Nurse Assistant Training Third Edition

American Red Cross

Nurse Assistant Training
Textbook
This textbook is part of the American Red Cross Nurse Assistant Training program. By itself,
it does not constitute complete and comprehensive training. Visit redcross.org to learn more
about this program.

The emergency care procedures outlined in this book reflect the standard of knowledge and
accepted emergency practices in the United States at the time this book was published. It is
the reader’s responsibility to stay informed of changes in emergency care procedures.

The infection control procedures outlined in this book reflect the current standards and
guidelines of the Centers for Disease Control (CDC) and Occupational Safety and Health
Administration (OSHA) in the United States at the time this book was published. Because
regulations influencing these standards and guidelines change frequently and because laws
are redefined, it is the reader’s responsibility to stay current with information such as infection
control by attending in-service courses offered by employers or through other sources.

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© 2013 American National Red Cross. ALL RIGHTS RESERVED.

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trademarks of The American National Red Cross and protected by various national statutes.

Published by Krames StayWell Strategic Partnerships Division

Printed in the United States of America

ISBN: 978-1-58480-582-3
This textbook is dedicated to the employees and volunteers of the
American Red Cross who contribute their time and talent to supporting
and teaching caregiving skills worldwide, and to the students who have
decided to make a career out of helping others.

How far you go in life depends on your being tender with the young, compassionate with
the aged, sympathetic with the striving, and tolerant of the weak and strong—because
someday in life you will have been all of these.
—George Washington Carver
 C O NTE NTS
UNIT 1
THE ART OF CAREGIVING 1
1 Being a Nurse Assistant 2
2 Working in the Health Care System 12
3 Understanding Legal and Ethical Aspects of Health Care 22
4 Understanding the People in Our Care 31
5 Communicating with People 44

UNIT 2
PROMOTING SAFETY 57
6 Controlling the Spread of Infection 58
7 Preventing Injuries 76
8 Responding to Emergencies 89

UNIT 3
PROVIDING CARE 102
9 Measuring Vital Signs, Weight and Height 103
10 Maintaining a Comfortable Environment 125
11 Providing Restorative Care 140
12 Assisting with Positioning and Transferring 158
13 Assisting with Personal Cleanliness and Grooming 187
14 Assisting with Meals and Fluids 228
15 Assisting with Elimination 245
16 Promoting Comfort and Rest 274
17 Assisting with Admissions, Transfers and Discharges 287

iv | | Nurse Assistant Training

 UNIT 4
SPECIAL CARE SITUATIONS 294
18 Providing Care for People with Specific Illnesses 295
19 Providing Care for People with Cognitive
Changes and Dementia 311
20 Providing Care for People at the End of Life 327
21 Providing Care to Infants and Children 338
22 Providing Care for People in Their Homes 356

UNIT 5
TRANSITIONING FROM STUDENT
TO EMPLOYEE 372
23 Entering the Workforce 373
24 Enjoying Professional Success 382

Appendices 400
A Medical Terminology and Abbreviations 401
B Body Basics 405
C Math and Measurements Review 417
D Additional Skills 429
E Answers to Questions for Review 434
Glossary 437
Resources 451
Index 462

Contents | v
ACKNOWLEDGMENTS
Many individuals shared in the development and revision process in various supportive, technical and creative
ways. The American Red Cross Nurse Assistant Training textbook was developed through the dedication of both
employees and volunteers. Their commitment to excellence made this manual possible.

The following members of the American Red Cross Scientific Advisory Council provided
guidance and review:

Jean Johnson, PhD, RN, FAAN Marie Etienne, DNP, ARNP, PLNC
Chair, Nursing and Caregiving Sub-Council Professor
Dean, School of Nursing Miami Dade College, School of Nursing
The George Washington University Miami, Florida
Washington, District of Columbia
Susan M. Heidrich, PhD, RN
Christy Blackstone, MSW, LCSW Helen Denne Schulte Emeritus Professor
Department of Veterans Affairs University of Wisconsin–Madison, School of
VA Health Care System Nursing Nurse Scientist
Alexandria, Louisiana William S. Middleton Memorial Veterans
Administration Hospital
Barbara J. Burgel, RN, ANP, PhD, FAAN Madison, Wisconsin
Professor of Nursing
University of California, San Francisco School Deanna Colburn Hostler, DPT, PhD (ABD)
of Nursing Senior Physical Therapist
San Francisco, California Presbyterian Hospital, University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Susan L. Carlson, MSN, APRN, ACNS-BC,
GNP-BC, FNGNA Carla M. Tozer, MSN, APN/CPN, ACHPH,
Neurology Nurse Practitioner ANP-BC, GNP-BC
South Texas Veterans Health Care System Visiting Nursing Practice Specialist
San Antonio, Texas Visiting Clinical Instructor
University of Illinois–Chicago, College of Nursing
Chicago, Illinois

The following individuals also provided guidance and review throughout the manuscript
development process:

Nelly Azizi, LVN Linda Carter, RN

Instructor, Nurse Assistant Training Program Instructor, Nurse Assistant Training Program
American Red Cross Southern California Territory American Red Cross Northern Ohio Territory
Commerce, California Cleveland, Ohio

Anika Bailey, MSN, MEd, RN Nancy Daly, RN

Health Care Training Programs Manager Instructor, Nurse Assistant Training Program
American Red Cross of Southeastern Michigan American Red Cross of Eastern Massachusetts
Detroit, Michigan Cambridge, Massachusetts

Melissa C. Beadle, MBA Abigail Filius, LVN

Program Manager II, Nurse Assistant Training Instructor, Nurse Assistant Training Program
American Red Cross Northern Ohio Territory American Red Cross Southern California Territory
Cleveland, Ohio Commerce, California

Mary Jane Carpenter, RN Sharon Garwood, RN, BSN

Instructor, Nurse Assistant Training Program Instructor, Nurse Assistant Training Program
American Red Cross Northern Ohio Territory American Red Cross of Southeastern Michigan
Cleveland, Ohio Detroit, Michigan

vi | | Nurse Assistant Training

Jason Kang, LVN Diane M. Minor, RN, BSN
Instructor, Nurse Assistant Training Program Program Manger I, Nurse Assistant Training
American Red Cross Southern California Territory American Red Cross Northern Ohio Territory
Commerce, California Cleveland, Ohio

Jane Lash, RN Loralyn Penzella, MPA

Instructor, Nurse Assistant Training Program Program Manager, Nurse Assistant Training/Competency
American Red Cross Evaluation Program Testing
Cambridge, Massachusetts American Red Cross Southern California Territory
Commerce, California
Agnes Liclican, RN
Interim Director of Nurses, Nurse Assistant Training Program Marion Reed, RN
American Red Cross Southern California Territory Instructor, Nurse Assistant Training Program
Commerce, California American Red Cross of Southeastern Michigan
Detroit, Michigan
Marianne Mastrangelo, BSN, RN
Director, Health Care Training Lula Robinson, RN
American Red Cross of Eastern Massachusetts Instructor, Nurse Assistant Training Program
Cambridge, Massachusetts American Red Cross Northern Ohio Territory
Cleveland, Ohio

The following individuals assisted with the creation of the content by providing subject matter
expertise:

Wanda Murray-Goldschmidt, RN, BSN, BC, MA Ginger Schuerger-Davison, RNBC, LNHA

Clinical Faculty Long-Term Care Consultant
Department of Nursing, Towson University Ohio Health Care Association Member
Towson, Maryland Berea, Ohio
Faculty
The Copper Ridge Institute Sandra J. Soditch, RN
Eldersburg, Maryland Long-Term Care Consultant
Centerville, Ohio
Theresa Kyle, RN, MSN, CPNP
Director of Nursing Diana F. Waugh, BSN, RN
El Camino College Long-Term Care Consultant
Torrance, California Waugh Consulting
Waterville, Ohio

The American Red Cross also gives special thanks to the following organizations and
individuals for their contributions to this project:

■ The residents, staff and administrators at Roland Park Place in Baltimore, Maryland, for their assistance with
the photography shoot
■ The residents, staff and administrators at Stella Maris in Timonium, Maryland, for their assistance with the
video shoot
■ The staff of Portfolio Productions in Portland, Oregon, for their assistance with producing the photography
and video assets
■ The staff of Krames StayWell Strategic Partnerships Division, for their assistance with editing and producing
the textbook
Photography credit: Chapter 21, page 338 © iStockPhoto.com/Juanmonino

Acknowledgments | vii
P R E FAC E
Nurse assistants are key members of the health care and enliven the reading, reinforce key concepts and
team, providing care for patients, residents and clients promote critical thinking skills.
in a variety of health care settings. The aging population, ■ Nurse Assistant Do’s and Don’ts. These boxes
longer life spans, and changes in the way health care is summarize guidelines for providing safe, efficient,
provided and paid for are presenting many opportunities person-centered care.
for people who want to train for a career in health care.
■ Observations into Action. A very important role
During a time when employment opportunities are
of the nurse assistant is to function as the “eyes
decreasing in many industries in the United States,
and ears” for the rest of the health care team.
employment opportunities in health care are increasing,
The “Observations into Action” feature highlights
and they are expected to continue to increase in the
observations the nurse assistant may make that
future. As a nation, we must maintain and continue to
should be reported immediately.
build a workforce prepared to meet the needs of the
population. ■ Elder Care Notes. Many of the people the
nurse assistant will care for will be elderly. This
The American Red Cross Nurse Assistant Training feature draws the student’s attention to special
textbook and course are based on the belief that considerations that should be kept in mind when
caregiving is an art. This textbook and course seek to caring for an elderly person.
train students in the art of caregiving, focusing on five ■ Skill Sheets. The skill sheets walk the student
principles of care that should inform every decision through key nurse assistant skills step by step.
the caregiver makes and every action the caregiver Photographs and illustrations are provided to clarify
takes: safety, privacy, dignity, independence and written instructions and enhance understanding.
communication. In addition to learning the technical Standard preparation and completion steps are
skills needed to provide competent care, students included as part of every skill to help students learn
learn the principles and concepts necessary to provide and remember these very important actions. All skills
compassionate, person-centered care. emphasize the five principles of care: safety, privacy,
dignity, independence and communication.
Features ■ Goals. Each chapter begins with a list of learning
The American Red Cross Nurse Assistant Training objectives or goals.
textbook was developed to help students understand, ■ Key Terms and Glossary. Important vocabulary
remember and put into practice important concepts and words to learn and remember are listed at the
skills. Features of the third edition that support student beginning of each chapter and defined within the
learning include a conversational, engaging writing style; context of the chapter. A glossary, included at the
a completely new art program; and a clean, open page end of the book, allows students to quickly look up
design. In addition, the following pedagogical features definitions for the key terms highlighted throughout
were developed to aid students in acquiring the skills the book.
and knowledge they need to provide safe, competent,
■ Check Your Understanding. Each chapter
compassionate care:
concludes with Questions for Review (multiple-
■ Case studies. Each chapter begins by introducing choice questions that allow students to assess
a recipient of health care and providing some basic their understanding of the chapter content) and
information about the person and his or her situation. Questions to Ask Yourself (short-answer, usually
As students progress through the chapter, they are scenario-based questions designed to help students
provided with more information about the person apply and think critically about the information they
introduced in the case study, and they are given the have just learned). The answers to the multiple-
opportunity to apply the concepts they have just choice Questions for Review are provided in
read about. The case studies serve to personalize Appendix E.

viii | | Nurse Assistant Training

Organization basic principles of care in the event of common
weather emergencies or disasters.
The third edition of the American Red Cross Nurse
Assistant Training textbook has been reorganized to Unit 3: Providing Care
facilitate logical progression from one topic to another
Unit 3 teaches the concepts and skills used to provide
and to allow students to build and expand on previously
routine care to patients, residents and clients. The unit
acquired knowledge. Chapters have been organized into
begins with Chapter 9, Measuring Vital Signs, Weight
thematic units.
and Height. In this chapter, students learn the skills
they need to obtain basic measurements accurately.
Unit 1: The Art of Caregiving Chapter 10, Maintaining a Comfortable Environment,
In this unit, students are introduced to fundamental teaches bedmaking skills and reviews environmental
concepts that are essential to working in the health care factors that can affect a person’s comfort while in a
field. Chapter 1, Being a Nurse Assistant, describes the health care facility. Chapter 11, Providing Restorative
nurse assistant’s roles and responsibilities as a member Care, introduces students to the important role nurse
of the health care team and the educational requirements assistants play in helping those in their care maintain or
necessary to become a nurse assistant, and it introduces regain function, and it reviews skills related to exercise
the concept of professionalism. Chapter 2, Working in the and preventing complications of immobility. Chapter 12,
Health Care System, provides an overview of the health Assisting with Positioning and Transferring, describes
care system. Settings where health care is delivered, pressure ulcer prevention strategies and reviews the
methods of paying for health care, and legislation and skills needed to safely assist with repositioning and
organizations that serve to protect both the recipients transferring. Chapter 13, Assisting with Personal
and providers of health care are described. Chapter 3, Cleanliness and Grooming, teaches personal care skills.
Understanding Legal and Ethical Aspects of Health Care, Chapter 14, Assisting with Meals and Fluids, describes
seeks to give students a basic understanding of legal and the concepts and skills needed to ensure adequate
ethical issues that can arise in health care, and it explains nutrition and hydration. Chapter 15, Assisting with
how to protect themselves from legal or ethical difficulties Elimination, describes the skills needed to assist people
on the job. Chapter 4, Understanding the People in Our with elimination and describes common problems with
Care, reviews qualities and experiences that all human elimination. Chapter 16, Promoting Comfort and Rest,
beings have in common. Chapter 5, Communicating with is new to this edition and discusses the nurse assistant’s
People, teaches students the skills they need in order to role in recognizing, reporting and managing pain and in
communicate effectively with those in their care, as well as promoting adequate rest and sleep. The unit concludes
with their co-workers. with Chapter 17, Assisting with Admissions, Transfers
and Discharges, which describes the nurse assistant’s
Unit 2: Promoting Safety responsibilities, including providing emotional support,
This unit focuses on topics, skills and principles that during these times of transition.
are essential for ensuring the safety of everyone who
lives or works in a health care setting. Chapter 6, Unit 4: Special Care Situations
Controlling the Spread of Infection, gives students This unit delves deeper into specific caregiving
a basic understanding of how infections can spread situations. The unit begins with Chapter 18, Providing
throughout a health care facility and the methods Care for People with Specific Illnesses, which provides
that are used to protect recipients of health care and an overview of commonly encountered medical
health care workers from health care–associated conditions and special considerations for the nurse
infections. Chapter 7, Preventing Injuries, provides assistant in caring for people with these conditions.
information about maintaining a safe workplace and Chapter 19, Providing Care for People with Cognitive
living environment. Principles of body mechanics and Changes and Dementia, begins by reviewing common
safe lifting are reviewed, along with “no-lift” policies, causes of cognitive changes, including normal age-
which seek to limit on-the-job injuries. Factors that put related changes in cognition, as well as delirium and
recipients of health care at risk for injury, along with dementia. The rest of the chapter is devoted to helping
common injuries and their prevention, are reviewed, students understand how a person with dementia
including expanded coverage of fall-prevention experiences the world, and provides strategies for
strategies. Chapter 7 also reviews the safe use of effectively communicating with and providing care for
equipment, including issues related to the use of the person with dementia. Chapter 20, Providing Care
side rails and restraints. Chapter 8, Responding for People at the End of Life, seeks to help students
to Emergencies, gives students a brief overview of understand the very important role nurse assistants
common medical emergencies, describes how to have in caring for people and their family members in
prevent and respond to fire emergencies and reviews the time leading up to and following a person’s death.

Preface | ix
Chapter 21, Providing Care to Infants and Children, Additional Skills, provides skill sheets for skills related
provides a basic overview of care considerations for the to measuring temperature with a glass thermometer
pediatric population. Chapter 22, Providing Care for and the one-step method of measuring blood pressure.
People in Their Homes, introduces the student to the Appendix E, Answers to Questions for Review, provides
unique aspects of working as a home health aide and the answers to the multiple-choice questions in the
providing care in the home. text for student self-assessment. Finally, the glossary
provides an alphabetized list of all of the key terms in the
book and their definitions, for quick reference
Unit 5: Transitioning from and review.
Student to Employee
The final unit in the textbook gives students the skills
they need to succeed in the workplace. Chapter 23,
Instructor Support Materials
Entering the Workforce, provides basic information In addition to this textbook, several items have been
about identifying appropriate job opportunities, developed to assist instructors in teaching the course
preparing a resume and reference list, writing and students in learning the content.
cover letters and thank-you notes, and interviewing
successfully. Chapter 24, Enjoying Professional American Red Cross Nurse Assistant Training
Success, helps students acquire the skills and Videos. These brand-new training videos, developed
knowledge they need to stay healthy and happy on in conjunction with the textbook, include step-by-step
the job. Time-management strategies, interpersonal demonstrations of key nurse assistant skills. In addition
skills, self-care skills and opportunities for career to step-by-step demonstrations of skills, testimonial-
advancement are reviewed. based videos focusing on topics such as end-of-life
care, dementia care and restorative care have been
added to the series. The five principles of care—safety,
Appendices and Glossary privacy, dignity, independence and communication—are
The textbook concludes with five appendices and emphasized throughout.
a glossary. Appendix A, Medical Terminology and
American Red Cross Nurse Assistant Training
Abbreviations, gives students tools they need to discern
Instructor’s Manual. The Instructor’s Manual provides
the meaning of unfamiliar medical words. A listing of
lesson plans, classroom activities, tips for individualizing
commonly used abbreviations and acronyms in health
teaching methods to meet individual students’ needs,
care is also provided. Appendix B, Body Basics, reviews
and tools and forms for course management and
the structure and function of the ten organ systems
administration.
and describes normal age-related changes for each.
Appendix C, Math and Measurements Review, helps Instructor’s Corner. This website provides course
students refresh their skills related to mathematical updates, digital materials, teaching tools, course record
calculations and units of measure. Appendix D, forms and more.

x | | Nurse Assistant Training

 D ETAI LE D TAB LE O F

C O NTE NTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii Sexuality and Intimacy . . . . . . . . . . . . . . . . . . .39
How to Use This Book . . . . . . . . . . . . . . . . .xviii Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
UNIT 1: THE ART OF CAREGIVING CHAPTER 5
Communicating with People . . . . . . . . . . . . 44
CHAPTER 1
Communication Basics . . . . . . . . . . . . . . . . . . .45
Being A Nurse Assistant . . . . . . . . . . . . . . . . . 2
Communicating with Those in Your
Nurse Assistant Responsibilities
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Communicating with Family Members . . . . .50
Working as a Member of the Health
Care Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Communicating with Other Members
of the Health Care Team . . . . . . . . . . . . . . . . .50
The Art of Caregiving . . . . . . . . . . . . . . . . . . . . . 7
Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
UNIT 2: PROMOTING SAFETY
CHAPTER 2
Working in the Health Care System . . . . . . 12 CHAPTER 6
Health Care Settings . . . . . . . . . . . . . . . . . . . . .13 Controlling the Spread of Infection . . . . . . 58

Paying for Health Care . . . . . . . . . . . . . . . . . . .17 What Causes Infection? . . . . . . . . . . . . . . . . . .59

Protecting the Recipients of The Chain of Infection . . . . . . . . . . . . . . . . . . . .59

Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Health Care–Associated Infections . . . . . . .60
Protecting Health Care Workers . . . . . . . . . .20 How to Recognize an Infection . . . . . . . . . . .61
How to Control the Spread of Microbes . . .62
CHAPTER 3
Bloodborne Pathogens and
Understanding Legal and Ethical Workplace Safety . . . . . . . . . . . . . . . . . . . . . . . .68
Aspects of Health Care . . . . . . . . . . . . . . . . . 22
Skill 6-1: Hand Washing . . . . . . . . . . . . . . . . .70
Legislation That Influences
the Delivery of Health Care . . . . . . . . . . . . . . .23 Skill 6-2: Using Personal Protective
Equipment (PPE) . . . . . . . . . . . . . . . . . . . . .72
Behaviors That Can Result in Legal
or Disciplinary Action . . . . . . . . . . . . . . . . . . . . .25 Skill 6-3: Handling a Plastic Trash Bag . . .75
Using Ethics to Guide Behavior . . . . . . . . . . .28
CHAPTER 7
Avoiding Legal and Ethical Difficulties Preventing Injuries . . . . . . . . . . . . . . . . . . . . . 76
on the Job . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Protecting Your Body from Injury . . . . . . . . . .77
CHAPTER 4 Using Equipment Safely . . . . . . . . . . . . . . . . . .78
Understanding the People in Our Care . . . 31 Keeping the People in Your Care Safe . . . .80
Human Growth and Development . . . . . . . .32 A Word About Restraints . . . . . . . . . . . . . . . . .84
Basic Human Needs . . . . . . . . . . . . . . . . . . . . .37 Performing Skills Safely . . . . . . . . . . . . . . . . . .85

