing procedure steps.

Document Vital Signs and ADLs Timely and Correctly

When: Each shift after care is completed.

Why: To ensure a complete and accurate client record.

What: Supplies needed for this skill include

Black pen or computer

How:

Complete your starting-up steps.
Complete caregiving or any required tasks such as vital signs for the client as per the care plan.
Complete your finishing-up steps.
Accurately document caregiving associated with ADLs, and other information such as vital signs, intake and output and other requirements specific to the client in the client’s flow sheets or chart as per the facility policy.

Use only black ink
Print legibly
Record in a timely fashion
Maintain confidentiality during and after the documentation process
Only document care and tasks that you have completed yourself
Sign your name
Should an error occur, draw one line through the error, correct the mistake, and initial the error

Document Changes in Client’s Body Functions and/or Behavior

When: As client changes occur.

Why: To ensure a complete and accurate client record.

What: Supplies needed for this skill include

Black pen or computer

How:

Complete your opening procedure steps.
Complete caregiving for the client as per the care plan.
If any new or changing behavior or level of functioning is noted, report both subjective and objective information to the nurse promptly.
Complete written documentation as per facility policy after reporting orally to the nurse.
Complete your closing procedure steps.

Closing Procedure

Ensure that the bedside table is within reach

Ask if the client needs anything before you go

Put bed in low position with side rail up, making sure bed is still locked

Remove gloves, if worn

Provide call light within reach

Open privacy curtain

Wash hands