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Reuter-Sandquist M; Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Assistant [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Assistant [Internet].

Chapter 5: Provide for Personal Care Needs of Clients

5.1. INTRODUCTION TO PROVIDE FOR PERSONAL CARE NEEDS OF CLIENTS

Learning Objectives

• Provide for personal grooming and hygiene

• Assist with nutrition and fluid needs

• Assist client with bowel and bladder elimination

• Maintain a urinary catheter

• Assist client with bowel and bladder retraining

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

5.2. ACTIVITIES OF DAILY LIVING (ADLS)

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

Figure 5.1

Activities of Daily Living

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

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

Assisting with grooming, such as shaving or hair care, and applying makeup, accessories, or jewelry per resident preference

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

References

5.3. PERSON-CENTERED CARE

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

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

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

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

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

References

This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 ↵.

This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 ↵.

This work is a derivative of Opening Eyes onto Inclusion and Diversity by Carter (Ed.) and is licensed under CC BY-NC 4.0 ↵.

5.4. PRE- AND POST-PROCEDURAL STEPS

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

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

Supplies: Many supplies are kept in the resident’s room, but ask yourself if anything is needed that is not available in the room. Being prepared prevents disruption of the procedure and possible delays that can result in discomfort for the resident.

Knock: Always knock before entering a room, even if the door is open. Knocking maintains dignity for the client and shows respect for their privacy.

Wash: Always perform hand hygiene when entering the resident’s room to reduce the risk of transmitting pathogens from other residents, equipment, or environmental surfaces.

Introduce and Identify: Introduce yourself to the resident with your name and your title or position at the facility. Identify the client following facility policy. For example, properly identifying a client in a hospital setting may include asking them their name and date or birth and checking their medical ID band. However, in a long-term care setting, some residents may have cognitive or sensory deficits and may not correctly state their own name, so asking their name is not always a safe manner to identify them. Instead, identification in long-term care settings is typically performed by using a photograph in the medical record or by asking another experienced staff member to confirm identification.

Privacy: Provide privacy by closing the door and pulling the privacy curtain to ensure dignity when providing personal care.

Explain: Explain what care you will be providing so the resident can ask questions or decline care if it is not desired at that time.

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

Comfort: Ask if the resident is comfortable and if they need anything else such as tissues, water, TV remote, etc.

Light, Lock, and Low: Place the resident’s call light within reach so they can call for staff when they need assistance. Check the brakes on the bed to ensure they are locked, and the bed won’t move. Place the bed in the lowest position. These and other measures such as ensuring bed and/or chair alarms are in place and turned on are vital for ensuring patient safety. If a resident decides to self-transfer out of bed instead of requesting assistance, locking and lowering the bed will reduce the risk of injury because it is lower to the floor and won’t move suddenly out from underneath them.

Open: Open the door and privacy curtain. For safety reasons, residents must be within staff eyesight when they are alone in their rooms, unless they are physically able to move independently.

Wash: Perform hand hygiene before leaving the room to reduce the risk of transmitting pathogens to another resident, equipment, or environmental surfaces.

Document: Ask yourself if you provided any cares that should be documented in the medical record or if you need to report anything to the nurse or other staff member. Routine cares (i.e., those cares provided to every resident every day) are not necessarily documented unless they are declined or something out of the ordinary occurred or was observed. Follow agency policy regarding documentation.

5.5. SKIN CARE

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

Figure 5.2

Layers of the Skin

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

Figure 5.3

Age-Related Changes in the Skin

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

Figure 5.4

Age-Related Changes in Skin

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

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

Skin Care Needs of Older Adults

Due to less oil and sweat production as one ages, daily showering or full body bathing is not necessary and can even be damaging to skin. Additionally, residents in long-term care settings don’t typically venture out into the community regularly, thus reducing their exposure to pathogens. Due to these factors, daily partial baths are provided to maintain hygiene, but full body bathing is typically performed only weekly.

It is important to adequately dry skin folds and moisturize the skin regularly to maintain skin integrity and prevent dryness, cracking, and infection. Additionally, clients who are immobile should be repositioned at least every two hours to reduce the risk of pressure injuries. Repositioning techniques can be found in Chapter 8.

Chronic Conditions Affecting Skin Integrity

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

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

Figure 5.5

Wounds on the Foot of a Client With Diabetes

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

References

This work is a derivative of Nursing Fundamentals by Chippewa Valley Technical College and is licensed under CC BY 4.0 ↵.

Balmain, B. N., Sabapathy, S., Louis, M., & Morris, N. R. (2018). Aging and thermoregulatory control: The clinical implications of exercising under heat stress in older individuals. BioMed Research International , 2018, 8306154. ↵ 10.1155/2018/8306154. [PMC free article : PMC6098859 ] [PubMed : 30155483 ] [CrossRef]

5.6. TYPES OF BATHS AND TECHNIQUES

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

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

Figure 5.6

Shower Chair With Transfer Bench

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

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

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

Considerations During Bathing

Nursing assistants should maintain privacy and comfort for those receiving assistance with bathing. Residents can become uncomfortable due to many factors during bathing. For example, if they require transportation to the shower area in the hallway on a shower chair, the chair can be uncomfortable or cold, or they may be concerned about being exposed. Bath blankets should be placed over the resident, paying attention to tucking the blanket behind the resident’s back and underneath their legs to keep any skin from showing. Residents should also wear shoes or socks to prevent any skin injuries to feet. A towel over the top of their head can assist in keeping them warm, and the shower chair can be padded around the seat with towels or washcloths. Often the seat back is made of mesh to aid in water drainage, which can be covered with a towel to prevent irritation to the resident’s back and shoulders. If the resident’s feet don’t reach the support bar of the chair, a wash basin can be turned upside down and placed under their feet to give them a more secure feeling during transport. There is an increased risk for patient falls during bathing, and NAs must take appropriate measures to prevent falls due to unsteadiness or wet floors or equipment.

During the bath, the aide should work from head to toe to prevent spreading pathogens from the perineal area to other parts of the body. Start with the face and neck, then proceed to the front and back of the upper body, then the front and back of the legs, and finish with the perineal area. The aide must ensure gloves are changed and hand hygiene is performed immediately after performing perineal care. See Skills Checklists 5.18 and 5.19 regarding performing perineal care for more information.

Because much of the body’s heat is lost through the head, it may be preferable to wash the resident’s hair last. Provide the resident with a dry washcloth or towel to cover their face and prevent shampoo from getting in their eyes. Gently tipping the head back will keep the majority of the water from falling onto their face.

When assisting a client with bathing, there are several things to observe, consider, and report to the nurse:

Report any open or reddened areas; dry, flaky skin; bruises; rashes; or irritation. Check all areas of the skin, especially where moisture can be trapped, such as underneath breasts, in abdominal and groin folds, in armpits, and between the toes. If a client has an existing wound or skin breakdown, the nurse should be notified prior to the bath so that an assessment can be completed.

Report subjective or objective signs of pain. For example, the client may pull away when a painful area on their body is touched with a washcloth.

See Skills Checklists 5.9-5.13 for performing specific steps for each type of bath and shampooing a client’s hair.