Detailed Table of Contents | xi

CHAPTER 8 Bedmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Responding to Emergencies . . . . . . . . . . . . 89 Skill 10-1: Making an Unocccupied
Medical Emergencies . . . . . . . . . . . . . . . . . . . .90 Bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Fire Emergencies . . . . . . . . . . . . . . . . . . . . . . . .95 Skill 10-2: Making an Occupied Bed . . . 137
Weather Emergencies,
Disasters and Other Events with CHAPTER 11
Widespread Impact . . . . . . . . . . . . . . . . . . . . . .97 Providing Restorative Care . . . . . . . . . . . . .140
Skill 8-1: First Aid for a Conscious Goals of Restorative Care . . . . . . . . . . . . . . 141
Choking Adult . . . . . . . . . . . . . . . . . . . . . . 101
The Nurse Assistant’s Role in
Providing Restorative Care . . . . . . . . . . . . . 141
UNIT 3: PROVIDING CARE Promoting Independence . . . . . . . . . . . . . . . 142
Promoting Mobility . . . . . . . . . . . . . . . . . . . . . 144
CHAPTER 9 Skill 11-1: Helping a Person
Measuring Vital Signs, Weight to Walk . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
and Height . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Skill 11-2: Helping a Person with
Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Passive Range-of-Motion
Weight and Height . . . . . . . . . . . . . . . . . . . . . 114 Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Skill 9-1: Using an Electronic
Thermometer to Measure a CHAPTER 12
Person’s Temperature . . . . . . . . . . . . . . . 116 Assisting with Positioning and
Skill 9-2: Evaluating a Person’s Transferring . . . . . . . . . . . . . . . . . . . . . . . . . .158
Radial Pulse . . . . . . . . . . . . . . . . . . . . . . . . 118 Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . 159
Skill 9-3: Evaluating a Person’s Assisting with Positioning . . . . . . . . . . . . . . 162
Apical Pulse . . . . . . . . . . . . . . . . . . . . . . . . 119
Assisting with Transferring . . . . . . . . . . . . . 166
Skill 9-4: Evaluating a Person’s
Respirations . . . . . . . . . . . . . . . . . . . . . . . . 120 Skill 12-1: Lifting a Person’s Head
and Shoulders off the Bed . . . . . . . . . . 169
Skill 9-5: Measuring a Person’s Blood
Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Skill 12-2: Moving a Person Up
in Bed (One Nurse Assistant) . . . . . . . 170
Skill 9-6: Measuring a Person’s Weight
and Height Using an Upright Scale . . . 123 Skill 12-3: Moving a Person Up in Bed
Using a Draw Sheet (Two Nurse
Assistants) . . . . . . . . . . . . . . . . . . . . . . . . . 172
CHAPTER 10
Maintaining a Comfortable Skill 12-4: Moving a Person Up in Bed
Using a Draw Sheet (One Nurse
Environment . . . . . . . . . . . . . . . . . . . . . . . . . 125 Assistant) . . . . . . . . . . . . . . . . . . . . . . . . . . 173
The Person’s Space . . . . . . . . . . . . . . . . . . . . 126 Skill 12-5: Moving a Person to
Common Furnishings in Health Care the Side of the Bed
Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 (One Nurse Assistant) . . . . . . . . . . . . . . 174

xii | | Nurse Assistant Training

 Skill 12-6: Moving a Person to Skill 13-4: Brushing and Combing
the Side of the Bed a Person’s Hair . . . . . . . . . . . . . . . . . . . . . 208
(Two Nurse Assistants) . . . . . . . . . . . . . 175 Skill 13-5: Shampooing a Person’s
Skill 12-7: Turning a Person onto Hair in Bed . . . . . . . . . . . . . . . . . . . . . . . . . 209
Her Side (One or Two Skill 13-6: Helping a Man
Nurse Assistants) . . . . . . . . . . . . . . . . . . 176 to Shave . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Skill 12-8: Turning a Person Using Skill 13-7: Helping a Person to
a Logrolling Technique . . . . . . . . . . . . . . 178 Change Clothes . . . . . . . . . . . . . . . . . . . . 213
Skill 12-9: Repositioning a Person Skill 13-8: Helping a Person to
in a Chair (Two Nurse Assistants) . . . . . . . 180 Put On Compression Stockings . . . . . 216
Skill 12-10: Transferring a Person Skill 13-9: Inserting and Removing
from the Bed to a Chair (One or an In-The-Ear Hearing Aid . . . . . . . . . . 217
Two Nurse Assistants) . . . . . . . . . . . . . . 181
Skill 13-10: Providing Hand and
Skill 12-11: Transferring a Person from Foot Care . . . . . . . . . . . . . . . . . . . . . . . . . . 218
the Chair to a Bed (One or Two
Nurse Assistants) . . . . . . . . . . . . . . . . . . 184 Skill 13-11: Providing Perineal
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Skill 12-12: Using a Mechanical Lift
to Transfer a Person (Two Nurse Skill 13-12: Helping a Person with
Assistants) . . . . . . . . . . . . . . . . . . . . . . . . . 185 a Complete Bed Bath . . . . . . . . . . . . . . . 222
Skill 13-13: Helping a Person with
CHAPTER 13 a Shower or Tub Bath . . . . . . . . . . . . . . . 225
Assisting with Personal Cleanliness Skill 13-14: Giving a Back Rub . . . . . . . . . 227
and Grooming . . . . . . . . . . . . . . . . . . . . . . . . 187
Mouth Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 CHAPTER 14
Assisting with Meals and Fluids . . . . . . . . 228
Hair Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
What Is Good Nutrition? . . . . . . . . . . . . . . . . 229
Shaving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Planning a Healthy Diet . . . . . . . . . . . . . . . . 230
Dressing and Undressing . . . . . . . . . . . . . . . 194
Factors That Affect What and
Vision and Hearing Aids . . . . . . . . . . . . . . . . 195 How We Eat . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Hand and Foot Care . . . . . . . . . . . . . . . . . . . 196 Special Orders Concerning
Perineal Care . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Skin Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Meal Time When a Person Is
Skill 13-1: Brushing and Flossing a Receiving Health Care . . . . . . . . . . . . . . . . . 233
Person’s Teeth . . . . . . . . . . . . . . . . . . . . . . 202 The Importance of Fluids . . . . . . . . . . . . . . . 238
Skill 13-2: Providing Denture Other Ways of Providing Nutrition
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 and Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Skill 13-3: Providing Mouth Care for Skill 14-1: Helping a Person
an Unconscious Person . . . . . . . . . . . . . 206 to Eat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Detailed Table of Contents | xiii

CHAPTER 15 Skill 16-2: Assisting with a Warm Soak . . . 284
Assisting with Elimination . . . . . . . . . . . . . 245 Skill 16-3: Applying an Aquathermia
Introduction to Elimination . . . . . . . . . . . . . . 246 Pad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Promoting Normal Elimination . . . . . . . . . . 247 Skill 16-4: Applying a Warm Water
Bottle or Ice Bag . . . . . . . . . . . . . . . . . . . 286
Assisting the Person to Use a Toilet,
a Portable Commode, a Bedpan
or a Urinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 CHAPTER 17
Assisting with Admissions,
Problems with Elimination . . . . . . . . . . . . . . 250
Transfers and Discharges . . . . . . . . . . . . . . 287
Special Tasks Related to Assisting
with Elimination . . . . . . . . . . . . . . . . . . . . . . . . 254 Assisting with Admissions . . . . . . . . . . . . . . 288
Skill 15-1: Helping a Person to Use Assisting with Transfers . . . . . . . . . . . . . . . . 290
a Portable Commode . . . . . . . . . . . . . . . 261 Assisting with Discharges . . . . . . . . . . . . . . 291
Skill 15-2: Helping a Person to Use
a Bedpan . . . . . . . . . . . . . . . . . . . . . . . . . . 262
UNIT 4: SPECIAL CARE
Skill 15-3: Helping a Man to Use
a Urinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 SITUATIONS
Skill 15-4: Applying a Condom
Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 CHAPTER 18
Skill 15-5: Collecting a Routine Providing Care for People with
Urine Specimen or Stool Specific Illnesses . . . . . . . . . . . . . . . . . . . . . 295
Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Musculoskeletal Conditions . . . . . . . . . . . . 296
Skill 15-6: Collecting a Clean Cardiovascular Conditions . . . . . . . . . . . . . . 299
Catch (Midstream) Urine
Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Respiratory Conditions . . . . . . . . . . . . . . . . . 299
Skill 15-7: Providing Catheter Care . . . . 268 Neurologic Conditions . . . . . . . . . . . . . . . . . 302
Skill 15-8: Emptying a Urine Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Drainage Bag . . . . . . . . . . . . . . . . . . . . . . 270 Kidney Failure . . . . . . . . . . . . . . . . . . . . . . . . . 305
Skill 15-9: Changing an Ostomy Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . 271
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Skill 15-10: Giving a Person an Enema . . . 272
Mental Health Conditions . . . . . . . . . . . . . . 308
CHAPTER 16
Promoting Comfort and Rest . . . . . . . . . . . 274 CHAPTER 19
Promoting Comfort . . . . . . . . . . . . . . . . . . . . 275 Providing Care for People with
Promoting Rest . . . . . . . . . . . . . . . . . . . . . . . . 280 Cognitive Changes and Dementia . . . . . . 311

Skill 16-1: Applying a Warm or Types of Cognitive Changes . . . . . . . . . . . . 312

Cold Compress . . . . . . . . . . . . . . . . . . . . . 283 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316

xiv | | Nurse Assistant Training

 Challenging Behaviors . . . . . . . . . . . . . . . . . 320
UNIT 5: TRANSITIONING FROM
Communicating with a Person
with Dementia . . . . . . . . . . . . . . . . . . . . . . . . . 322 STUDENT TO EMPLOYEE
The Needs of the Caregiver . . . . . . . . . . . . 323
CHAPTER 23
Entering the Workforce . . . . . . . . . . . . . . . .373
CHAPTER 20 Planning Your Job Search . . . . . . . . . . . . . . 374
Providing Care for People at the End
Applying for Jobs . . . . . . . . . . . . . . . . . . . . . . 375
of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Going on Job Interviews . . . . . . . . . . . . . . . . 378
A Peaceful and Comfortable
Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328 Responding to a Job Offer . . . . . . . . . . . . . 379
Providing End-of-Life Care . . . . . . . . . . . . . 329 Becoming a New Employee . . . . . . . . . . . . 380
Providing Care in the Hours CHAPTER 24
Immediately Before and After Enjoying Professional Success . . . . . . . . .382
Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Basic Expectations for Those
Skill 20-1: Providing Postmortem Employed as Nurse Assistants . . . . . . . . . 383
Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Dealing with Violence and Harassment
in the Workplace . . . . . . . . . . . . . . . . . . . . . . . 384
CHAPTER 21 Contributing to a Positive Work
Providing Care to Infants Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
and Children . . . . . . . . . . . . . . . . . . . . . . . . .338 Managing Time . . . . . . . . . . . . . . . . . . . . . . . . 387
General Childhood Responses Caring for Yourself . . . . . . . . . . . . . . . . . . . . . 396
to Illness, Injury and Hospitalization . . . . . 339
Developing Your Career . . . . . . . . . . . . . . . . 397
Factors Affecting a Child’s
Response to Illness, Injury Making a Difference . . . . . . . . . . . . . . . . . . . 398
and Hospitalization . . . . . . . . . . . . . . . . . . . . . 340
Caring for Infants and Children . . . . . . . . . 343 APPENDICES
Specific Care Responsibilities . . . . . . . . . . 349 Appendix A: Medical Terminology
and Abbreviations . . . . . . . . . . . . . . . . . . . . . . 401
Appendix B: Body Basics . . . . . . . . . . . . . . . 405
CHAPTER 22
Providing Care for People in Appendix C: Math and Measurements
Their Homes . . . . . . . . . . . . . . . . . . . . . . . . .356 Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

Overview of Home Appendix D: Additional Skills . . . . . . . . . . . 429

Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 Appendix E: Answers to Questions
The Home Health Aide’s Role . . . . . . . . . . 359 for Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434

The Home Health Care Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437

Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Caregiving Skills in the Home . . . . . . . . . . 364 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

Detailed Table of Contents | xv

S K I LLS
Skills are numbered according to chapter number and sequence within the chapter.

CHAPTER 6 CHAPTER 12
Controlling the Spread of Infection Assisting with Positioning and Transferring
Skill 6-1: Hand Washing Skill 12-1: Lifting a Person’s Head and Shoulders
Skill 6-2: Using Personal Protective Equipment off the Bed
(PPE) Skill 12-2: Moving a Person Up in Bed
Skill 6-3: Handling a Plastic Trash Bag (One Nurse Assistant)
Skill 12-3: Moving a Person Up in Bed Using
CHAPTER 8 a Draw Sheet (Two Nurse Assistants)
Responding to Emergencies Skill 12-4: Moving a Person Up in Bed Using
a Draw Sheet (One Nurse Assistant)
Skill 8-1: First Aid for A Conscious Choking
Adult Skill 12-5: Moving a Person to the Side of
the Bed (One Nurse Assistant)
CHAPTER 9 Skill 12-6: Moving a Person to the Side of
Measuring Vital Signs, Weight and Height the Bed (Two Nurse Assistants)
Skill 9-1: Using an Electronic Thermometer Skill 12-7: Turning a Person onto Her Side
to Measure a Person’s Temperature (One or Two Nurse Assistants)
Skill 9-2: Evaluating a Person’s Radial Pulse Skill 12-8: Turning a Person Using a Logrolling
Technique
Skill 9-3: Evaluating a Person’s Apical Pulse
Skill 12-9: Repositioning a Person in a Chair
Skill 9-4: Evaluating a Person’s Respirations (Two Nurse Assistants)
Skill 9-5: Measuring a Person’s Blood Pressure Skill 12-10: Transferring a Person from the
Skill 9-6: Measuring a Person’s Weight Bed to a Chair (One or Two Nurse Assistants)
and Height Using an Upright Scale Skill 12-11: Transferring a Person from the
Chair to a Bed (One or Two Nurse Assistants)
CHAPTER 10 Skill 12-12: Using a Mechanical Lift to
Maintaining a Comfortable Environment Transfer a Person (Two Nurse Assistants)
Skill 10-1: Making an Unocccupied Bed
Skill 10-2: Making an Occupied Bed CHAPTER 13
Assisting with Personal Cleanliness
CHAPTER 11 and Grooming
Providing Restorative Care Skill 13-1: Brushing and Flossing a Person’s Teeth
Skill 11-1: Helping a Person to Walk Skill 13-2: Providing Denture Care
Skill 11-2: Helping a Person with Passive Skill 13-3: Providing Mouth Care for
Range-of-Motion Exercises an Unconscious Person

xvi | | Nurse Assistant Training

Skill 13-4: Brushing and Combing Skill 15-5: Collecting a Routine Urine
a Person’s Hair Specimen or Stool Specimen
Skill 13-5: Shampooing a Person’s Hair in Bed Skill 15-6: Collecting a Clean Catch
Skill 13-6: Helping a Man to Shave (Midstream) Urine Specimen
Skill 13-7: Helping a Person to Change Clothes Skill 15-7: Providing Catheter Care
Skill 13-8: Helping a Person to Put On Skill 15-8: Emptying a Urine Drainage Bag
Compression Stockings Skill 15-9: Changing an Ostomy Appliance
Skill 13-9: Inserting and Removing Skill 15-10: Giving a Person an Enema
an In-The-Ear Hearing Aid
Skill 13-10: Providing Hand and Foot Care CHAPTER 16
Skill 13-11: Providing Perineal Care Promoting Comfort and Rest
Skill 13-12: Helping a Person with Skill 16-1: Applying a Warm or Cold Compress
a Complete Bed Bath Skill 16-2: Assisting with a Warm Soak
Skill 13-13: Helping a Person with Skill 16-3: Applying an Aquathermia Pad
a Shower or Tub Bath
Skill 16-4: Applying a Warm Water Bottle or
Skill 13-14: Giving a Back Rub Ice Bag

CHAPTER 14 CHAPTER 20
Assisting with Meals and Fluids Providing Care for People at the End of Life
Skill 14-1: Helping a Person to Eat Skill 20-1: Providing Postmortem Care

CHAPTER 15 APPENDIX D
Assisting with Elimination Additional Skills
Skill 15-1: Helping a Person to Use Skill D-1: Cleaning a Glass Thermometer
a Portable Commode
Skill D-2: Using a Glass Thermometer to
Skill 15-2: Helping a Person to Use a Bedpan Measure a Person’s Temperature
Skill 15-3: Helping a Man to Use a Urinal Skill D-3: Measuring a Person’s Blood Pressure
Skill 15-4: Applying a Condom Catheter (One-Step Method)

Skills | xvii
HOW TO USE TH IS

BOOK
The American Red Cross Nurse Assistant Training textbook is designed with you, the
student, in mind. Let’s look at some of the features that have been included to help you
learn and retain key information and skills.

GOALS
The goals listed at the
beginning of each chapter
provide a road map for
the chapter; they tell you
which ideas are most
important to learn. Before
you begin reading, review
the list of goals. This will
give you an overview of
the concepts and skills
that will be covered in the
chapter. After you finish reading the chapter, review the goals again. Can you meet each
goal? If not, review the sections of the chapter where that information is covered.

KEY TERMS
At the beginning of each
chapter, you will also
find a list of key terms, or
vocabulary words. These
words are boldfaced and
defined in the chapter.
You can also look up the definitions of these words in the glossary that appears at the
end of the textbook. Familiarize yourself with these words before you begin reading the
chapter. When you are finished reading the chapter, review the list of key terms again.
Can you define each one?

CASE STUDY
At the beginning of each chapter, you will
be introduced to a person who is receiving
care in a health care setting, and you will
be given a little bit of information about the
person and his or her situation. Throughout
the chapter, you will be prompted to pause
and think about how the concepts and
skills you are learning would apply to the
person you met. Take these opportunities to
reflect on what you are learning, and think
about how this knowledge could apply to
situations you will encounter on the job.

xviii | | Nurse Assistant Training

NURSE ASSISTANT DO’S AND DON’TS
Throughout the text,
you will see boxes that
summarize guidelines
for key nurse assistant
responsibilities. Learning
and following these
guidelines will help you
provide safe, efficient,
person-centered care.

OBSERVATIONS INTO ACTION

As a nurse assistant, you will get to know
the people in your care well. Knowing
what is “normal” for each of them gives
you the ability to recognize changes in
their condition. These boxes summarize
changes in a person’s condition that are
important to report to the nurse.

ELDER CARE NOTES

Many of the people you will care for will
be elderly. Elder Care Notes placed
throughout the text raise your awareness
of special considerations you must take
into account when caring for people who
are older.

How to Use This Book | xix

SKILL SHEETS
At the end of each chapter that contains
skills, you will find illustrated skill sheets.
These skill sheets guide you step by step
through the skills you must learn to be
a nurse assistant. The skill sheets are
divided into three parts. The first part, the
preparation section, lists the steps you
should follow before beginning any skill.
Similarly, the last part, the completion
section, lists the steps you should perform
after finishing any skill. These preparation
and completion steps emphasize the five
principles of care—safety, privacy, dignity,
independence and communication—and
help to promote safe, efficient, person-
centered care. In between, in the procedure
section, you will find the steps you take that
are specific to the particular skill.

CHECK YOUR UNDERSTANDING

The Check Your Understanding section
at the end of each chapter gives you an
opportunity to see how well you learned and
understood the chapter content. Questions
for Review are multiple-choice questions.
Each has one best answer. Try answering
these questions and then check the answers
in Appendix E at the end of the book. If you
answered any of the questions incorrectly,
go back and review the appropriate sections
of the chapter. The Questions to Ask
Yourself section poses real-life situations
that encourage you to apply your knowledge
and decision-making skills. These questions
may have several correct answers. Think
about the situations posed in the questions
and how you would respond. Because there
may be many different ways to approach the
situation, try discussing your answers with
your instructor, your classmates or both.

xx | | Nurse Assistant Training

APPENDICES, GLOSSARY, RESOURCES
AND INDEX
The appendices at the end of the book provide additional information that may be
useful to you. Appendix A, Medical Terminology, will help you become familiar with the
“language of caregiving.” A listing of common abbreviations is also provided. Appendix B,
Body Basics, gives you an overview of how the human body works, and changes that
normally occur with aging. Appendix C, Math and Measurements Review, will help you
refresh your skills related to mathematical calculations and units of measure. Appendix D,
Additional Skills, provides skill sheets for skills that are taught in some states, but not
all. Your instructor will tell you if you need to learn these skills. Appendix E, Answers to
Questions for Review, provides the answers to the multiple-choice questions at the end
of each chapter, so that you can check your understanding of what you have learned.
Also at the end of the book, you will find a Glossary, which is an alphabetized list of the
key terms in the book, with their definitions. You will also find Resources, which provides
references for the information given in the text, and an Index, which you can use to find
specific topics within the book quickly and easily.

How to Use This Book | xxi

1
2
3

4
5
THE ART OF CAREGIVING

Being a Nurse Assistant

Working in the Health Care System
Understanding Legal and Ethical Aspects
of Health Care
Understanding the People in Our Care
Communicating with People
1
UNIT

Unit 1 | The Art of Caregiving | 1

C HA P T E R

1 Being a Nurse Assistant

After reading this chapter, you will have the information needed to:
■ Describe the nurse assistant’s responsibilities and the requirements that a person must
meet in order to work as a nurse assistant.
■ Describe how the nurse assistant functions as a member of the health care team and
of the nursing team.
Goals ■ Describe tasks that are usually outside of the nurse assistant’s scope of practice.
■ Explain how focusing on the person who is receiving care can lead to better care.
■ List the five principles of care, and explain why each is important.
■ Explain what it means to be a professional, and describe how a nurse assistant can
display professionalism on the job.

2 | | Nurse Assistant Training

 Key Terms:
activities of daily nursing team empathy
living (ADLs)
delegation compassion
health care team
scope of practice

Angus McCarthy is a 78-year-old man who was

admitted to Morningside Nursing Home yesterday
after being discharged from the hospital with chronic
heart failure. When you enter the room today to
provide care, Mr. McCarthy’s 75-year-old wife,
Martha, is sitting with him. You introduce yourself
and explain that you are there to help Mr. McCarthy
with bathing and dressing. After talking with
Mr. McCarthy and his wife for several minutes, you
ask him about getting washed and dressed. He says,
“Let me finish watching my favorite game show first,
and then we can take care of business.” You agree and
ask if you can sit with him while he watches his show.
He says, “Have a seat and I’ll tell you why I like this
show so much.”
Figure 1-1 Many of the nurse assistant’s responsibilities involve helping
people with activities of daily living (ADLs).

NURSE ASSISTANT As a nurse assistant, you will have a great deal of daily
RESPONSIBILITIES contact with the people in your care and their family
members. Getting to know the people in your care as
AND TRAINING individuals and taking a genuine interest in them are
things you can do to support them emotionally. A smile,
The Nurse Assistant’s a pat on the shoulder, and a willingness to listen lets the
Responsibilities person know that you care, and that she is not alone
(Figure 1-2).
A nurse assistant works under the supervision of a
licensed nurse (that is, a registered nurse [RN] or
licensed practical nurse [LPN]) to provide basic nursing
care to people who are ill, injured or disabled. Nursing
care seeks to care for the whole person, meeting the
person’s physical and emotional needs.
As a nurse assistant, many of your responsibilities will have
to do with helping the people in your care with activities
of daily living (ADLs), such as eating, bathing, dressing,
grooming, using the toilet and moving (Figure 1-1). Nurse
assistants are also responsible for obtaining routine
measurements (such as vital signs, height and weight);
assisting with admissions, transfers and discharges; and
maintaining a safe and clean environment.
In addition to helping to meet the physical needs of the
people in your care, you will help to meet their emotional
needs. People who find themselves in need of health
care, and their family members, are often frightened, Figure 1-2 Providing emotional support is an important part of the nurse
worried and upset. They may feel lonely and isolated. assistant’s job too.

Chapter 1 | Being a Nurse Assistant | 3

Because of the amount of time you will spend with the When you share this type of information with the nurse,
people in your care, you may be the first to recognize a you promote quality care by helping to ensure that steps
change in the person’s condition, or learn of a concern are taken to determine the cause of the change or to
the person has. For example, you may notice that a address the person’s concerns.
person’s appetite has decreased, or a person may
A sample job description for a nurse assistant is shown
mention to you that she is worried about a surgical
in Figure 1-3.
procedure she is scheduled to have the next day.

Morningside Nursing Home

JOB DESCRIPTION
Certified Nurse Assistant (CNA)

Duties 1. Reports to work as scheduled and on time.

2. Attends shift report, organizes assignments and makes rounds on residents.
3. Delivers personal care and emotional support to those under his or her care.
4. Regards all residents as under his or her care when assistance or supervision is needed; answers all
requests for help promptly within 5 minutes.
5. Provides care according to the resident’s care plan in a manner that protects the resident’s dignity
and privacy.
6. Assists residents to maintain or regain their maximum level of independence.
7. Works to build relationships with residents and their family members that are warm, positive and supportive.
8. Reports to supervisor/charge nurse any observations or concerns about the resident’s status in a
timely fashion.
9. Documents the care provided and observations promptly and accurately.
10. Practices infection-control measures, including taking standard precautions, in accordance with facility
policy and the resident’s care plan.
11. Keeps work area and residents’ environment neat, clean and orderly.
12. Measures and accurately reports and records vital signs, height and weight.
13. Monitors and records intake and output; assists in serving meals, meal supplements and fluids;
assists residents with eating as necessary.
14. Assists residents with repositioning, transferring and exercise.
15. Assists residents with toileting, bathing and grooming.
16. Assists with admissions, transfers and discharges as necessary.
17. Takes initiative in delivery of services—sees what needs to be done and does it, within scope of practice.
18. Participates in providing end-of-life care to residents who are dying, and their family members.
19. Knows fire and disaster plans and personal duties in case of fire or disaster.
20. Participates in resident-care conferences.
21. Attends all mandatory in-service training sessions.

Job * Must have a valid nurse assistant certification in good standing with the state
Requirements * Must have current CPR certification
* Must pass a criminal background check
* Must complete a health screening and tuberculosis screening within 2 weeks of hire
* Must pass a mandatory drug screening test within 90 days of hire
* Must be able to lift, push and pull up to 30 pounds
* Must possess basic computer skills
* Must possess good communication skills and the ability to interact in a tactful and respectful manner with
residents, family members and visitors
* Must be able to multitask in a fast-paced work environment and prioritize duties
* Must have the ability to understand and follow policies and procedures
Figure 1-3 A sample job description for a nurse assistant.

4 | | Nurse Assistant Training

Requirements to Become a After completing the training course and passing the
state’s certification evaluation, a person becomes
Nurse Assistant certified to work as a nurse assistant in that state.
A person who wants to become a nurse assistant must Depending on the state and the employer, a person who
complete a state-approved training course and pass the is certified to work as a nurse assistant may be called by
state’s certification examination. The federal government many different titles, including certified nurse assistant or
specifies that a minimum of 75 hours of training is certified nursing assistant (CNA), nurse aide or geriatric
required, and that the training must include: nursing assistant (GNA).

■ Classroom learning.
■ Hands-on practice of skills in a skills lab.
■ A clinical practicum (that is, the opportunity to gain
WORKING AS A MEMBER OF
supervised experience providing direct care in an THE HEALTH CARE TEAM
actual health care setting).
Many states require more hours of training than the The Health Care Team
federally mandated 75 hours.
As a nurse assistant, you will be a key member of the
In addition to completing the training course, a person health care team. The health care team consists of
who wants to work as a nurse assistant must pass the person receiving care, the person’s family members,
the state’s certification evaluation. This evaluation and staff members and other professionals who are
consists of two parts: a multiple-choice written exam, responsible for providing care and other services
and a skills test. During the skills test, the candidate (Figure 1-4). Each member of the health care team
is required to demonstrate randomly selected nurse has specialized knowledge and skills and contributes
assistant skills and must perform each skill satisfactorily equally to achieving the health care team’s goal, which
in order to pass. is to provide personalized quality care that meets the

Figure 1-4 The person receiving care is always the leader of the health care team. Other team members vary depending on the individual
person’s needs.

Chapter 1 | Being a Nurse Assistant | 5

person’s physical, emotional, social and spiritual needs. depending on the needs of the person who is receiving
The person receiving care is always the “captain” of the care. Examples of staff members who may be part of the
team. The other members of the health care team vary health care team are given in Table 1-1.

Table 1-1 Examples of Health Care Team Members*

Health Care Team Member Responsibilities
Registered Nurse (RN) Performs assessments, develops care plans, provides nursing care
(directly and by delegating certain tasks to other nursing team
members) and supervises other members of the nursing team

Licensed Practical Nurse (LPN) or Licensed Helps plan, deliver and supervise some types of nursing care under the
Vocational Nurse (LVN) direction of a registered nurse

Certified Nurse Assistant (CNA) or Home Provides basic nursing care under the supervision of a RN or LPN/LVN
Health Aide (HHA)
Doctor Determines the person’s illness or condition and supervises medical care;
writes medical orders and prescribes medication and other treatments

Advanced Practice Nurse (Nurse Practices independently or along with the doctor to diagnose, treat
Practitioner, Clinical Nurse Specialist) and manage medical conditions; is qualified to do so by completing
graduate-level education and training

Discharge Planner (Continuing Care Nurse, Works with other members of the health care team to develop a plan
Case Manager or Utilization Manager) for meeting the person’s care needs after the person leaves the health
care setting, and assists with making the necessary arrangements

Activities Director or Recreational Plans and coordinates activities that provide opportunities for
Therapist socializing, spiritual support, creativity, entertainment, exercise and
community and civic involvement (for example, voting)

Physical Therapist Helps people improve their ability to move their bodies

Occupational Therapist Helps people improve their independence in performing actions related
to everyday living, such as managing a home (for example, preparing a
meal or doing laundry) or functioning in a job

Speech Therapist Helps people improve their ability to speak, chew and swallow

Dietitian Uses knowledge of nutrition and of the person to plan a diet that the
person will enjoy and that will help him maintain or regain health

Social Worker Helps the person and the family solve everyday problems related to the
person’s illness by putting him and his family in touch with resources
that can help, such as meal-delivery services, adult day care services,
and support groups

Psychologist Provides mental health assessment services

Pharmacist Provides medications ordered by the doctor or advanced practice

nurse, and keeps a record of all medications

Religious Leader (for example, priest, Provides spiritual support, as needed and requested, for the person
minister, rabbi) receiving care, the family and staff members

Environmental Services Employee (may Ensures a clean, safe, attractive environment by maintaining the
work in laundry, housekeeping or facility building and grounds, and by maintaining the equipment used in the
maintenance departments) facility (such as linens or wheelchairs)

* This list of team members represents only some of the many people who could be members of the health care team. The specific
members of the health care team will vary depending on the person’s needs.

6 | | Nurse Assistant Training

The Nursing Team you are allowed to do, as detailed in the job description
given to you by your employer. Job descriptions vary from
The nursing team is a subset of the health care team employer to employer, so you must always read each
(Table 1-2). The nursing team consists of, at minimum, new job description carefully to make sure you know
a licensed nurse and a nurse assistant. Licensed your responsibilities. Perform only the tasks listed in your
nurses may be registered nurses (RNs) or licensed job description. If the nurse delegates a task to you that
practical/vocational nurses (LPN/LVNs). An advanced is outside of your scope of practice, or that you do not
practice nurse (APRN), who may also be called a nurse feel qualified to perform safely, you must speak up and
practitioner (NP) or clinical nurse specialist (CNS), may ask the nurse to reassign the task. Tasks that are usually
also be part of the nursing team. outside of the scope of practice for a nurse assistant are
Usually, nurse assistants are supervised by an RN or described in Box 1-1.
LPN/LVN. The nurse who supervises you may be called
the charge nurse, head nurse, primary nurse, supervisor
or team leader. The nurse will give you the authority THE ART OF CAREGIVING
and responsibility for completing certain tasks on his or
her behalf. This is called delegation. After completing Many people learn the skills of caregiving, but not
a task that has been delegated to you, it is important everyone can perform those skills with kindness,
to report back to update the nurse on the person’s empathy and compassion. Empathy is the quality
condition, and to let the nurse know that you have of seeking to understand another person’s situation,
completed the task. point of view or feelings. Compassion is the
quality of recognizing another person’s hardship,
To protect yourself, the person receiving care, and your accompanied by a desire to help relieve that hardship.
employer, you must always work within your scope of Providing skillful care in a thoughtful way is an
practice (that is, the tasks that you are legally permitted art. As you prepare for your job, you will learn the
to do). Your scope of practice is defined by the state difference between just getting your job done and
and by your employer. Be very familiar with the tasks that providing quality care that goes above and beyond

Table 1-2 Nursing Team Members

Title Requirements to Practice Responsibilities
Certified Nurse Assistant (CNA) Certificate obtained by completing Assists with the delivery of nursing care
or Home Health Aide (HHA) a minimum of 75 hours of training by performing basic nursing tasks under
and passing a state-administered the supervision of a registered nurse (RN)
certification examination or licensed practical/vocational nurse
(LPN/LVN)

Licensed Practical/Vocational Certificate obtained by completing a Helps plan and deliver certain types
Nurse (LPN/LVN) 12- to 18-month training program of nursing care under the direction
AND a license obtained by passing a of a registered nurse (RN); may also
state-administered board examination be responsible for supervising nurse
assistants

Registered Nurse (RN) Bachelor of science in nursing (BSN) Performs assessments, develops care
degree obtained from a 4-year college plans, provides nursing care (directly and
OR an associate degree (ADN) by delegating certain tasks to other nursing
obtained from a 2-year college team members) and supervises other
AND a license obtained by passing a members of the nursing team
state-administered board examination

Advanced Practice Nurse Bachelor of science in nursing (BSN) Independently or in conjunction with a
(APRN) degree AND a doctorate or master’s doctor, performs medical assessments,
Clinical Nurse Specialist (CNS) degree obtained from an accredited diagnoses disease and prescribes
Nurse Practitioner (NP) college or university AND a license treatments
obtained by passing a national
specialty-based board examination

Chapter 1 | Being a Nurse Assistant | 7

 ▼ Box 1-1 Tasks That Are Usually Outside of the Nurse Assistant’s
Scope of Practice*
■ Supervising or delegating nursing responsibilities treatments (such as medications) for illnesses
to other nurse assistants. Only a licensed nurse and injuries.
(an RN or an LPN) can supervise nurse assistants and ■ Administering medications and oxygen.
delegate nursing responsibilities to them. Medications must be administered by a licensed nurse
■ Analyzing or interpreting data. A nurse assistant may or a doctor. In some settings, such as assisted living
gather data, but it is outside of the nurse assistant’s scope of facilities, nurse assistants may be permitted to help
practice to determine the meaning of the data. For example, the person as he takes his own medication (but they
a nurse assistant may obtain a blood pressure measurement cannot actually give the medication to the person).
and note that it is higher than normal. However, determining Nurse assistants who have received advanced training in
why the blood pressure reading is higher than normal is the medication administration may be allowed to administer
responsibility of the doctor and nurse. some types of medications in some states in certain
■ Receiving verbal orders for the person’s medical settings, but this is not normally within the scope of
care. The person’s primary care provider (a doctor or practice for a nurse assistant.
an advanced practice nurse) may give verbal orders for ■ Inserting or removing medical equipment. Nurse
the person’s care over the telephone or in person. Only assistants are usually not allowed to insert medical
licensed nurses can receive these verbal orders and act equipment (such as feeding tubes, urinary catheters or IV
on them. lines) into a person’s body, or to remove these items from
■ Diagnosing illness and injury and prescribing the person’s body once they are in place.
treatments. Only doctors and advanced practice * The nurse assistant’s scope of practice may be expanded
nurses (nurses who have obtained additional training in some settings and when the nurse assistant has received
at the post-graduate level) can diagnose and order additional training to perform more advanced skills.

basic expectations. Getting to know each person helping you to remember to put the person in your care
as an individual and seeking to meet her emotional, first. The five principles of care are:
social and spiritual needs, in addition to her physical
■ Keep the person safe. As a nurse assistant,
needs, is the key to providing the highest quality care
you are responsible for protecting the people in
possible (Figure 1-5).
your care from harm. You will do this by taking
Throughout this book, you will see references to “the steps to prevent the person from physical injuries
five principles of care” (Figure 1-6). These principles (such as skin tears, bruises or burns) and from
provide a framework for providing quality care by situations that can put the person at risk for

Figure 1-5 Getting to know and appreciate each person in your care as Figure 1-6 Applying the five principles of care can help you to provide
an individual is one of the keys to providing quality care. “star-quality” care.

8 | | Nurse Assistant Training

 injury (such as wandering away from the facility).
You will also help to keep the people in your care PROFESSIONALISM
safe by practicing infection-control methods, such As a nurse assistant, you will be a professional caregiver.
as washing your hands, consistently and correctly. You will have the training and knowledge to perform
■ Protect the person’s dignity. Dignity is the quality a certain role, that of the nurse assistant. But being
of being worthy of respect. In addition to treating a professional is about more than having certain
the people in your care with respect, you will help training, credentials or qualifications. It is about
them to maintain their sense of dignity by fostering having a positive attitude toward your job, and doing
their sense of self-esteem, or self-respect. Actions your job to the best of your ability at all times. Help
you can take to help protect the person’s dignity others see you as the professional that you are
include taking care not to expose the person’s body through your actions and appearance.
unnecessarily, avoiding talking down to the person
or using baby talk, involving the person in decision Acting in a Professional Manner
making about her care, encouraging the person to
do as much for herself as possible, and helping the Let’s look at some of the actions that will help you excel
person to have a clean and neat appearance. as a nurse assistant:
■ Foster the person’s independence. Being able ■ Dependability. Being dependable means that others
to make decisions and do things for oneself is can count on you. For the people in your care, this
important for maintaining a sense of dignity and means they can trust you to come to work on time and
self-esteem. In addition, it is important to encourage to help them in a timely fashion. For your co-workers,
the people in your care to do as much for this means that if they ask you to do something, they
themselves as possible to maintain the abilities that can trust you to follow through on the request.
they have, and to prevent future loss of function. ■ Accountability. Being accountable means taking
■ Protect the person’s privacy. Keep a person’s responsibility for your actions and the results of
private business private, and do not allow private those actions. Sometimes, you may make a mistake
things to be seen or overheard by other people. while delivering care. An accountable person takes
■ Practice good communication skills. Be responsibility for the mistake, and looks to prevent
available to talk, listen and respond to a person’s similar mistakes from occurring in the future.
thoughts and feelings. Tell the person about the ■ Integrity. Having integrity means that you behave
care you plan to provide, and involve the person in according to an understanding of the right way to
making decisions about her care. behave. One way to think about integrity is that it
means doing the right thing even when no one is
After the game show is over, Mr. McCarthy watching. Acting in an honest manner is one way
smiles and says to you, “OK, I promised I would let you that you show integrity. Keeping private information
do your job after my program was over, so let’s get to it. about the people in your care to yourself is another.
Can you just give me a hand getting to the bathroom?” As ■ Conscientiousness. Being conscientious means
you help Mr. McCarthy walk to the bathroom, you notice paying attention to the details of your work. The
that he begins to tire quickly and appears to get short of people in your care, and your co-workers, count on
breath. He says, “I never realized how much work it is you to do your job the right way and to the best of
sometimes just to walk.” You get to the bathroom and your ability, every day.
say, “Why don’t you just sit down here on the commode
■ Courtesy. A person who behaves professionally is
and rest a bit while I get your supplies together?”
courteous to everyone. Simple courtesies can make
How can actions like watching the game the workplace a more pleasant environment, and
show with Mr. McCarthy and listening to him increase the likelihood that others will also treat you
when he explains why he likes it so much help courteously. Remember to say please and thank you.
you provide better care? Address others as they prefer to be addressed. If you
While you are assisting Mr. McCarthy with do not know how a person prefers to be addressed,
bathing and dressing, what actions can you err on the side of formality (for example, “Mr. Johnson”
take to protect his dignity and promote his instead of “Bill”). Offer to hold the door or elevator
independence? How will you help to keep for others, and clean up after yourself in shared areas
him safe? (such as the kitchenette or the nurses’ station).
After you are finished caring for Mr. McCarthy, ■ Stewardship. A steward safeguards something
is there any information you would share with from harm. As a nurse assistant, you will be
the nurse? If so, what and why? entrusted with the care of items belonging to others.
You have an obligation to treat these items with the

Chapter 1 | Being a Nurse Assistant | 9

 same care and respect you would treat your own
valued possessions. Stewardship also means using
your employer’s resources wisely and avoiding waste
(for example, by only taking the supplies you will use
for a procedure into a person’s room).
■ A willingness to help. A willingness to pitch in
and work as part of a team makes many tasks much
easier and safer, and contributes to a healthy work
environment by helping to reduce stress.
■ The ability to communicate. Being able to
communicate effectively with the people in your care,
their family members and your co-workers is a critical
skill in health care. An effective communicator is a good
listener, is able to express her own needs clearly and is
able to advocate (speak up for) others when necessary.
■ The ability to problem solve. This book provides
guidelines to help you make the best decisions to
provide the best care to each person. Each person
receiving care is different, as is each situation. Using
critical thinking skills allows you to look at a problem,
identify possible solutions, name the pros and cons
of each solution, decide which solution is best and
then act on it.
Figure 1-7 Help others see you as the professional that you are by
Maintaining a Professional maintaining a professional appearance.

Appearance your employer and your facility or agency. You will spend
As a health care professional, you are expected to look a great deal of time interacting with the people in your
a certain way (Figure 1-7). Many of the standards that care, and with their family members. When you make an
relate to a health care worker’s appearance are based effort to present a neat, clean appearance, the people
on principles of safety and infection control. However, in your care feel more assured that you will do the same
maintaining a clean, neat appearance serves another for them. Guidelines for maintaining a professional
purpose as well. As a nurse assistant, you represent appearance are given in Box 1-2.

Box 1-2 Nurse Assistant DO’s and DON’Ts

Maintaining a Professional Appearance
DO wear a clean, pressed uniform; a confused person or a young child may DON’T wear excessive make-up.
clean shoes; and your name badge in pull it. Keeping hair off your face is also
DON’T wear fragrance (for example,
accordance with your employer’s policies. important for infection control; you do not
perfume or cologne).
want to be reaching up to move your hair
DO bathe or shower, shampoo your hair
out of the way with dirty hands or gloves. DO keep facial hair trimmed and neat.
and brush your teeth regularly.
DON’T wear dangly or excessive jewelry. DO try to select a uniform style that will
DO keep your nails short, filed smooth,
A confused person or a child may pull cover tattoos.
free of polish, and clean. This helps to
necklaces, bracelets or dangly earrings.
prevent accidental scratches when you DO remove visible body piercings.
Wearing rings and bracelets makes it
are providing care, and is also important
difficult to wash your hands properly. DON’T wear undergarments that show
for infection control.
Although some employers permit through your clothing (for example, avoid
DO keep your hair neatly styled and employees to wear a plain wedding band, wearing dark-colored undergarments
pulled back from your face. If not secured, it is safest to avoid wearing rings while under a light-colored uniform).
long hair can get tangled in equipment, or you are at work.

10 | | Nurse Assistant Training

 c. Wear a clean, pressed uniform; clean shoes;
CHECK YOUR UNDERSTANDING and a name badge.
d. Keep your nails clean, trimmed, filed smooth,
and free of nail polish.
Questions for Review
7. The goal of the health care team is to:
1. The “captain” of the health care team is the:
a. Minimize health care costs by spreading the
a. Doctor. workload over many people.
b. Registered nurse (RN). b. Make sure the person is sent home from the
c. Advanced practice nurse. facility as soon as possible.
d. Person receiving care. c. Provide personalized quality care that meets
the person’s physical, emotional, social and
2. Which one of the following is a nurse assistant’s spiritual needs.
responsibility? d. Make decisions on behalf of the person
a. Administering medications receiving care.
b. Communicating verbal orders related to the
person’s medical care to the nurse 8. Which of the following statements about
delegation is true?
c. Assisting people with activities of daily living
(ADLs) a. It is outside the nurse assistant’s scope of
d. Analyzing and interpreting data practice to decline to do a delegated task.
b. When one person delegates a task to another,
3. At minimum, how many hours of training are that person gives the other person the authority
required to become a nurse assistant? and the responsibility to complete the task on
a. 65 his or her behalf.
b. 75 c. Nurse assistants may delegate tasks to other
c. 40 members of the health care team.
d. 50 d. All of the above

4. A nurse assistant finds a 10-dollar bill in the

linens while changing a person’s bed, and places Questions to Ask Yourself
the money on the person’s bedside table. This 1. What are some of the most important qualities a
nurse assistant acted with: nurse assistant should have?
a. Integrity. 2. What special qualities would you bring to your work
b. Courtesy. as a nurse assistant?
c. Dependability.
3. What do you think the most rewarding part of
d. Stupidity. being a nurse assistant will be? The most
5. Empathy is the quality of: challenging part?

a. Acting in a way to gain the trust of others. 4. Think of someone you know who is currently
b. Pitching in to work as part of a team. receiving health care, or who has received health
care in the past. What does the person think of the
c. Recognizing another person’s hardship,
care he or she received, or is receiving?
accompanied by a desire to help relieve that
hardship. 5. At Morningside Nursing Facility, Mr. Flanagan spends
d. Seeking to understand another person’s a lot of time holding a picture of his wife. Sometimes
situation, point of view or feelings. he talks to the picture. Every day he tells you that he
wants to go home. How would you respond?
6. To maintain a professional appearance, you
6. Mrs. Landers clearly loves the fresh flowers her
should do all of the following EXCEPT:
daughter brought her and wants to keep them on
a. Avoid smiling too much while at work. her bedside table, but her roommate is allergic to
b. Keep your hair pulled back from your face. flowers. What would you do?

Chapter 1 | Being a Nurse Assistant | 11

C HA P T E R
Working in the Health
2 Care System
After reading this chapter, you will have the information needed to:
■ Identify different types of health care settings, and describe the types of services
each provides.
■ Discuss some differences between working as a nurse assistant in an acute care
setting, a sub-acute care setting, a long-term care setting and a home setting.
Goals ■ Describe government insurance programs that help to offset the costs of health care.
■ Describe legislation, programs and organizations that are in place to help protect the
recipients of health care, and ensure that quality standards for care are met.
■ Give examples of rights that people who are receiving health care are entitled to.

12 | | Nurse Assistant Training

 ■ Explain how legislation brought about by the Omnibus Budget Reconciliation Act
(OBRA) seeks to ensure quality care for nursing home residents.
Goals ■ Discuss how the Occupational Safety and Health Administration (OSHA) seeks to
protect workers from on-the-job injuries.

Key Terms:
acute care setting long-term care setting client ombudsman

patient resident Medicare accreditation

inpatient care nursing home Medicaid Occupational Safety and

Health Administration
outpatient care assisted-living facility Omnibus Budget (OSHA)
Reconciliation Act of 1987
sub-acute care setting cognitive impairment (OBRA)

several parts of the system to meet his or her health

It was a rainy morning in April when 72-year- care needs.
old Alma Renaldo was rushed by ambulance to the local
hospital’s emergency room. She had been talking with Acute Care Settings
her husband, Luis, while she prepared breakfast. All of a
sudden, while Alma was serving the plates, she suddenly Services provided in acute care settings
collapsed and the plate she was holding clattered to Acute care settings specialize in providing care to
the floor. She was unconscious and unresponsive. Luis people who become sick or injured suddenly, or who have
called 9-1-1 and waited anxiously for the ambulance to other conditions (such as delivering a baby) that require
arrive. In the emergency room, the doctors determined short-term health care (Figure 2-1). Care is provided in
that Alma had experienced a massive stroke. the acute care setting until the person is medically stable.
After spending nearly 2 weeks on life support Usually, the length of stay in an acute care setting is short.
in the intensive care unit of the hospital, Alma’s
condition was stable enough for her to be moved to a
rehabilitation facility. The stroke had paralyzed the
right side of Alma’s body, left her unable to speak, and
made it difficult for her to swallow without choking. In
the rehabilitation facility, Alma worked with physical
therapists and speech therapists to try to regain as
much function and independence as possible.

Despite several weeks of therapy, Alma was not

able to regain enough function to care for herself
anymore. Now Alma and her family had to make
a difficult decision. Would it be possible for Luis
to provide the care Alma would need at home, or
would other arrangements for Alma’s care need to be
made? Alma’s and Luis’ two daughters, Isabela and
Maria, were both married and busy with families and
careers of their own, and neither lived close by. They
would only be able to provide limited support to their
parents. After thinking through all of the options as
a family, the Renaldos made the difficult decision for
Alma to move into Morningside Nursing Home.

HEALTH CARE SETTINGS

Figure 2-1 People with illnesses or injuries who are medically unstable
The health care system has many parts, each with a are cared for in acute care facilities. Image © Monkey Business Images,
special function. In some instances, a person may use 2012. Used under license from Shutterstock.com.

Chapter 2 | Working in the Health Care System | 13

The most common type of acute care setting is a What is it like to work in an acute
hospital. A person who receives care in a hospital or care setting?
other acute care setting is called a patient. Patients
Many nurse assistants work in hospitals. When you work
who stay overnight in the hospital receive inpatient
as a nurse assistant in a hospital, the people in your care
care. Not all hospital patients stay overnight, however.
will change fairly often because most patients do not
Some patients may come to the hospital to receive
stay in the facility for a very long time. A nurse assistant
a specific therapy (for example, a chemotherapy
working in a hospital must have a special ability to form
treatment for cancer, or surgery to repair a broken
effective relationships quickly with people who are
bone) and go home the same day. This is called
under stress. For the patient and family, receiving acute
outpatient care. Outpatient care may also be
care can be very upsetting. Injuries and illnesses that
delivered by other acute care settings, such as a clinic
require treatment in a hospital are usually quite serious,
(a health care facility that is devoted to providing
and patients (and their family members) are often very
services such as treatments or diagnostic tests on an
worried about the potential for recovery, the long-term
outpatient basis) or a surgical center (a health care
effects of the illness or injury, the results of diagnostic
facility that performs outpatient surgeries, where the
tests and the risks associated with undergoing certain
person is admitted for the surgery and sent home the
procedures and treatments. Things happen quickly in
same day).
a hospital, and patients and family members may not
Many hospitals provide a wide variety of services for remember or may not understand information they were
patients of all ages and with many different types of given by other members of the health care team. You will
illnesses or injuries. Within the hospital, patients are become an important link between the patient and family
grouped according to age or the type of care they and the other members of the health care team by telling
require (Table 2-1). Other hospitals specialize in the nurse about any questions and concerns the patient
providing care for only one age group or for people or family discuss with you.
with a certain type of disorder (for example, a children’s
You will also play an important role in promoting comfort
hospital or a hospital that cares only for people with
and providing emotional support. The hospital environment
cancer).

Table 2-1 Examples of Clinical Services Provided Within a Hospital

Service Care Recipients
Medical People who have conditions that are treated medically (for example, with drugs or other
non-surgical therapies)

Surgical People who are recovering from conditions that are treated surgically

Cardiology People who have heart conditions

Emergency People who have signs or symptoms of illness that require immediate evaluation and treatment by a
health care professional

Intensive Care People who are very medically unstable and who have life-threatening illnesses or conditions

Neonatal Newborns

Obstetric Pregnant women and newborns

Oncology People with cancer

Operating Room People who are having surgery

Orthopedic People with bone and joint problems

Pediatric Children up to 18 years of age

Psychiatric/Mental People with mental illness

Health

14 | | Nurse Assistant Training

can be uncomfortable, with unfamiliar sounds and smells, What is it like to work in a sub-acute
and few comforts of home. Most patients share a room care setting?
with one or more others. Depending on the person’s illness
The people receiving care in sub-acute care settings
or injury and hospital policy, visiting hours may be limited,
are often still quite ill and require a great deal of medical
so patients may not always have the comfort of having
and nursing care. In addition to helping people receiving
friends and family near. The compassionate care you
sub-acute care to meet their physical needs, a nurse
provide can make a big difference in how the patient and
assistant who works in a sub-acute care setting must be
family feel about their experience in the hospital.
able to provide a great deal of emotional support. Many
people who are admitted to sub-acute care settings are
Think back to Alma Renaldo’s family. recovering from illnesses or injuries that significantly
impact their ability to function independently. As a
How might they have been feeling while Alma result, they and their family members are often very
was hospitalized and in intensive care? What worried about what the future holds. Will the illness or
factors might have contributed to these feelings? injury have a permanent impact on the person’s ability
What actions could staff members at the to function, and if so, how severe will that impact be?
hospital take to try and help the Renaldos Will the person be able to return home, or is this the
through this difficult time? injury or illness that will make moving to a nursing home
necessary? In addition, undergoing rehabilitation is
very difficult, both physically and emotionally. As with
all people you care for, your ability to show empathy for
Sub-Acute Care Settings the person and her situation will be extremely important.
You will play a very important role in reinforcing
Services provided in sub-acute the techniques that the person learns in therapy,
care settings encouraging the person, and recognizing the person’s
Being cared for in a hospital is very expensive, so progress toward her goal.
patients are usually discharged from the hospital as soon
as they are medically stable. However, some patients
will still require treatments such as intravenous (IV) Long-Term Care Settings
drug therapy, physical rehabilitation or wound care for
complex wounds that can only be provided by health Services provided in long-term
care professionals (Figure 2-2). This type of care is care settings
provided in a sub-acute care setting, which may be a In a long-term care setting, people receive
special unit of a hospital or nursing home, or a separate assistance meeting their medical, personal and social
facility, such as a long-term acute care hospital (LTACH). needs over an extended period of time (Figure 2-3).
The typical length of stay for a person receiving care in a The term resident is used to refer to a person who
sub-acute care setting is less than 30 days. receives care in a long-term care setting, because

Figure 2-3 Long-term care facilities provide nursing care and supervision
Figure 2-2 People who are well enough to leave the acute care setting for people who can no longer live independently because of illness or
but who still require treatments that are too complex to be delivered by disability. Care focuses on helping residents achieve or maintain their
family members at home may be admitted to a sub-acute care setting. highest level of function.

Chapter 2 | Working in the Health Care System | 15

the facility becomes the person’s home, either physical needs, nurse assistants are an important source
temporarily or permanently. Short-term residents are of emotional support for residents and their families.
those who leave the facility in 3 to 6 months. They tend Coming to live in a long-term care facility can be a big
to be younger, and may be admitted from a hospital to adjustment for the person and his or her family members.
receive sub-acute care until they are well enough to Many times, a sudden event (such as a stroke or the
return home. Long-term residents stay in the facility for loss of a spouse) makes admission to a long-term care
6 months or more. The average stay for a person in a facility necessary. Most people do not choose to come
long-term care facility is 7 months to 2 years. to live at a long-term care facility, and have little time
to prepare for this change in their lives. The emotions
There are two major types of long-term care settings,
that accompany admission to a nursing home can be
nursing homes and assisted-living facilities. People
complex for both the person and the family members and
who are cared for in assisted-living facilities require
may include loneliness, grief, guilt and anger.
some assistance with tasks such as activities of daily
living (ADLs) or reminders to take medications, but are Working in a long-term care setting can be both very
otherwise fairly independent. Most residents of assisted- challenging and very rewarding. Many of the people
living facilities live in their own apartments, but have access you will care for will be nearing the end of their lives,
to shared services in the building or on the campus, such which means you will often have to face losing people
as a restaurant or dining room and areas for recreation. you have come to care about. Caring for people with
People who are cared for in nursing homes require a much cognitive impairments (such as dementia) can be very
higher level of nursing care and supervision as compared stressful for the person providing care. In addition to
with those who live in assisted-living facilities. being emotionally demanding, the job is physically
demanding, because nursing home residents need
Although most people who receive care in a nursing
so much assistance with their ADLs. Despite these
home are elderly with one or more chronic conditions
challenges, the ability to form long-term relationships
(long-lasting conditions that require regular treatment),
with the people in your care, being able to help them
younger people with debilitating conditions (such as
maintain or achieve their highest level of functioning, and
multiple sclerosis), mental disabilities or serious disabling
helping them to enjoy the best quality of life possible can
injuries (such as traumatic brain injury or a spinal cord
be very satisfying, and are the reasons why many nurse
injury) may also receive care in a nursing home. The
assistants choose to work in long-term care.
most common reason for admission to a nursing home
is the loss of the ability to perform one or more ADLs
independently. Many residents of nursing homes have You are the nurse assistant assigned to care
some degree of cognitive impairment. Cognitive for Mrs. Renaldo on her first day at Morningside.
impairment is difficulty with thinking processes involving As you greet Mrs. Renaldo and her family members
memory, reasoning, judgment and language, such as that when they arrive at the facility, you can tell that
caused by disorders like Alzheimer’s disease (a form of everyone is very upset. Mr. Renaldo smiles sadly at
dementia). Most residents of nursing homes also have you as he shakes your hand, and his voice cracks when
one or more chronic conditions that can affect their he introduces himself, his wife and his daughters.
physical abilities, such as heart disease, lung disease Later, Isabela Renaldo takes you aside and says, “I’m
or arthritis. The effects of the medical conditions, rather so worried about my parents. Mama and Papa have
than the conditions themselves, often lead to the nursing been married for 53 years, and hardly ever spent
home admission. For example, someone who has arthritis a night apart before Mama’s stroke. These last few
may no longer be able to get in and out of bed, go to the weeks, Papa has just been rattling around the house.
toilet or dress without help. Someone with dementia may He doesn’t know what to do with himself, and he’s
be physically able to function but may need a great deal terribly lonely. And Mama—she can’t stop crying.
of help because she has trouble remembering how to I think this is going to kill them both.”
care for herself. Think about each member of the Renaldo
family. What losses do you think each of them
What is it like to work in a long-term has experienced as a result of Mrs. Renaldo’s
care setting? stroke?
Nurse assistants are the key staff in providing for the As a nurse assistant, what things can you do
needs of long-term care residents, especially those in to help make this time of change less difficult
nursing homes. Providing restorative care (care that for Mrs. Renaldo and her family?
helps people maintain abilities that they still have, and
regain, to the greatest extent possible, abilities that they What will be a primary focus of care for
have lost) is a major focus for nurse assistants working in Mrs. Renaldo going forward?
nursing homes. In addition to helping residents meet their

16 | | Nurse Assistant Training

Home Settings
PAYING FOR HEALTH CARE
Services provided in home settings Because you will be working within the health
Today, many people receive health care in their homes care system, it is important for you to have a basic
(Figure 2-4). A person who receives home health care understanding of how people pay for the services you
is called a client. Home health care agencies provide provide. In the United States, people pay for health care
services for clients of all ages with many different in a variety of ways. Some people may pay the entire
types of health care needs. For example, a home health cost for health care out of their own personal earnings
care agency may provide sub-acute care services in a or savings. However, because health care can be very
person’s home, following hospitalization for the treatment expensive, most people rely on insurance to pay all or
of an acute injury or illness. A home health care agency part of the costs of the services they receive. Many
may also provide services for a person who cannot employers offer health care insurance as part of their
manage some tasks independently, but is not quite ready benefits program for employees. Usually, the employer
or willing to move to a long-term care facility. and the employee share the cost of the insurance,
which makes the insurance more affordable for the
What is it like to work in a employee. People who are self-employed or
home setting? unemployed may purchase health care insurance
independently.
Nurse assistants who work for home health care
agencies are usually called home health aides. Home Many people receive health insurance through
health aides work under the supervision of a licensed government programs like Medicare (a federally
nurse, but usually visit the person’s home alone to funded insurance program for people who are
provide assistance with personal care, meal preparation 65 years and older) and Medicaid (an insurance
and light housekeeping tasks, such as laundry. Home program for people with low incomes, jointly funded by
health aides must be confident in their own abilities and federal and state governments). If you work for a facility
comfortable working on their own because co-workers or agency that receives funding from the Medicare or
and supervisors will not be readily available to provide Medicaid programs, accurate documentation of the care
hands-on assistance. Flexibility and adaptability are also you provide is essential to ensure that the people in your
important characteristics for a home health aide to have. care continue to be eligible to receive the services they
Furniture and equipment that is available in a facility is need. Proper documentation is also necessary to ensure
not always available in a person’s home. Finally, home that the facility receives the proper payment for services
health aides, like all nurse assistants, must also have that have been provided.
excellent communication skills because often the home
health aide is the only link between the client and the
other members of the health care team. You will learn PROTECTING THE RECIPIENTS
more about working in a home setting in Chapter 22.
OF HEALTH CARE
People who require health care want to know that they
will receive good quality care. Many regulations and
agencies exist to define standards of quality and to
ensure that the care provided meets those standards.

Patient, Resident and Client

Rights
People who receive health care have certain basic rights
and privileges, such as:
■ The right to competent care that is delivered with
respect.
■ The right to know the kind of care they will receive
and the cost of that care.
■ The right to participate in decisions made about the
care they receive and who will provide it.
■ The right to confidentiality and privacy.
Figure 2-4 Home health agencies provide health care for people in their
own homes. ■ The right to be free from restraints and abuse.

Chapter 2 | Working in the Health Care System | 17

These basic rights are similar across all health care at home have client rights. When a person becomes a
settings. In nursing homes, these rights are called patient, resident or client, she is informed of her
resident rights (Box 2-1). People receiving care in rights. Discussing these rights helps the person and
hospitals have patient rights, and people receiving care the family understand what they are entitled to and

▼ Box 2-1 Resident Rights

DIGNITY ■ To have reasonable access to any personal funds
You have the right: held for you by the facility.
■ To be valued as an individual, to maintain and ■ To retain and use personal possessions.
enhance your self-worth. ■ To receive notice in advance of any plans to change
■ To be treated with courtesy, respect and dignity, your room or roommate.
free from humiliation, harassment or threats. ■ To organize and participate in a resident council
■ To be free from physical, sexual, mental, verbal and and for your family to organize and participate in a
financial abuse. family council.
■ To be free from chemical and physical restraints ■ To participate in social, religious and community
and involuntary seclusion. activities, including the right to vote.
■ To read the results of the most recent state or
PRIVACY
federal inspection survey and the facility’s plan to
You have the right: correct any violations.
■ To personal privacy during care and treatment.
■ To contact your ombudsman, or the state survey
■ To confidentiality concerning your personal and
agency, or any advocate or agency of your choosing.
medical information.
■ To private and unrestricted visits with any person of TRANSFER OR DISCHARGE
your choice, in person and by telephone. You have the right:
■ To remain in the facility unless there is a valid,
■ To send and receive mail without interference.
legal reason for your transfer or discharge.
GRIEVANCES ■ To receive a 30-day written notice with the reason
You have the right: for the transfer or discharge, including appeal
■ To voice grievances about care or services without rights and information.
discrimination or reprisal. ■ To have a planning conference at least 14 days
■ To expect the facility to promptly investigate and prior to the transfer or discharge.
try to resolve your concerns. ■ To receive assistance to assure a safe transfer.
■ To contact the ombudsman to advocate on your ■ To be offered to hold your bed if your transfer
behalf, free from discrimination or reprisal, if you is temporary, such as for hospitalization or
feel any of your rights have been violated. therapeutic leave.

ACCESS SELF-DETERMINATION
You have the right: You have the right:
■ To be fully informed, both orally and in writing, of ■ To be offered choices and allowed to make

your rights and the facility's rules before admission decisions important to you.
and during your stay in the facility. ■ To expect the facility to accommodate individual
■ To be fully informed of the services available and needs and preferences.
related costs. ■ To participate in the planning of your care and
■ To not provide a third-party guarantee of payment. services.
■ To be informed and to receive assistance in ■ To self-administer medications.

accessing all of your benefits through Medicare or ■ To accept or refuse care and treatment.

Medicaid. ■ To choose your health care providers, including

■ To equal access to quality care for all residents. your doctor and pharmacy.
■ To be told in advance about care and treatment, ■ To manage your own personal finances, or to be

including all risks and benefits. kept informed of your finances if you choose to let
■ To look at your records and receive copies at a someone else manage them for you.
reasonable cost. ■ To refuse to perform work or services for the facility.

Reprinted with permission from the Wisconsin Board on Aging and Long-Term Care.

18 | | Nurse Assistant Training

how they can expect to be treated while receiving Omnibus Budget Reconciliation
health care.
Act (OBRA) Regulations
As a nurse assistant, you will play an important role
in making sure that the rights of the people in your The Omnibus Budget Reconciliation Act of 1987
care are upheld. Practicing the five principles of (OBRA) led to legislation that was put into effect by the
care (see Chapter 1, Figure 1-6) consistently with federal government in 1990. To guarantee that people
every person in your care is one way you can help being cared for in nursing homes received a certain level
to make sure that the person’s rights are respected. of care, this legislation established standards for staffing
As you continue through your training course, you and operation that all nursing homes accepting federal
will learn about actions you can take in specific funding must meet. OBRA legislation emphasizes the
situations to protect the rights of the people in responsibility of nursing homes to provide residents with
your care. a comfortable and fulfilling lifestyle and to promote their
physical, mental, emotional and spiritual well-being to the
highest degree possible (Figure 2-5). OBRA legislation
As a resident of a nursing home, what addresses areas such as training requirements for nurse
rights will Mrs. Renaldo be entitled to? assistants, the physical environment of the facility and
the basic rights of nursing home residents (see Box 2-1).
What actions can you take as a nurse In addition, OBRA legislation establishes a mechanism
assistant to support Mrs. Renaldo’s rights? for ensuring that facilities are providing care up to OBRA
standards. Per OBRA, nursing homes that receive

A B

C D
Figure 2-5 Quality care seeks to meet the person’s (A) physical, (B) mental, (C) emotional and (D) spiritual needs.

Chapter 2 | Working in the Health Care System | 19

federal funding must undergo routine inspections by the the United States. You have already learned about one
government, called surveys, to make sure that the facility is important piece of federal legislation, OBRA, which
providing care in accordance with government standards. applies to nursing homes that receive federal funding.
However, government at all levels is involved in setting
Ombudsman Programs standards, and making sure these standards are met,
for other types of health care facilities and agencies
The federal government requires each state to have as well.
an ombudsman program that serves nursing homes.
Ombudsmen are volunteers who advocate for (act on
the behalf of) nursing home residents and their family
Accrediting Organizations
members to resolve problems related to quality of care. Professional associations and organizations that are
The ombudsman has the same goal that you have: to not associated with the government also exist to
make sure the needs of the people in your care are met, ensure that people receive quality health care. Health
and that their rights are respected. The ombudsman visits care facilities that meet the standards established by
the nursing home regularly to talk with residents and these organizations receive accreditation (official
family members (Figure 2-6). Residents, family members recognition that the facility provides care to a certain
or even staff members may also contact the ombudsman standard). Accreditation is another way for recipients of
directly if they have concerns about the quality of care that health care to have confidence that they are receiving
is being provided. Information given to the ombudsman quality care.
is treated confidentially. After receiving permission from
The most well-known of these organizations is The
the person who voiced the concern to investigate further,
Joint Commission. You may hear The Joint Commission
the ombudsman talks with those involved to find out what
referred to as “JAYCO” because in the past, the name
happened and asks questions to find out what actions the
of this organization was The Joint Commission on
facility has already taken to address the problem. After
Accreditation of Healthcare Organizations (JCAHO).
investigating the problem, the ombudsman works with the
The Joint Commission works to establish national
appropriate people or agencies to find a solution to the
standards of care, especially with regard to safety,
problem and make sure the resident’s, family member’s
for all types of health care facilities. Facilities that
or staff member’s concerns are addressed. The most
meet these standards receive accreditation and are
frequent concerns reported to ombudsmen have to do
permitted to display The Joint Commission’s Gold
with accidents, neglect of personal cleanliness, lack of
Seal of Approval.
respect for residents, poor staff attitudes and resident
requests that go unanswered.

Government Oversight PROTECTING HEALTH CARE

Federal, state and local governments are all involved in WORKERS
establishing regulations and monitoring the quality of The Occupational Safety and Health
care provided by health care facilities and agencies in Administration (OSHA) is a government agency that
was established in 1970 to help protect workers in all
industries (not just health care) from on-the-job injuries.
OSHA establishes standards that employers must follow
to protect employees from hazards. For example, OSHA
has established standards relating to:
■ The prevention of employee exposure to harmful
substances and chemicals.
■ Equipment employers must provide, and
environmental standards they must maintain, to keep
workers safe on the job.
■ Training employers must provide to help keep
employees safe on the job.
■ The need for employers to monitor hazards and keep
records of workplace injuries and illnesses.
As you continue reading this text, you will see
Figure 2-6 Ombudsmen advocate on behalf of nursing home residents references to OSHA standards that apply to health
and their families to ensure quality care. care workers.

20 | | Nurse Assistant Training

 c. OBRA
CHECK YOUR UNDERSTANDING d. Social Security

6. Mr. Johnson was admitted to the hospital for

Questions for Review pneumonia and was hospitalized for 4 days.
What word best describes Mr. Johnson?
1. Where is care provided for a person who
a. Outpatient
requires treatment for a sudden injury or illness?
b. Resident
a. Sub-acute care setting c. Inpatient
b. Home setting d. Client
c. Acute care setting
d. Long-term care setting Questions to Ask Yourself
1. As a nurse assistant, in which type of health care
2. Mr. Bowler is 85 years old. He has dementia and
setting would you most like to work? Why?
requires close supervision to make sure that he
does not hurt himself. He also requires a great 2. In this chapter, you read about legislation,
deal of help with his activities of daily living government agencies and programs, and accrediting
(ADLs). What health care setting would provide organizations that are in place to ensure that people
the most appropriate care for Mr. Bowler? who use the services provided by the health care
a. Acute care setting system receive quality care. Think about words or
phrases you would use to describe quality care.
b. Nursing home setting
What are some of these words or phrases?
c. Hospital setting
d. Sub-acute care setting 3. Mrs. O’Brien’s husband is receiving care in a
nursing home. Lately, when Mrs. O’Brien has come
3. Which legislation establishes quality standards to see her husband, she has noticed that he smells
for the care of residents of nursing homes? of urine. Mrs. O’Brien spoke to the nurse about her
concerns, but the problem has continued. What
a. Ombudsman Act (OA)
resources are available to help Mrs. O’Brien resolve
b. Occupational Safety and Health Administration
this problem?
(OSHA)
c. Omnibus Budget Reconciliation Act (OBRA) 4. Mary is a nurse assistant at a nursing home. For
d. Resident Rights Act (RRA) each of the following actions, what resident right is
Mary supporting?
4. Which of the following is a basic right of people ■ Mary asks Mr. Cleary’s permission before
who are receiving health care? opening the dresser drawer where he keeps
a. The right not to pay personal items.
b. The right to competent care that is delivered ■ Mary asks visitors to leave, shuts the door, and
with respect pulls the privacy curtain before assisting Mr.
c. The right to abuse health care workers Howe to dress.
d. All of the above ■ When assisting Mrs. Lyons with a bed bath,
Mary makes sure to keep Mrs. Lyons covered
5. Which of the following is a government-funded with a bath blanket, rearranging the bath blanket
insurance program for people older than as necessary so that only the body part she is
65 years? washing is exposed.
a. Medicare ■ Mary asks Mr. Upchurch whether he would
b. Medicaid prefer to bathe in the morning or the evening.

Chapter 2 | Working in the Health Care System | 21

C HA P T E R
Understanding Legal and
3 Ethical Aspects of Health
Care
After reading this chapter, you will have the information needed to:
■ Explain important legal obligations health care providers have as specified by the
Patient Self-Determination Act, and identify actions a nurse assistant can take to make
sure Patient Self-Determination Act requirements are met.
■ Explain important legal obligations health care providers have as specified by the Health
Goals Insurance Portability and Accountability Act (HIPAA), and identify actions a nurse
assistant can take to make sure HIPAA requirements are met.
■ Describe behaviors that can result in legal or disciplinary action, and understand how to
avoid these behaviors.
■ Describe types of abuse, and recognize possible signs of abuse.
■ Describe the nurse assistant’s responsibilities related to reporting suspected abuse.

22 | | Nurse Assistant Training

 ■ Describe ethical principles that health care workers can use to guide their decision
making and behavior.
Goals ■ List actions a nurse assistant can take to protect himself or herself from legal and
ethical difficulties on the job.

Key Terms:
laws durable power of assault larceny
attorney for health care
ethics battery ethical dilemma
living will
informed consent negligence ethics committee
abuse
advance directive fraud

to make decisions about his or her care. These rights

Mrs. Geneva Millen is a 58-year-old woman include the right to accept or refuse care and to develop
who was transferred yesterday afternoon to the advance directives.
Golden Shepherd Rehabilitation Facility after
undergoing back surgery. You are assigned to care Informed consent
for Mrs. Millen today. While you are passing through The Patient Self-Determination Act obligates health care
the common area on the unit, you overhear two other providers to obtain the patient’s, resident’s or client’s
nurse assistants talking about Mrs. Millen. One of permission, or informed consent, before going ahead
them says, “The evening and night shifts said she was with a treatment or procedure. To make sure that the
really demanding after she got here. She kept putting person’s decision is informed (that is, based on a thorough
on her call light every five minutes. I’m really glad understanding of the benefits and risks associated with the
she wasn’t assigned to me today!” You notice that proposed treatment or procedure), the health care team
Mrs. Millen’s call light has just come on. must give the person the information he needs in order to
make the decision he feels is best. This includes explaining
why the procedure or treatment is being recommended,
Every day, you make decisions about how to behave. reviewing the risks associated with the procedure or
Some of these decisions are guided by your knowledge treatment, and explaining what the risks are if the person
of our society’s laws (rules established by a governing chooses not to have the procedure or treatment. If
authority to protect citizens from harm and provide a the person agrees to go ahead with the procedure or
framework for resolving conflicts). Other decisions are treatment, he then signs a document giving his consent.
guided by ethics (moral principles or standards that we Even if a person initially consents to a procedure or
use to decide the correct action to take). In this chapter, treatment, he has the right to withdraw that consent and
we will take a closer look at issues relating to the law refuse the treatment or procedure at any time.
that nurse assistants should be aware of. We will also Although as a nurse assistant you will not be
discuss how ethics can guide behavior in the workplace. responsible for getting a person’s written consent to
perform a procedure or treatment, you still must obtain
the person’s verbal consent before providing care. Tell
the person what you are there to do, and ask him if it
LEGISLATION THAT INFLUENCES is okay to continue (Figure 3-1). Make sure to explain
things in a way that the person can understand. A
THE DELIVERY OF HEALTH CARE person who is confused (for example, someone with
In Chapter 2, you learned about the Omnibus Budget dementia) may resist standard care, such as a bath.
Reconciliation Act (OBRA), legislation that was put into Although every person in your care has the right to
place to ensure standards of care for residents of nursing refuse a bath (or any other care procedure), you may
homes. Let’s look at two other important pieces of legislation be able to gain the person’s cooperation and consent
that affect the delivery of health care in all settings. by taking a different approach, or by coming back later
and asking again. For example, a person with dementia
might not agree to a bath, but maybe she will agree
Patient Self-Determination Act to freshening up at the sink. Remember that even if a
In 1991, the federal government passed the Patient person gives you consent to do something, she can
Self-Determination Act. This law gives a person the right withdraw that consent at any time.

Chapter 3 | Understanding Legal and Ethical Aspects of Health Care | 23

 Figure 3-1 Before providing care, always explain to the person what you Figure 3-2 A living will is a document that allows a person to specify
are there to do, and ask the person’s permission to continue. her wishes for care in the event that she is no longer able to express
those wishes herself.

Advance directives this to the nurse immediately so that proper follow-up

can take place.
Under the Patient Self-Determination Act, people have
the right to be informed about how they can communicate
their preferences regarding health care decisions Health Insurance Portability
in the event that they are no longer able to make or and Accountability Act (HIPAA)
communicate these decisions themselves. An advance
directive is a legal document stating how the person In 1996, the federal government passed the Health
wants health decisions made if he or she is unable to Insurance Portability and Accountability Act (HIPAA).
make or communicate these decisions independently in People who are receiving health care have the legal right
the future. There are different types of advance directives: to have their medical information kept secure and private.
This law defines who can look at and receive information
■ A durable power of attorney for health care is a about a person’s health status and care, and sets rules
legal document that gives the responsibility for making related to how information that is communicated in
decisions on the person’s behalf to someone else, writing, verbally or electronically should be handled to
such as a family member, in case the person becomes protect the person’s privacy.
unable to make these decisions on her own behalf.
■ A living will is a legal document that gives specific As a nurse assistant, you play an important role in
directions about what steps the health care team helping to ensure that a person’s rights under HIPAA
should or should not take to prolong the person’s are protected (Figure 3-3). You will have access to
life when death seems near. When a person’s
wishes are not known, health care providers must
assume that the person would want life-sustaining
treatments initiated. However, in some situations, a
person may wish to avoid life-sustaining treatments
if they would potentially cause more suffering. A
living will allows the person to specify these desires
so that others are aware of them and can provide
care accordingly (Figure 3-2).
The Patient Self-Determination Act requires health care
facilities and agencies to teach patients, residents, and
clients and their family members about the purpose of
advance directives, and to assist them with putting a
durable power of attorney for health care, a living will
or both in place, if they so desire. If a person in your
care expresses concern about his or her ability to make
decisions independently in the future, or a desire to put Figure 3-3 The people in your care have a legal right to have information
an advance directive in place, you should communicate about their health status and care kept private and secure.

24 | | Nurse Assistant Training

information about the person’s health status and
treatments. This is protected information. Steps you BEHAVIORS THAT CAN RESULT IN
can take to help keep this information secure include
the following:
LEGAL OR DISCIPLINARY ACTION
As a nurse assistant, it is important for you to understand
■ Share information about the person’s condition or
behaviors that could result in legal or disciplinary action
the care you have provided only with those who
being taken against you. There can be significant
need to know and who are also directly involved
consequences if you commit one of these acts, ranging
in providing care for the person (for example,
from disciplinary action being taken by your employer,
the nurse).
to losing your job, to being arrested and tried in a court
■ Avoid having conversations about the person’s of law. In many cases, behaviors that result in legal or
health status or care in places where you may be disciplinary action being taken against a nurse assistant
overheard by others. are recorded on the nurse assistant’s record in the state
■ Never discuss a person’s condition or care as registry. A record of having committed one of these acts
part of casual conversations with friends or can have a very negative impact on the nurse assistant’s
neighbors, or on social media posts (for example, ability to get another job in health care.
Facebook or Twitter).
■ Take care to secure tools used for documentation
(such as the person’s chart or electronic medical
Abuse
record) per your employer’s policy. For example, Abuse is the willful infliction of injury or harm on another.
return the chart to the designated area when A person can commit abuse by actively doing something
you are finished charting, or close the computer to another person (for example, by hitting the person or
screen. Never share the user name and password verbally tormenting or threatening the person). Failing to
that you use to log into the computer system at provide necessary care for someone who is dependent
work with anyone. on others for that care is also a form of abuse. Abuse
■ If someone asks you for information about a person can take many forms (Table 3-1).
in your care and you are not sure whether that
person has a right to this information, refer the ELDER CARE NOTE. Older people, especially
person to the nurse. This includes the person’s those who have multiple health conditions and
family members, if you are not sure the person rely on others for care, are particularly vulnerable
would want them to have this information. to being abused. This is called elder abuse, and
■ Always follow your employer’s policies and it can take any of the forms described in Table
procedures relating to how private information 3-1. An older person who is being abused is
about patients, residents, or clients is to be handled often reluctant to report abuse, especially when
and secured. he or she depends on the abuser for care. When
caring for older people, be alert to changes in
the person’s behavior or appearance that might
indicate that abuse is occurring (see Table 3-1).
You enter Mrs. Millen’s room and find her
crying. She tells you that she is in pain and can’t get Abuse can happen to anyone, and anyone can be an
comfortable. You offer to help her change her position. abuser. People who depend on others for care, such
While you are there, she says, “I’m just not used to as children and the elderly, are at the highest risk
this place. It’s all so new and I don’t know the staff. for being abused. Caregivers can be at high risk for
At least when I was in the hospital, I knew what to committing abuse when the stress of providing care
expect. I heard the staff talking about me last night.” becomes overwhelming. For example, many families
Imagine that you were Mrs. Millen. How struggle when one family member (such as a spouse or
would you feel if you overheard staff members an adult child) must take on most of the responsibility
talking about you? for providing care to a loved one. Sometimes the
stress becomes too much, which can lead to abuse.
Would you say anything to the nurse assistants Even professional caregivers, like nurse assistants, are
you overheard talking about Mrs. Millen in subject to on-the-job stress that can lead to abuse.
the common area? Why or why not?
Abuse is never an acceptable form of behavior,
What measures can you take to help protect and acting in an abusive manner can lead to
Mrs. Millen’s privacy going forward? the end of your career in health care. Many
employers offer counseling to help employees manage

Chapter 3 | Understanding Legal and Ethical Aspects of Health Care | 25

Table 3-1 Forms of Abuse
Form of Abuse Examples Possible Signs
Physical Abuse: Deliberately ■ Hitting ■ Cuts, bruises or other signs of injury,
hurting another person’s body ■ Pushing or shoving especially when the person seems to
■ Pulling the hair experience a lot of these types
■ Biting of injuries
■ ■ Burns, especially when they occur in
Burning
■ Choking unusual places or have unusual patterns
■ Person may be withdrawn or fearful,
■ Shaking
■ Endangering the person (putting especially in the presence of the person
him in a life-threatening situation he who is causing the abuse
cannot respond to)
■ Using restraints inappropriately

Emotional Abuse: Degrading, ■ Threatening a person with physical ■ Person may be withdrawn or fearful,
belittling or threatening another harm or the withdrawal of support especially in the presence of the person
person ■ Humiliating a person who is causing the abuse
■ Teasing a person in a cruel way
■ Refusing to speak to the person or
ignoring the person
■ Preventing a person from interacting
with others (involuntary seclusion)
■ Using restraints inappropriately

Sexual Abuse: Forcing the ■ Inappropriately touching a person’s ■ Bruises, scratches or cuts around the
person to take part in sexual breasts, buttocks or genitals, or breasts, buttocks or genitals
activity of any kind forcing the person to touch someone ■ Unexplained vaginal or rectal bleeding
else in an inappropriate way ■ Person may refuse personal care
■ Forcing another person to participate ■ Person may be withdrawn or fearful,
in sexual activities especially in the presence of the person
■ Making inappropriate, sexually who is causing the abuse
suggestive comments
■ Sexually exploiting the person (for
example, by photographing the
person’s nude body)

Neglect: Failing to provide for a ■ Failing to provide food, water, clothing, ■ Signs of poor personal hygiene (for
dependent person’s basic needs shelter or necessary treatments example, dirty hair, body odor, dirty
(such as medications) fingernails, crusty eyes, bleeding gums
■ Failing to assist the person with or lips)
personal hygiene and toileting ■ Dehydration
■ Weight loss
■ Pressure ulcers

Financial Exploitation: Taking ■ Stealing a person’s money, Social ■ Person reports that money or assets are
or misusing another person’s Security checks or belongings missing
money or assets ■ Using a person’s funds for a purpose ■ Correspondence from banks or other
other than what they were intended financial institutions that the person did
for not expect or does not understand
■ Using a person’s checks or credit ■ Unpaid bills, even though the person
card, or withdrawing money from a has enough money to pay them
person’s bank account, without the
person’s knowledge or permission
■ Forging the person’s signature on
checks or legal documents

26 | | Nurse Assistant Training

job-related stress. Take advantage of the opportunity don’t stop trying to pull that IV line out I’m going to tie
to attend counseling sessions if they are offered. Other your hands behind your back!”) could be considered
methods for managing stress include participating in assault. Battery is actually touching another person
activities that you enjoy outside of work, taking time in a harmful or unwelcome way. Hitting, pinching or
for yourself on a regular basis to relax and recharge, slapping a person in your care would be considered
and creating an environment where co-workers pitch forms of battery. The inappropriate use of physical
in to help one another. Sometimes, despite all of your restraints (devices used to restrict a person’s ability to
stress management techniques, you may find yourself move freely) is also considered a form of battery. Even
becoming overwhelmed at work. Ask a co-worker to beginning a procedure without obtaining the person’s
cover for you and remove yourself from the situation. verbal consent to do so could be considered a form of
Take a few minutes to get your feelings under control. battery, because you would be touching the person in
If you find a situation to be too difficult to manage an unwelcome way.
appropriately, you may need to ask your supervisor to
reassign you.
Negligence
If you have concerns that someone is abusing a person
Negligence is failure to do what a reasonable and
in your care, you have a legal responsibility to report your
careful person would be expected to do in a given
concerns to your supervisor (or to another person in the
situation. Examples of negligence include the following:
organization, per your employer’s policy) (Figure 3-4).
There may be times when you are unsure whether abuse ■ A nurse assistant has been trained in how to use
has actually occurred; in these circumstances it is best the mechanical lift (a device used to assist people
to err on the side of reporting. The name of the person with moving from one place to another). While using
making the report is kept confidential unless the person the lift to move a person from the bed to a chair, the
permits his or her name to be used, or a court of law nurse assistant fails to lock the brakes on the lift,
requires the person to testify. You are not responsible for resulting in injury to the person.
investigating abuse, just reporting your concerns. The ■ A nurse assistant is helping a person to get out of
state agency that investigates cases of suspected abuse bed. The person repeatedly tells the nurse assistant
will follow up and investigate accordingly. that he is feeling dizzy, but the nurse assistant
encourages him to stand up anyway, because she
Assault and Battery does not have time to wait for the person’s dizziness
to pass. The person stands up and then experiences
Assault is an action that causes a person to fear a fall.
being touched in a harmful or unwelcome way. For ■ A nurse assistant is asked to do a task that she has
example, raising your hand as if to strike a person not been trained to do. Instead of declining to do
in your care, or making a statement that suggests the task, the nurse assistant attempts the task and
you will physically harm the person (such as, “If you causes injury to the person.

Fraud
Fraud is lying to gain profit or advantage. For example, a
very problematic type of fraud in health care is Medicare
fraud, which occurs when an individual or an organization
seeks Medicare reimbursement for services that were
not provided. Always document the care that you provide
accurately and honestly. A health care worker can also
commit fraud by misrepresenting his qualifications to
others. For example, it would be fraudulent for a nurse
assistant to tell a person in his care that he is a nurse,
because he does not have the training or license
necessary to practice as a nurse.

Larceny
Larceny is theft. As a nurse assistant, you will have
Figure 3-4 If you suspect that a person in your care is being abused, access to the personal belongings of the people in your
you have a legal obligation to report your concerns to your supervisor.
Make careful note of the person’s behavior, injuries or both so that you care. This is especially true if you work in a long-term
can give your supervisor accurate information. care or home setting. It is never acceptable to take

Chapter 3 | Understanding Legal and Ethical Aspects of Health Care | 27

something that belongs to someone else, even if the people in your care. For example, consider the
person does not seem to need the item. People who following situation. A resident is slightly injured when
are elderly or ill are particularly at risk for having money another nurse assistant accidentally catches his finger
or belongings stolen from them. Family members, in the wheelchair brake. The nurse assistant does not
friends, staff members or even other people receiving report the incident, so you have to decide whether to
care in the facility may commit larceny. If you notice report it. If you decide not to report the incident, you
that items are missing, or if you see someone taking an may not be committing a crime. But are you acting in
item that belongs to one of the people in your care, an ethical manner?
you must report this to the nurse.
A job in health care also gives employees access to Later that morning, you approach the nurse
things like medications. Taking medications from the to discuss the situation with Mrs. Millen. You tell
people receiving care in the facility, or from the facility the nurse that you overheard two nurse assistants
itself, is another form of larceny. talking about Mrs. Millen, and that she apparently
heard them talking about her too. You ask the nurse’s
opinion about the best way to deal with the situation.

USING ETHICS TO GUIDE How is making the decision to discuss

the situation involving Mrs. Millen with
BEHAVIOR the nurse a reflection of your personal
As a nurse assistant, you have a responsibility to act ethical standards? What about your ethical
within the law. However, not every decision you make standards as a health care worker?
with regard to how to behave or act will be guided by
your knowledge of what you must do in order to avoid
Often situations arise in health care where there may
breaking the law. Many decisions will be guided instead
be more than one good or moral solution, depending on
by your knowledge of what is right, meaning what is
one’s point of view. These situations are called ethical
good or moral. When you do what is right (that is, when
dilemmas. Ethical dilemmas can arise when a person
you act in an ethical manner), you go beyond what is
receiving health care is not able to make her preferences
legally required.
known. When this occurs, members of the health care
Your own personal code of ethics is influenced by team have to make the decision that they feel is best
the beliefs and principles that you choose to live for the person in their care. Different members of the
by. These beliefs and principles are in turn team may have differing but equally valid viewpoints,
influenced by many different factors, including your depending on their own personal ethical standards
upbringing, your religious or spiritual beliefs, your and their individual knowledge of the person and the
culture and your life experiences. Many professions situation. In difficult situations like this, the health care
also have codes of ethics that guide decision making team may seek the help of an ethics committee in
and behavior for the people who practice that resolving the ethical dilemma. Members of the ethics
profession. For example, five ethical principles that committee have many different areas of expertise, and an
are especially relevant to health care workers include in-depth knowledge of ethical principles. After the facts
the following: of the case are presented to the ethics committee, the
committee members help the health care team to find a
■ Autonomy. Every person has the right to make
solution that takes into account the best interests of the
decisions about matters that affect him personally.
person receiving care.
■ Justice. All people—regardless of race, religion,
culture, sexual orientation, disability or ability to pay
for services—deserve fair and equal treatment.
■ Beneficence. Health care workers are obligated to AVOIDING LEGAL AND ETHICAL
act in a way that promotes the well-being of those in DIFFICULTIES ON THE JOB
their care.
Your work as a nurse assistant will put you in
■ Nonmaleficence. Health care workers are
many different situations and require you to make
obligated to avoid harming those in their care.
many different decisions about how to behave or
■ Fidelity. Health care workers are obligated to act in what to do. These decisions may not always be
a way that is truthful and trustworthy. straightforward. To best serve those in your care,
Any behavior that could cause harm to a person, either and to help protect yourself and your employer from
physically or emotionally, is unethical. You may have legal and ethical difficulties, follow the guidelines
to decide the right thing to do in situations involving in Box 3-1.

28 | | Nurse Assistant Training

 Box 3-1 Nurse Assistant DO’s and DON’Ts
Avoiding Legal and Ethical Difficulties
DO practice the five principles of care Insurance Portability and Accountability DON’T accept gifts of personal
(safety, dignity, independence, privacy, Act (HIPAA). belongings or money from those in
communication) with every person in your care or from their family members.
DO be aware of ethical principles
your care. Although the gift is often a genuine
that guide the actions of health care
gesture of gratitude and appreciation
DO be knowledgeable about the rights workers: autonomy, justice, beneficence,
for a job well done, accepting such a
of the people in your care, as outlined in nonmaleficence and fidelity.
gift could set you up for accusations
the Resident Rights portion of OBRA,
DO be familiar with your employer’s of illegal or unethical behavior later.
the American Hospital Association’s
policies and procedures. Most employers have policies that
The Patient Care Partnership, or the
prohibit employees from accepting gifts
National Association for Home Care and DO be familiar with your scope of from those in their care, or from their
Hospice’s Patient Rights. practice, as defined by your job family members.
description, your employer and
DO be aware of legislation that
your state. DO seek help from your supervisor if you
protects the rights of the people
are not sure of the correct legal or ethical
receiving health care, such as the Patient DON’T perform tasks or make decisions action to take in a situation.
Self-Determination Act and the Health that are outside of your scope of practice.

3. Which legislation supports a patient’s, resident’s

CHECK YOUR UNDERSTANDING or client’s right to make decisions on his or her
own behalf?

Questions for Review a. Health Insurance Portability and Accountability

Act (HIPAA)
1. A nurse assistant is careless and fails to check b. Advance Directive Act
the linens for personal items before stripping the c. Patient Self-Determination Act
bed and sending the soiled linens to the laundry. d. Patient Autonomy Act
As a result, a resident’s dentures are put through
the washing machine and damaged. This is an 4. Mrs. Underwood has dementia and has signed
example of: a document giving her husband the authority to
make decisions about her care on her behalf.
a. Larceny What is this document called?
b. HIPAA violation
a. Durable power of attorney for healthcare
c. Negligence
b. Living will
d. Abuse
c. Informed consent form
2. You suspect that one of your home health d. Beneficence form
clients is being abused by her son. The woman
becomes withdrawn and fearful whenever he 5. Which of the following actions supports a
is in the room, and you have noticed some person’s legal rights under HIPAA?
strange bruises on her arm. What should a. A nurse assistant closes the door to a person’s
you do? room before having a conversation with the
a. Call the police immediately. person about her care.
b. Confront the son and tell him to stop, or you will b. A hospital stops documenting patient care
call the police. on paper records and begins using a
c. Report your concerns to your supervisor at computer instead.
the agency. c. A nursing home has a policy that says all
d. Nothing; this is a private family matter. residents will receive equal treatment, regardless
of their ability to pay for services.
d. A nurse obtains informed consent from a person
before the person undergoes a surgical procedure.

Chapter 3 | Understanding Legal and Ethical Aspects of Health Care | 29

Questions to Ask Yourself 4. You meet some people in the grocery store who
recognize you as the nurse assistant who is
1. One of the friends you made during nurse assistant providing care for their aunt, Mary. They ask you
training is posting comments about situations and specific questions about her medical condition.
the people she cares for on a social networking How do you reply?
site. Last night, she wrote “My thoughts and
prayers are with the Miller family.” Would you say 5. One of your home health clients tells you that he
anything to your friend about her posts? Why or hides his pills and does not take them. He shows
why not? you his hiding place for the pills because he trusts
you. What should you do?
2. You are providing care for Miss Eller. She is dying.
She says she would like for you to have a ring that 6. You see a nurse assistant removing a watch belonging
belonged to her sister, who died last year. What to one of the residents in her care from the resident’s
should you say? bedside table drawer while the resident is attending
an activity session. What are possible reasons the
3. You see a co-worker slapping a person in her care. nurse assistant could be removing the watch? Are all
What should you do? of them necessarily unethical or illegal?

30 | | Nurse Assistant Training

 C H A PT E R
Understanding the
People in Our Care 4
After reading this chapter, you will have the information needed to:
■ List the stages of human growth and development, and describe some of the physical
changes and developmental tasks a person who is in each stage may face.
■ Explain the five levels of human needs as defined by Maslow, and describe actions a
nurse assistant can take to help a person meet his or her needs at each level.
Goals ■ Explain the concepts of sexuality and intimacy, and understand how a nurse assistant
can respect others’ sexuality and need for intimate relationships.
■ Describe preferences a person may have while receiving health care that may be
influenced by the person’s culture.
■ Describe how a nurse assistant can help to support a person’s spirituality.

Chapter 4 | Understanding the People in Our Care | 31

 Key Terms: Continued from previous page

human growth gender identity erection homosexual

human development sexual identity transgender bisexual

sexuality intimacy transsexual culture

sexual behaviors masturbation heterosexual spirituality

Mrs. Josie McMillen, age 77, came to live at HUMAN GROWTH AND
Morningside Nursing Home 3 years ago after health
problems made it impossible for her to remain in
DEVELOPMENT
her own home. Mrs. McMillen has many chronic All people move on the same basic track through
health problems, including severe rheumatoid life. They begin as infants, then grow into children,
arthritis in the joints of her hands. You have cared develop into teens, mature into adults and become
for Mrs. McMillen for the past 2 years, and you elderly. The process of moving from one stage of life
can always tell when she is having a flare-up of her to the next is called human growth and development.
arthritis. On those days, Mrs. McMillen has little Human growth and development is characterized by
interest in eating, socializing or doing anything else changes. Human growth refers to physical changes,
because the pain is so bad. She often just wants to such as growing bigger and cutting teeth in infancy, or
stay in bed and watch her favorite religious program developing breasts or a beard in adolescence. Human
on the television, or listen to one of her favorite books development refers to social changes (the way the
from the Bible on CD. person relates to others), emotional changes (the way
the person feels and expresses those feelings) and
Mrs. McMillen’s husband died many years before cognitive changes (the way the person thinks and
Mrs. McMillen came to live at Morningside. Over the understands the world).
years, Mrs. McMillen developed a close friendship
with Mr. Frank Knoll, a man who attended her There are many different theories related to human growth
church. Mr. Knoll’s wife had also died several years and development. Scientists who study human growth
previously. One day, Mr. Knoll invited Mrs. McMillen and development typically divide the process into separate
to lunch after church, and soon they were spending stages. Although ages are given here as a point of
more and more time together. But eventually, reference, it is important not to confuse ages with stages,
Mr. Knoll’s house became too much for him to take because there is no definite age at which someone can
care of on his own, so he decided to sell his house or should be able to do something. One common way of
and move in with his daughter and son-in-law. defining these stages is as follows (see also Table 4-1):
Usually, Mr. Knoll’s daughter or son-in-law brings ■ Infancy (birth to 1 year). When babies are born,
him to Morningside to visit with Mrs. McMillen at they have been growing and developing since
least once a week. Mrs. McMillen tells you often how conception, about 9 months. At birth, babies are
much she looks forward to Mr. Knoll’s visits. She called neonates, and by the time they are 1 month
says, “He always makes me laugh, and it’s so good to old, they are called infants. Infancy is a time of rapid
talk to him.” growth and development changes.
■ Toddlerhood (1 to 3 years). During toddlerhood,
Throughout the first few chapters of this book, you the child is very busy learning about his world.
have learned how important it is to appreciate each Physical coordination increases, allowing the toddler
person in your care as the individual that he or she is. to be quite active and develop the skills necessary for
Our upbringing, our beliefs and values, our culture, tasks such as dressing, eating and using the toilet.
our life experiences and the qualities we are born ■ Preschool age (3 to 5 years). Preschool-age
with (for example, our personality, sense of humor, children can do many things for themselves; have
or brown eyes) all combine to make each of us a friends; may go to nursery school or kindergarten;
unique individual. But at the same time, there are many and spend a great deal of time “pretending” to be
experiences and needs that all humans share. In this grown-ups. However, they still see the world through
chapter, we’ll take a look at some of the things that all young children’s eyes and imagine and fear things
human beings have in common. adults know cannot be possible.

32 | | Nurse Assistant Training

Table 4-1 Stages of Human Growth and Development
Social/Emotional
Stage Physical Changes Changes Cognitive Changes
■ May triple in weight and ■ Cries to communicate ■ Uses senses to explore the
increase greatly in length ■ Begins to smile and laugh world
by 1 year ■ Begins to trust caregivers ■ Begins to say a few short
■ Begins to control body and cry at the sight of words
movement: lifts head; holds strangers
Infancy: birth to and throws objects and
1 year puts them in mouth; rolls
over, sits up, crawls, climbs,
takes first steps with
assistance; and stands
■ Begins cutting teeth and
taking solid food

■ Does many things that ■ Likes to play alone or side ■ Able to follow simple
require coordination of by side with another child, instructions when given
large muscles in arms and and tends not to share toys slowly and clearly
legs: walks, runs, jumps ■ Independence increases, ■ Responds fairly well to
and climbs and the toddler does not like adult language and can
■ Plays with toys to be told what to do point to objects named by
■ Has 6 to 12 baby teeth and ■ Throws temper tantrums adults
Toddlerhood: eats regular table food when desires are not met ■ Has a strong, self-oriented
1 to 3 years ■ Learns to use the toilet and ■ May be afraid when point of view and is unable
eats, drinks and dresses separated from parents or to understand others’
with little or no help other familiar caregivers points of view
■ Needs to rest frequently ■ Begins to put words
during the day together to make short
sentences
■ Understands that objects
taken out of sight still exist
■ Likes to choose own
activities and toys

■ Has improved large-motor ■ Has a strong sense of ■ Learns new words quickly
skills identity and may start to read
■ Has more control over ■ Makes own choices some words; counts and
small-motor skills such as ■ Plays easily with other enjoys learning things with
drawing or writing children and enjoys games numbers
■ Does many things to involving sharing and taking ■ Groups objects that are
take care of self such as turns alike and is able to pick out
dressing, eating and using ■ Looks up to and imitates objects that do not fit with
the toilet adults others
■ Likes routine and may feel ■ Follows directions
insecure if schedule is ■ Has strong curiosity and
changed too often imagination and asks many
Preschool Age:
questions
3 to 5 years
■ Has a strong, self-
oriented point of view and
sometimes is unable to
understand others’ points
of view

Continued on next page

Chapter 4 | Understanding the People in Our Care | 33

Table 4-1 Stages of Human Growth and Development continued

Social/Emotional
Stage Physical Changes Changes Cognitive Changes
■ Grows steadily ■ Begins to form lasting ■ Pays attention longer,
■ Develops muscle tone, relationships with friends remembers longer and
balance, strength and ■ Forms small, close-knit follows more complex
endurance and is physically groups that exclude other directions
well coordinated children, especially those of ■ Ability to think logically and
■ Uses large muscles for the opposite sex make decisions increases
games and sports, cycling ■ Spends more time away ■ Starts to organize new
and dance from parents or other information in meaningful
■ Uses small muscles to caregivers ways
write, draw and do crafts ■ Begins to understand that ■ Behaves more responsibly
School Age: ■ Enters puberty at about other people also have ■ May question and resist
5 to 12 years age 10 to 12 for girls and feelings adult decisions
age 12 for boys ■ Has many emotions and
sometimes has difficulty
expressing them; may have
dramatic mood swings
that accompany hormonal
changes when going
through puberty

■ Reaches reproductive ■ May feel awkward or ■ Able to think logically

maturity: in girls, breasts embarrassed around adults and understand abstract
develop, hips widen, and strangers because of concepts
pubic and underarm hair recent physical changes ■ Imagines alternatives when
appears and menstruation ■ Assumes more making a decision, which
begins; in boys, penis and responsibility for own makes decision making
testes grow to adult size, behavior more difficult
ejaculations begin, pubic ■ Often rebels against adult ■ Plans for the future
and facial hair develops, authority ■ Becomes more self-
voice deepens and neck conscious and concerned
and shoulders grow with physical appearance
■ Girls tend to be taller than ■ Is easily disappointed and
Adolescence: boys of the same age at the discouraged
12 to 20 years beginning of this age range ■ May set unreasonable
and tend to be shorter at goals
the end

■ Muscle strength, bone ■ Establishes lasting and ■ Functions at higher

density and senses are at intimate relationships with level than children and
their peak friends and partners adolescents, although
■ Gets sick infrequently, ■ Makes commitments some young adults
and recovers quickly from ■ May begin a family continue to think and
illnesses and injuries reason much like
■ Women may experience adolescents and children
physical changes of ■ Is able to imagine being in
pregnancy another person’s situation
and recognize how another
feels
Young Adult Years: ■ Has better-developed
20 to 45 years moral reasoning

34 | | Nurse Assistant Training

Table 4-1 Stages of Human Growth and Development continued

Social/Emotional
Stage Physical Changes Changes Cognitive Changes
■ May develop chronic ■ Begins to feel anxious ■ Increases in mental growth
illnesses, although some about aging and has high levels of
find that existing health ■ Feels more satisfied by work intellectual performance
conditions disappear or ■ May become depressed ■ Finds this is often the most
become less problematic as children grow up and creative time of life
■ May have slight decreases leave, or may delight in the
in senses, physical strength new freedom
and coordination ■ Often takes on more
■ Women experience responsibility for caring for
menopause aging parents
■ May have to cope with the
Middle Adult Years: loss of one or both parents
45 to 64 years ■ May become a grandparent

■ Is likely to experience the ■ May retire from a job, which ■ Generally maintains
onset of more chronic can lead to increased intellectual abilities and may
illnesses, but is generally energy, productivity and pursue new interests and
healthy enough to continue creativity; feelings of loss; hobbies
normal physical activities or both
■ May have to cope with
death of a spouse, friends
or other family members
(such as siblings)
■ May have to cope with
losses of independence,
such as those caused by
giving up a driver’s license,
moving out of one’s own
Young-Old Years: home or accepting the
65 to 75 years need for someone else
to enter the home to
provide care

■ May have decreased vision, ■ May be less confident and ■ Generally maintains
with loss of night vision have lower self-esteem intellectual abilities but may
and less depth and color because of loss of loved not process information
perception ones and diminished as quickly and may make
■ May experience some physical and sensory decisions with less speed
hearing loss and a capabilities ■ Is able to learn new
decreased sense of smell ■ Often has to cope with information and skills but
and taste major life changes, such needs more time to learn
■ May have less strength and as the death of a spouse
balance and may be prone or the need to sell a house
to accidents and falling and move
■ May be noticeably shorter
because of spinal column
shrinkage
Middle-Old Years: ■ May adjust less quickly
75 to 85 years to cold

Continued on next page

Chapter 4 | Understanding the People in Our Care | 35

Table 4-1 Stages of Human Growth and Development continued

Social/Emotional
Stage Physical Changes Changes Cognitive Changes
■ Physical abilities may ■ May struggle with accepting ■ Generally maintains
continue to decrease, failing health or increased intellectual abilities but may
both as a result of normal dependency on others for not process information
changes of aging and assistance and care as quickly and may make
illness or injury ■ May begin to think about decisions with less speed
and plan for own death ■ Is able to learn new
■ May look back and reflect information and skills but
on own life needs more time to learn

Old-Old Years:
85 years and older

■ School age (5 to 12 years). School-age children to notice changes in physical abilities related to the
seem like miniature adults at times. They can process of aging, or the onset of disease or disability.
hold very interesting conversations and have firm ■ Middle-old years (75 to 85 years). Many people
opinions. Throughout the school-age years, the child continue to enjoy good health, although others will
goes through many growth spurts, leading to steady begin to experience health problems. The person
increases in height and weight. may need to come to terms with an increased need
■ Adolescence (12 to 20 years). During to rely on the help of others with tasks such as
adolescence, children leave their childhood ways maintaining the house or driving. The person may
behind and gradually move into adulthood. Their begin to experience repeated losses, such as the
bodies reach full size during these years, and loss of independence associated with having to
their minds begin to work like those of adults. give up a driver’s license or home, or the deaths of
Social and emotional experiences are intense a spouse or other family members and friends.
as strong friendships and early love relationships ■ Old-old years (85 years and beyond). During
develop. Some adolescents begin sexual this stage, people look back on their lives and
relationships and may parent children of begin to prepare for their own deaths. Often, the
their own. person must cope with increasing losses: the
■ Young adult years (20 to 45 years). For most deaths of friends, family members, and possibly a
people, the young adult years are filled with spouse; physical limitations caused by the process
beginnings: living on one’s own away from parents, of aging; and the increasing loss of independence.
starting a career, beginning a relationship with Many older adults become mentors to younger
someone who may eventually be a life partner people by sharing the perspectives and knowledge
or spouse. Many young adults begin a family by only a lifetime of experiences can provide.
conceiving or adopting children. Being able to recognize the developmental stage of a
■ Middle adult years (45 to 65 years). During the person in your care will help you to better understand
middle adult years, many people experience the the person’s needs, behavior and responses to
satisfaction of enjoying what they began in their situations. This understanding will also help you to
20s and 30s. Their careers are often at their peak, communicate more effectively with the person, in terms
children are growing or grown, and finances may that are appropriate for the person’s developmental level.
be secure enough to allow for more leisure time. However, always remember that the characteristics given
During this stage, many people become caregivers in Table 4-1 are general guidelines, not rules. You should
to aging parents, and may experience the loss expect to see many individual differences among those
of a parent. Many middle adults also become in your care.
grandparents.
■ Young-old years (65 to 75 years). During this ELDER CARE NOTE. Many people have beliefs
period, the person may retire from a job. For some about aging that are not based in fact. These
people, this is a welcome event, but others may beliefs can lead to ageism (having preconceived
struggle with the change in role or the need to adjust negative ideas about aging or elderly people).
to living on a fixed income. The person may begin For example, although many of the people who

36 | | Nurse Assistant Training

 become residents of nursing homes are elderly Maslow defined five levels of needs: physical needs,
and have some form of cognitive impairment safety and security needs, social needs, self-esteem
(such as dementia), dementia is not a normal needs, and self-fulfillment needs. As a nurse
or expected consequence of aging. Similarly, assistant, you play a large role in helping people
neither is incontinence (an inability to control the meet their physical, safety and security, social, and
release of urine or feces). Many older adults enjoy self-esteem needs. As the needs at these first four
relatively good health and are able to remain quite levels are met, the person turns inward to meet the
independent well into their later years. As a nurse self-fulfillment needs at the top of the pyramid on
assistant, it is important to understand each person his or her own.
in your care as the unique individual that he is,
Maslow’s theory is just one of many theories about
and to avoid making assumptions about what the
basic human needs, but it provides a good framework
person can do or should do based on his age.
for caregiving. Understanding the idea that basic
needs must be met before more advanced needs can
be met will help you provide better care. For example,
Remember Mrs. McMillen, whom you a person who is having difficulty breathing is not going
met at the beginning of this chapter? What to have the interest or energy to try to meet higher
developmental tasks might she be facing at level needs, such as the need to socialize with others.
this point in her life? By helping people to meet their most basic needs first,
you can make it easier for them to meet their higher
level needs.

BASIC HUMAN NEEDS Physical Needs

To live and to be healthy and happy, certain basic needs
must be met. Many years ago, Abraham Maslow, a Physical needs are basic requirements for life,
famous psychologist, developed a theory about people such as food, water, oxygen, exercise, sleep, the
and their needs. According to Maslow’s theory, people ability to eliminate bodily wastes and the ability to
have needs on different levels. A person must meet experience human touch. As a nurse assistant,
lower level needs before she can meet higher level many of your daily responsibilities will have to do
needs. To illustrate his theory, Maslow organized human with helping people to meet basic physical needs
needs into a pyramid, called a hierarchy, from lowest to (Figure 4-2). For example, you will help people
highest (Figure 4-1). with eating, toileting, and walking or other forms
of exercise. You will help to ensure that the people
in your care are able to rest by maintaining a quiet,
restful environment and providing clean linens.
You will help meet the person’s need for physical
contact by gently squeezing her hand, patting her
arm or giving her a hug.

Figure 4-2 Physical needs must be met before a person can think
Figure 4-1 Maslow’s hierarchy of needs. about meeting higher level needs.

Chapter 4 | Understanding the People in Our Care | 37

 Figure 4-3 Making sure the person has a way to call for help if she Figure 4-4 All people have the need to interact socially with others.
needs it is one way nurse assistants help to meet the person’s need to
feel safe and secure.

Safety and Security Needs little while. In long-term care facilities, there are
many ways you can help residents to meet their
Remember that safety is one of the five principles of social needs. For example, planned activities
care. As you continue through this course, you will (such as games, holiday celebrations and musical
learn many different actions that you can take performances) give residents an opportunity to meet
to keep the people in your care safe and secure. other residents and socialize. You will also help
For example, you will take steps to prevent the residents to meet their social needs by assisting them
spread of microbes that can cause infection, lock to the dining room for meals, so that they can enjoy
the brakes on equipment with wheels to prevent the company of others while eating.
injuries, and keep a close eye on people who may be
confused and at risk for wandering away from
the facility.
Self-Esteem Needs
In addition to helping the people in your care be safe,
People need to feel good about themselves, and that
you will help them to feel safe (Figure 4-3). When we
they are worthy of the respect of others. People who
feel safe, we can relax and rest. Simple actions, such
are in need of health care often feel that they are no
as checking on each person in your care frequently
longer important and that they cannot contribute in a
and answering requests for help promptly, build trust
meaningful way. The loss of ability and independence
and help the people in your care to feel safe and
that may come with illness, injury or advanced age
secure. What makes someone feel safe and secure
can affect a person’s self-esteem. A loss of cognitive
may vary from person to person, so make an effort to
ability (such as that which occurs with dementia)
find out each person’s preferences. For example, one
can also affect a person’s self-esteem. For a person
person may feel more secure with the door to her room
with dementia, even a simple question like “What
closed, while another may want to leave the door to
do you want to wear today?” may be very difficult
her room open.
to answer. The person’s inability to answer the
question easily can have a very negative impact
Social Needs on her self-esteem.
Most people need to be liked, loved and accepted As a nurse assistant, you help to protect and build
by individuals and groups (Figure 4-4). These are the self-esteem of those in your care by allowing
social needs. No one wants to be ignored, to feel left them to do as much as possible for themselves, and
out or to feel unloved or lonely. As a nurse assistant, recognizing their accomplishments. Take an interest
you can help meet the social needs of the people in in the person, and encourage him to talk about past
your care many times each day. You can be especially accomplishments (such as raising a family or serving
helpful when a person’s family and friends cannot in the military) that make him feel proud. Make sure
be with her. Take the time to sit with the person and you communicate with the person at a level she
look through a photo album together, help with a understands, to make it easier for her to respond
crossword puzzle or just talk with the person for a appropriately. (For example, instead of asking a

38 | | Nurse Assistant Training

person with dementia what she wants to wear, offer
her two choices of outfits so that she can easily pick This morning, when you go to Mrs. McMillen’s
one.) Show the person that he is still worthy of the room to help her with her morning care, you can tell
respect of others by treating him with respect yourself that she is not having a good day. As you help her get
(for example, address the person in the way that he out of bed and to the bathroom, she tells you that she
likes to be addressed). On a very basic level, helping did not sleep well the night before, and that the pain is
the person with bathing and grooming also builds really bad. She says, “Frank is supposed to come today
self-esteem by helping the person feel confident and and we were going to have lunch, but I don’t know if I
attractive to others (Figure 4-5). even have the energy. Maybe I should call him and tell
him not to come.”
Self-Fulfillment Needs Which needs of Mrs. McMillen’s are a priority
now? How are these needs affecting her
Self-fulfillment means that a person feels satisfied with
ability to meet her other needs?
herself and her life. When a person’s self-fulfillment
needs are satisfied, she believes that she is doing what What can you do to help Mrs. McMillen meet
she is best suited to do (Figure 4-6). For example, a her needs?
person may experience self-fulfillment by writing a great
book, working toward finding a cure for a disease,
becoming a terrific parent or working to provide good
care for the elderly. Because each person excels
in different areas of life, each person’s self-fulfilling SEXUALITY AND INTIMACY
experience will be different.
All people are sexual beings, and have a need for
sexual expression and sexual pleasure. How we
perceive ourselves and express ourselves sexually is
called sexuality. Sexuality is related to many different
concepts, including sexual behaviors (physical
activities, such as sexual intercourse and masturbation,
related to obtaining sexual pleasure and reproducing),
gender identity (a person’s inner sense of being male
or female), and sexual identity (a person’s sexual
orientation and preferences with regard to sexual
partners).
The need and ability of a person to feel emotionally close
to another human being and to have that closeness
returned is called intimacy. Intimacy includes all the
good feelings that people have for one another, such as
Figure 4-5 Helping a person to look and feel her best helps to build liking, loving, sharing and caring (Figure 4-7). To express
the person’s self-esteem.

Figure 4-6 This resident of a nursing home, a retired teacher, continues Figure 4-7 All people have the need to develop close emotional ties
to find self-fulfillment by leading a book discussion group at the facility. with others.

Chapter 4 | Understanding the People in Our Care | 39

their feelings of intimacy, people may kiss, hug, touch example, a man may have an erection while you
or hold hands, or they may simply engage in private are providing care. This physical change does not
conversations. Intimate relationships may or may not necessarily mean that he is attracted to you or that he
involve sexual activity. is thinking about you sexually. An erection may mean
the man has a full bladder, is thinking about something
ELDER CARE NOTE. It is important to remember else that is sexually exciting, is feeling afraid or is feeling
that all people, young and old alike, have the pleasure. You and the man may feel embarrassed. To
need to think of themselves as sexual beings and make the situation more comfortable, you may want to
engage in intimate relationships (which may or talk about something unrelated or simply continue the
may not involve sexual activity). task without talking.

Sexual Behaviors Gender and Sexual Identity

Sexual behaviors include activities a person engages Gender identity refers to how a person perceives his or
in to derive sexual pleasure or to reproduce, such as her “maleness” or “femaleness.” Most children recognize
sexual intercourse with a partner or masturbation whether they are male or female by the age of two. They
(touching or rubbing one’s own genitals for sexual know by looking at their bodies whether they are girls
release or pleasure). or boys. Some people have a personal feeling that their
gender does not match the physical body they were
As a nurse assistant, you must respect the right of those born with. They may be males who feel themselves to
in your care to engage in sexual behaviors, and provide be female, females who feel themselves to be male,
the necessary privacy. Since many people might be or people who do not strongly identify themselves
embarrassed to ask for privacy, you must look for cues as either male or female. Such people are called
that a person or couple may want to be alone. When a transgender. Transgender individuals may or may not
couple is together, excuse yourself and say what time become transsexuals, people who alter their physical
you will be back. As always, knock on the person’s door appearance to more closely match the gender they most
and wait for a reply before entering. Be aware that a strongly identify with. A person who is transsexual may
person who is confused may engage in sexual behaviors, take hormones, have surgical procedures or both to alter
such as masturbation, outside of the privacy of his or her his or her body to better match his or her inner sense of
room. If this occurs, help the person back to his or her gender identity.
room and provide the necessary privacy.
Sexual identity refers to a person’s preferences
You will also have the responsibility of protecting the with regard to sexual partners. A person can be
people in your care from unwanted sexual advances. attracted to someone of the opposite sex, the same
Although everyone has the right to express himself or sex or both. A person who is attracted to people of the
herself sexually, he or she must only exercise that right opposite sex is called heterosexual (some also use
with someone who is a willing participant. A person the word “straight”), and a person who is attracted to
who is confused may not be able to consent to sexual people of the same sex is called homosexual (some
activity, because he or she may not understand what also use the word “gay” to refer to a man
is happening. Similarly, a person with a developmental who is attracted to other men, or “lesbian” to refer to
disability may be physically old enough to engage in a woman who is attracted to other women). A person
sexual activity, but may not be emotionally ready or who is attracted to people of both sexes is called
intellectually able to understand what is happening. bisexual.
Sometimes, a person may make unwanted sexual
advances toward you. If this happens, gently but firmly
let the person know that you want the behavior to stop. Respecting Others’ Sexuality
You can say something such as: As a nurse assistant, you will provide care for
■ “I really like you as a person, but I don’t like it when people whose feelings and beliefs about sexuality
you touch me that way.” will differ from yours. For example, you may have
been raised with the belief that people who are not
■ “I really enjoy providing care for you, but I feel
married should not have sex, that masturbation is
uncomfortable when you talk to me that way.”
wrong or that homosexual relationships are wrong.
■ “I want you to stop touching me like that. Please do Regardless of your own beliefs and feelings, you must
not do that again.” avoid being judgmental of those in your care, and
At the same time, you must be careful not to misread treat every person in your care with respect
something that may look like sexual attraction. For and consideration.

40 | | Nurse Assistant Training

 a person might prefer based on the person’s name,
CULTURE nationality or physical appearance. The best approach
is to be aware of areas where a person’s culture may
Culture is a shared set of beliefs, values, customs and
influence preferences, ask what the person’s preferences
practices that characterizes a group of people or a
are and then respect those preferences, even if they seem
society. Our culture affects how we view the world and
strange to you. Asking about the person’s preferences
respond to life’s experiences. It helps us to understand
shows the person you are interested in him or her as an
who we are and how we fit into our society. Culture may
individual, and can also prevent misunderstandings due to
be based on a common ethnic heritage, on a common
a lack of knowledge about the person’s culture.
geographic location, on common religious beliefs or on a
combination of these (Figure 4-8).
Here in the United States, you may have the opportunity to SPIRITUALITY
care for people from many different cultures. It is important
Spirituality is a belief in something greater than oneself
to understand how culture influences behavior. A person’s
that helps a person assign meaning and purpose to life.
cultural beliefs, values, customs and practices can influence
For many people, organized religion is closely linked to
many preferences a person receiving health care, or her
spirituality. However, many people are spiritual without
family members, may have, such as preferences regarding:
participating in a formal, organized religion. Spirituality
■ What foods are eaten, how they are prepared, when has to do with having an awareness of the purpose
they are served and how they are served. and meaning of life, and finding guidance and comfort
■ Personal care rituals, such as when and how to in that awareness. Having a strong sense of spirituality
bathe, or clothing selections. can strengthen a person’s ability to cope with difficult
■ Who can provide care, especially care that involves situations. Spiritual beliefs (such as the belief in a power
exposing the person’s body. greater than oneself) and practices (such as attending
a religious service or engaging in quiet meditation or
■ Which family member should be consulted about the
prayer) can provide mental relief by reducing stress and
person’s care.
worry and increasing feelings of hope and gratitude.
■ What type of touch is acceptable.
■ What type of eye contact is acceptable. As a nurse assistant, there are many things you can do
to support and foster a person’s sense of spirituality
■ Social customs, such as what actions are
(Figure 4-9). A person may find it comforting to have you
considered polite and impolite.
read from a book that is meaningful to him (such as a
■ How illnesses should be managed and treated. religious text or a book of poetry), to engage in a meaningful
■ What rituals should be followed leading up to and activity or ritual with him (such as prayer) or to help him with
after death. activities that strengthen his spirituality (such as writing
■ What rituals should be followed leading up to and in a journal, attending a religious service or visiting with a
after giving birth. clergy member). Remember that you do not have to share
Although information is available about cultural the person’s spiritual beliefs and practices in order to
preferences, it is risky to make assumptions about what help the person benefit from those beliefs and practices.

Figure 4-8 Quinceañera, a festive celebration surrounding a girl’s fifteenth

birthday, is a common tradition in many Hispanic cultures. Image © AISPIX Figure 4-9 For many people that you care for, religious or spiritual
by Image Source, 2012. Used under license from Shutterstock.com. beliefs will be a source of strength and comfort.

Chapter 4 | Understanding the People in Our Care | 41

 c. How a person perceives of herself and
CHECK YOUR UNDERSTANDING expresses herself sexually.
d. Knowing whether you are a girl or a boy.
Questions for Review 6. A nurse assistant must care for people from
many different cultures. How should the nurse
1. You are providing care for 13-year-old Kathy assistant handle this?
Harrison at her home while she is recovering
a. The nurse assistant should advise people that
from injuries caused by a car crash. She has
when they are in the health care facility, they
stitches along her forehead and across one
must follow the health care facility’s policies and
cheek. Her friends call, but she doesn’t want to
procedures.
see them. She may be worrying that:
b. The nurse assistant should seek to understand
a. She will have to tell her friends that she cannot each person as an individual, and accommodate
leave the house to go to the mall. the person’s preferences whenever possible.
b. Her friends will think she is ugly. c. The nurse assistant should use his or her own
c. Her mother won’t let them come over. cultural beliefs to guide care.
d. Her friends will bring her schoolwork. d. The nurse assistant should avoid caring for
people who are from a different culture.
2. A nurse assistant helps Mrs. Smith, a resident of
a nursing home, to meet her social needs by: 7. Which of the following statements about older
a. Ensuring Mrs. Smith has enough to eat. adults is true?
b. Helping Mrs. Smith get ready to attend a group a. Older adults are not capable of learning new
activity. skills or concepts.
c. Encouraging Mrs. Smith to do as much for b. Older adults may be sexually active and continue
herself as possible. to need to have close, intimate relationships with
d. Making sure that Mrs. Smith feels safe and others.
secure. c. Most people start to become confused as they
age and become incapable of taking care of
3. Mr. Jameson always talks about his days as themselves.
a leader in his union but he hardly ever talks
d. Older adults usually become depressed
about the present. When he starts to talk about
because they no longer have anything to
the past, you should:
contribute to their families, communities or
a. Tell him not to dwell on the past. society in general.
b. Tell him how interesting it must have been in
those days and ask him some questions about it. 8. Which of the following actions helps to meet a
person’s safety and security needs?
c. Change the subject by asking him what he
would like to do today. a. Encouraging the person to do as much for
d. Remind Mr. Jameson that he is retired now. himself as he is able
b. Answering the person’s requests for help promptly
4. A nurse assistant helps a person meet his c. Locking the person in his or her room
self-esteem needs in all of the following ways
d. Providing the person with privacy when he or
EXCEPT:
she has visitors
a. Addressing the person in the way he prefers to
be addressed.
Questions to Ask Yourself
b. Doing everything for the person so that that he
does not have to do anything. 1. Mr. Robinson was admitted to the nursing home
c. Taking care to protect the person’s privacy and where you work last week. Mr. Robinson has a
modesty. partner, Mr. Benning, who comes to visit him every
d. Taking an interest in the person as an individual. day. You are on your break with another one of the
nurse assistants who works on the floor, and he
5. Sexuality is: says to you, “I really don’t approve of Mr. Robinson’s
a. The physical act of having sexual intercourse. relationship with Mr. Benning. It’s just not natural.”
Do you think your co-worker’s feelings might
b. The ability to form intimate relationships with
negatively affect his ability to care for Mr. Robinson?
others.
What would you say to your co-worker?

42 | | Nurse Assistant Training

2. You are Mrs. Sokoloski’s home health aide. 3. Mrs. Kipper has dementia and is a resident in the
Mrs. Sokoloski is receiving home care because nursing home where you work. Today, you found
she has several health issues that make it difficult Mrs. Kipper half undressed and trying to get into
for her to provide for her own personal care. bed with Mr. Lyons, another resident who also
Previously, Mrs. Sokoloski’s husband took care of has dementia. When you arrived in the doorway
her and managed the house, but he died suddenly of Mr. Lyons’ room, Mr. Lyons was pushing
last month. Today, you make Mrs. Sokoloski lunch Mrs. Kipper away and yelling, “Get out!” How
and sit with her while she eats. She just pushes should you handle this situation?
the food around on the plate and she looks like
4. Mrs. Ali, a patient in the hospital where you work,
she is on the verge of crying. She says to you,
has very different religious beliefs from your own.
“Ralph and I used to always eat together. I’m so
Today, she asks you to help her with a ritual that
lonely and I miss him so much.” What needs does
involves praying aloud together and reading from a
Mrs. Sokoloski have? How can you help her to
religious text. How would you respond?
meet those needs?

Chapter 4 | Understanding the People in Our Care | 43

C HA P T E R
Communicating with
5 People
After reading this chapter, you will have the information needed to:
■ Describe a model for effective communication.
■ Explain the difference between verbal and nonverbal communication.
■ List strategies for enhancing communication.
■ List strategies for communicating with people with sensory impairments.
Goals ■ Describe communication techniques that can be effective when it is necessary to
discuss difficult topics.
■ Describe how nurse assistants use communication skills to assist with teaching and
reinforcing new information and skills.
■ Describe the nurse assistant’s role in communicating with family members.
■ Describe a process for determining the meaning of unfamiliar medical words.

44 | | Nurse Assistant Training

 ■ Describe the nurse assistant’s role in making and reporting observations.
Goals ■ Describe guidelines for recording information.
■ Describe guidelines for using the telephone.

Key Terms:
communication nonverbal communication recording (documenting) care plan

verbal communication reporting medical record

sender provides is called the message. After receiving

As you are walking down the hall, you notice the sender’s message, the receiver becomes the sender
that Mrs. Whitchurch’s call light has come on again. and delivers his own message, called confirmation. This
You knock on her door and enter when she tells you back-and-forth flow of information is very important,
to come in. When you ask Mrs. Whitchurch how you because this is how the sender knows that his message
can help her, she says, “Oh, dear, I need to use the has been received and understood.
commode again.” As you help Mrs. Whitchurch to
the commode, you realize that this is the third time Communication Methods
since you started your shift 2 hours ago. After you get
Mrs. Whitchurch back in bed, you take the commode People express themselves both verbally and
bucket to the bathroom to empty it. You notice that it nonverbally. Verbal communication involves the
does not contain much urine, and the urine is cloudy use of spoken language and written language, as
and strong-smelling. When you come back out of the well as American Sign Language, the system of
bathroom, Mrs. Whitchurch says to you, “I just can’t get hand movements used by many people with hearing
comfortable. I feel like I need to go again, but I know impairments. Nonverbal communication is the
I don’t have any urine to pass.” You decide you had better sharing of information and feelings through body
share your observations with the nurse right away. language, including gestures, body position, movement,
facial expressions and tone of voice.

Communication is the process of giving and As a nurse assistant, you will use both verbal and nonverbal
receiving information. Good communication skills methods to communicate with others. For example, when
are essential to providing quality care. As a nurse you are caring for a person with dementia, it is often most
assistant, you must be able to communicate effectively effective to show, as well as tell, the person what you need
with those in your care, as well as other members of him to do. If you want the person to sit down, you could say,
the health care team. “Mr. Greene, please sit here” (verbal communication) while
patting the seat of the chair (nonverbal communication). To
reassure a person, you might say, “I’m here for you” (verbal
communication) while gently resting your hand on the
COMMUNICATION BASICS person’s hand (nonverbal communication). You must also
Most people think that communication is something we be aware of the methods others are using to communicate
all do naturally every day. However, you probably realize with you. Paying attention to a person’s nonverbal body
from personal experience how common it is for people to language can give you important information, in addition to
misunderstand one another. Good communication skills what the person may tell you. For example, a person may
need to be learned. not complain of pain, but the way she carries her body or
the expression on her face when she moves a certain body
part may tell you that something is wrong.
Communication Model
Figure 5-1 shows a model for effective communication. Strategies for Effective
You can see that effective communication involves a
sender, the person who is providing information, and a
Communication
receiver, the person to whom the information is being To be a skilled communicator, you must be able to
sent. The people who are communicating with each express yourself clearly in a way the other person can
other repeatedly switch roles, sending and receiving easily understand. You must also be able to receive
messages back and forth. The information that the information from the other person, which requires good

Chapter 5 | Communicating with People | 45

 FPO

Figure 5-1 Communication involves a sender and a receiver. The sender sends a message. The receiver then provides confirmation that she
received the message. Communication continues in this way, with the sender and receiver switching roles.

listening and observing skills. Strategies for effective when you are the sender, it may be necessary
communication include the following: to prompt the receiver to provide confirmation.
One effective way to do this is to ask an open-
■ Make sure your message is clear. ended question. An open-ended question is one
Communication can fail when the other person that requires more than a simple “yes” or “no”
does not fully understand your message. Tips answer, such as “Could you repeat back the plan
for ensuring that your message is clear are given for tomorrow?” This type of question requires
in Box 5-1. the person to repeat, in his own words, what
■ Provide and seek confirmation. When you he understands your message to be, which will
are the receiver, confirm that you have received allow you to correct any misunderstandings as
the sender’s message by repeating, in your needed. If you ask a close-ended question (one
own words, what the sender said. If you have that can be answered with a simple “yes” or “no”),
misunderstood the sender’s message, this will such as “Do you understand what is happening
be clear to the sender and she can correct any tomorrow?” the person might say “yes” even if he
misunderstandings immediately. Sometimes, did not fully understand your message.

▼ Box 5-1 Ensuring a Clear Message

When speaking: effective for communicating simple messages. More
■ complex messages may require the aid of a translator to
Use words that the person understands. Avoid using terms
ensure that your meaning is clear.
or abbreviations that are unfamiliar to the person you are
communicating with. Use the simplest words you can to
When writing:
get the message across.
■ Talk slowly enough to express your thoughts clearly and to ■ Write neatly. If your handwriting is hard to read, print instead.
give the person time to think about what you are saying. ■ If you are writing something for a person with limited
Pause periodically to give the person the opportunity to eyesight, use large letters. Write with a thick black or dark
respond or ask questions. blue pen on white paper.
■ Speak loudly enough to be heard, but not too loudly. If the ■ Be specific. For example, if you are noting the time, be
person is having trouble hearing you, move closer to her. sure to write a.m. or p.m.
■ If the person speaks a different language than you do, ■ Spell correctly. If you are not sure of the spelling, look the
hand gestures, drawings and picture boards can be word up in a dictionary or ask.

46 | | Nurse Assistant Training

■ Be an active participant in the conversation. do not like to be touched. Be sure you are aware
When you are the receiver, give the sender your full of the person’s comfort level with this form of
attention. Be an active listener. Avoid interrupting communication before using it!
the person, or thinking about what you are going to
say next. Instead, really focus on what the person is
trying to tell you, both verbally and nonverbally. Ask You find the nurse down the hall, at the
questions as necessary to make sure you understand medication cart. She is busy trying to make sure
the person correctly. As appropriate, prompt the that all of the residents receive their medications on
person to give you more information or to continue time. You say, “Mary, I need you to check on Mrs.
talking by repeating the person’s own statement back Whitchurch. I’ve helped her to the commode three
to him. For example, if Mr. Jones says to you, “I just times in the last 2 hours, and each time, she passes
don’t feel like myself today,” you could respond by only a small amount of cloudy, strong-smelling urine.
saying, “You don’t feel like yourself today, Mr. Jones?” She also told me that she can’t get comfortable and
This type of response indicates to Mr. Jones that you she feels like she needs to urinate, even right after
were listening to what he said, and that you would using the commode.” Mary tells you that she will
like him to tell you more about how he is feeling. check on Mrs. Whitchurch as soon as she is finished
■ Be mindful of the nonverbal messages you are giving Mr. Ivers his medication.
sending. Remember that your body language sends
What strategies for effective communication
a message too (Table 5-1). Pay attention to things
were used here?
like your tone of voice, your facial expressions, your
gestures and how you hold your body, and make sure
that your nonverbal messages match your verbal ones.
■ Remember the importance of touch. A caring
touch, such as a hand on a shoulder, a pat on the
COMMUNICATING WITH THOSE
back or a hug, is often a good way to make someone IN YOUR CARE
feel special or emphasize what you are saying.
In your work as a nurse assistant, your ability to
However, as you know, touching is not considered
communicate can have a positive impact on the health
appropriate in all cultures, and some people simply
and well-being of the people in your care.

Table 5-1 Body Language

Sends a Positive Message Sends a Negative Message
Tone of Voice ■ Moderate volume ■ Too loud or too soft
■ Calm, relaxed pace ■ Sharp, rushed pace
■ Clear ■ Mumbling
■ Sighing loudly

Facial Expressions ■ Smiling ■ Frowning

■ Concerned (depending on the situation) ■ Grimacing
■ Eye rolling
■ Yawning

Gestures ■ Sitting down ■ Checking watch or looking toward door

■ Patting a person’s arm or holding a ■ Glancing away from the person as he
person’s hand or she talks
■ Nodding as the person speaks
■ Making good eye contact (unless this
is considered disrespectful in the
person’s culture)

Body Position and ■ Positioning yourself to be at eye level ■ Standing over the person
Movement with the person ■ Crossing your arms
■ Leaning toward the person as he or ■ Tapping your feet
she talks ■ Slouching

Chapter 5 | Communicating with People | 47

Communicating with People with
Sensory Impairments
We rely very much on our senses of hearing and sight
for effective communication. Many of the people in your
care will have difficulty seeing or hearing. When you are
caring for a person with impaired sight or hearing, there
are strategies you can use to enhance communication.

Visual impairment
Visual impairment may have many causes, such as
cataracts (a clouding of the lens of the eye that is
caused by aging, injury or other diseases) or diabetes.
When caring for a person with impaired sight, use
your communication skills to help orient the person to
surroundings and events.
Figure 5-2 When speaking with a person who is hearing impaired, face
■ Knock on the person’s door or tell him right away the person so that she has a good view of your face and mouth.
that you are there so that you don’t startle him. Stand
■ Be aware that hearing-impaired people often learn
where he can see you, and call him by name: “Good
to read lips and rely on watching your mouth move.
morning, Mr. Wilson.” Then tell him who you are.
When speaking with the person, position yourself so
■ Describe the person’s surroundings and tell him what that she can see your mouth and facial expressions
is going on. Describe the people or events in a way (Figure 5-2). Pronounce your words slowly and
that helps to create a mental picture: “Mr. Wilson, clearly, and speak in short sentences.
your daughter Susan is here, and she’s wearing a
■ If the person does not seem to understand what you
beautiful red dress.” Or “It’s sunny today, and the
say, change your words, not the volume of your voice,
patio door is open if you would like to go outside.”
unless you spoke too softly. Shouting sometimes
■ As you move through a skill, describe each step as creates more distress for the person, and she still
you are doing it. When using a piece of equipment, may not understand what you are saying.
describe it to the person. If it doesn’t cause an
■ Reduce background noise as much as possible,
infection control risk and if he is interested, let him
because television or radio sounds can be very
touch what you are holding.
distracting to the person with a hearing impairment
■ When helping the person move around, encourage during conversation.
him to hold your arm just above your elbow for support,
■ Use gestures to help explain what you are saying.
describe where you are going and mention things that
Or, if the person can read, write messages on paper.
are in your path: “We’re going up three steps now.”
When you have important information to get across,
make sure that the person understands you by
Hearing impairment asking her for confirmation.
Some people who are hearing-impaired may be deaf,
whereas others may have problems hearing only Communicating About
certain sounds. Learn what the people in your care can
and cannot hear. Hearing aids improve some hearing
Difficult Topics
problems but are not always completely effective. If the People receiving health care and their family members may
person uses a hearing aid, encourage her to wear it face difficult situations, which are often accompanied by
whenever she is awake, and ask her from time to time complex emotions. The people in your care, or their family
whether it is working well. Help her use and care for the members, may express these emotions and thoughts to
hearing aid properly (see Chapter 13). Other ways you you. For example, a person who has just been admitted to a
can help improve communication with a person with nursing home might say, “My family doesn’t care about me
impaired hearing include the following: anymore.” Or a family member whose mother is in the last
■ Always approach the person from the front, and stage of a terminal illness might say, “I wish she would just
gently touch the person on the hand or arm to gain die.” Comments like this may make you feel uncomfortable,
the person’s attention before speaking. afraid, nervous or unsure about how to respond.
■ If someone hears more clearly in one ear than the Your first response might be to try and end the
other, find out which ear is better, and position conversation quickly by leaving the room or changing
yourself near that ear when you talk. the subject. Or, you might say something like “You don’t

48 | | Nurse Assistant Training

really mean that” or “Don’t be silly.” However, these sorts skills to provide ongoing support and encouragement as
of responses cut off communication with the person. the person learns new skills and behaviors.
Because part of your job is to listen and talk with those in
Because you will spend the most time with the person
your care, it is important to keep lines of communication
every day, you will often be in a good position to help
open. The following suggestions may help you when it is
reinforce (strengthen) the teaching that another member
necessary to communicate about difficult topics:
of the health care team has started. For example, the
■ Show the person that you care about her feelings physical therapist has been working with Mr. Wilson to
by stopping what you are doing, paying full attention teach him how to walk with a cane. You can reinforce
and making eye contact. If it is appropriate, hold these lessons by observing Mr. Wilson’s use of the cane
or gently squeeze her hand or touch her on the when you help him to get from one place to another, and
shoulder. Sometimes all the person needs is for reporting your observations about Mr. Wilson’s ability
someone to listen. If the person feels your interest to use the cane to the nurse or physical therapist. You
and concern, your silent support can sometimes may also be responsible for teaching a person how to
help more than words (Figure 5-3). do certain things that are within your scope of practice.
■ Encourage the person to talk by asking a question that For example, Mrs. Simmons has weakness on her left
focuses on what she is telling you (for example, “Are you side because of a stroke. You can show Mrs. Simmons
saying that you miss being close to another person?”) techniques that will make it easier for her to dress herself.
Or confirm the person’s message by repeating it in
As you provide care, you may recognize that a person
your own words: “It sounds like you are saying that
does not fully understand information he has been given
you miss seeing and hearing from your family.”
or skills he has been taught. For example, the person
■ If the person needs answers or help that you are may make a comment or ask a question that alerts you
unable to provide, involve other members of the to the need for more teaching. Reinforce the information
health care team. Tell the person in your care that the person has already been given, and then make sure
you will talk with someone who may be able to help. to report the person’s need for more information to the
Then be sure to follow through. nurse. For example, Mr. Rivera, a 78-year-old man in your
care who had a stroke, takes medication that increases
Teaching and Reinforcing New the amount of time it takes for blood to clot. Even a small
Information and Skills cut may cause serious bleeding. The nurse has instructed
you to have Mr. Rivera switch from shaving with a safety
As a nurse assistant, you play an important role in helping razor to shaving with an electric razor to help prevent
the people in your care achieve or maintain their best nicking his skin. One morning, while helping Mr. Rivera
level of health and functioning. One way you will do this shave, you have the following conversation with him.
is by using your communication skills to provide people
with information and skills that can help them to remain Mr. Rivera: “I don’t see why I have to use this electric
independent and regain their health to the greatest extent razor. I’ve been shaving with my safety razor for years,
possible (Figure 5-4). You will also use your communication and I never had a problem.”

Figure 5-4 Nurse assistants use their communication skills to help

Figure 5-3 Sometimes a willingness to listen and a gentle touch are the people in their care achieve or maintain their best level of health
more powerful than words for communicating your care and concern. and function.

Chapter 5 | Communicating with People | 49

You could say: “I know you like the safety razor better,
Mr. Rivera, but because of the kind of medication you are
taking, it is important that you don’t cut yourself. The electric
razor doesn’t nick your skin, so it is safer for you to use.”
Mr. Rivera: “I don’t like electric razors, but I don’t like
bleeding either, so I guess I’d better try it.”
By providing Mr. Rivera with an explanation for the
change, you have helped him become more accepting
of it. You should also report this conversation to the
nurse, because it is possible that Mr. Rivera needs more
information about the medication he is taking
(for example, why he is taking it and how it works).

In about half an hour, Mary finds you and

says, “Mrs. Whitchurch’s primary care provider has Figure 5-5 Communicating with family members is an important part
requested that we obtain a ‘clean catch’ urine sample of the nurse assistant’s job, too.
because she suspects a urinary tract infection. Can
one. Welcome their input and feedback. The information
you make sure to obtain this sample the next time
provided by family members can make your job easier
Mrs. Whitchurch uses the commode? I explained to
and increase the quality of the care you provide.
Mrs. Whitchurch that she will need to start the flow of
urine, then stop it, and then collect the urine sample Sometimes, family members may voice a complaint or
from the restarted flow, but she might forget, so be a concern about their family member’s care. When this
sure to remind her.” happens, it is important to respond in a professional
manner, and to seek a solution to the problem. Avoid
How will you use your communication skills
becoming defensive or angry. Instead, use your
to reinforce the information Mary has given
communication skills to gain a full understanding of the
Mrs. Whitchurch?
family member’s concerns and to reassure the family
member that you understand her concerns and will take
the appropriate measures to resolve them.

COMMUNICATING WITH
FAMILY MEMBERS COMMUNICATING WITH
As a nurse assistant, you must be able to communicate
OTHER MEMBERS OF THE
effectively with the family members of the people in your HEALTH CARE TEAM
care. Because you will spend a great deal of time with
The members of the health care team must communicate
the person and provide the most assistance with routine
effectively with each other in order to ensure coordinated,
activities, you will often be the first member of the health
high-quality care. As a nurse assistant, you are in a
care team family members ask for information about the
position to gather important information about those in
person’s physical health and abilities, emotional status
your care on a daily basis, and you must know how to
and overall well-being. If a family member asks a question
report and record this information so that it is available to
that you are not qualified to answer, make arrangements
other members of the health care team who need it.
for the family member to speak with the nurse.
Be aware that the way you communicate with family Understanding Medical Words
members contributes to the overall impression they have
of the care their loved one is receiving. You can help
and Abbreviations
family members feel more comfortable by explaining your To communicate effectively with other members of the
role in providing care, and explaining why you do things health care team, you must be able to understand and
in a certain way. Build a relationship with the family by use medical words and abbreviations. For students who
getting to know the family members, learning about their have never worked in a health care setting, learning
family history, talking with them and listening to them medical words may seem to be an overwhelming task.
(Figure 5-5). Family members often can provide valuable Some of the words are long, some are difficult to
information, for example, about what techniques they pronounce and spell and many of them are not used in
have found to be most effective in caring for their loved everyday conversation. However, it is often possible to

50 | | Nurse Assistant Training

break long, complex words into smaller parts, making it
easier to determine the meaning of the word.
A word can contain the following parts:
■ Root. The root is the foundation of the word. All
medical words have at least one root, and some may
have two.
■ Prefix. A prefix may be added before the root to
make the root more specific.
■ Suffix. A suffix may be added after the root to make
the root more specific.
■ A combining vowel. A combining vowel, which
may be an “o,” an “a” or an “i,” is added between the
root and the suffix to join them together and make
the word easier to say.
To determine the meaning of an unfamiliar word, first Figure 5-6 Objective observations are observations you make based on
identify each of its parts, and determine what they mean. one of your five senses. Here, this nurse assistant is using her sense of
For example, let’s look at the word cholecystectomy. touch to determine that the person’s skin is hot and dry.

In this word, the root is cholecyst, which means

“gallbladder.” The suffix is –ectomy, which means throughout the shift, when it is necessary to communicate
“removal of.” So the word cholecystectomy means a change in a person’s condition to other members of the
“removal of the gallbladder.” Now, let’s look at the word health care team. Typically, you will report to the nurse
hypoglycemia. The root is glyc, and means “sugar.” before and after you finish providing care for a person,
The prefix is hypo-, which means “under.” The suffix and whenever else you think it is necessary.
is –emia, which means “blood disorder.” So the word
hypoglycemia means “low blood sugar.” Appendix A You spend a great deal of time with the people in
contains a list of commonly used roots, prefixes and your care. As a result, you will often be the first to
suffixes. Familiarizing yourself with these will help you to notice a change in the person’s condition, abilities or
determine the meaning of unfamiliar words. emotional status that should be reported to the nurse.
Observations you make about the person’s condition can
You will also notice that the members of the health care take two main forms:
team often use abbreviations, or shortened forms of
■ Objective observations relate to information that
words and phrases, when communicating with each
you obtain directly, using one of your five senses.
other. Using abbreviations can make communication
For example, you may feel that a person’s skin is hot
more efficient by saving time and space. Sometimes
and dry (Figure 5-6), or you may measure a person’s
abbreviations are formed from the initial letters of
blood pressure using a blood pressure cuff.
each word in a phrase, such as “DON” for “director of
nursing.” Others are just shortened versions of a word, ■ Subjective observations relate to information
such as “cath” for “catheter.” Some abbreviations used that you cannot detect with one of your five senses
in health care do not seem to relate to the words they or cannot measure using equipment (Figure 5-7).
stand for at all, such as “NPO.” This is because “NPO,” For example, a person may tell you that she has a
which means “nothing by mouth,” comes from the Latin headache or that she did not sleep well the night
phrase “nils per os.” When using abbreviations, it is very before. These observations are subjective because
important to only use those that have been approved you cannot detect the person’s pain or tiredness
by your employer. This helps to ensure that the meaning with your own senses. Instead, you must rely on
of the abbreviation is clear to everyone. Common what the person is telling you.
abbreviations that are often used in health care are also As you make observations, you must decide what
listed in Appendix A. information to pass on to other members of the health
care team. When deciding what to report, focus on the
word change. Report observations that indicate changes
Reporting in the person’s:
Reporting is the verbal exchange of information between ■ Mood.
members of the health care team. Reporting happens
routinely at the change of shift, when the staff members ■ Mental awareness.
who are finishing their shift update the staff members ■ Level of independence.
who are coming on duty. Reporting also happens ■ Behavior.

Chapter 5 | Communicating with People | 51

 Helpful: “Mr. Rivera has made progress with his shaving
skills. He is able to shave his whole face.”
Less helpful: “Mr. Rivera is doing better holding the razor.”
Example 3. Mrs. Kline has dementia. This morning while
you were trying to help her with her morning care, she
picked up a brush, threw it at you, and yelled “Get out!”
Usually, Mrs. Kline is cooperative when you provide care.
Helpful: “This morning while I was trying to help Mrs.
Kline get dressed, she picked up her hairbrush and
threw it at me, telling me to get out. She does not usually
behave like this.”
Less helpful: “Mrs. Kline tried to hit me with a hairbrush
this morning.”

Figure 5-7 Subjective observations are observations that you make

based on what the person tells you. Here, this person is describing pain Think back to the observations you made
that he is having to the nurse assistant. The nurse assistant cannot feel when you were helping Mrs. Whitchurch
his pain herself, but she knows it exists because the person is telling her
about it. to use the commode. Which of these
observations were objective? Which were
■ Vital signs. subjective?
■ Urine or bowel movements. How did promptly reporting your
■ Skin condition or color. observations and providing factual details
■ Appetite. lead to better care for Mrs. Whitchurch?
■ Sleep habits.
■ Comfort level.
Recording
If you are ever in doubt about whether you should report
an observation to the nurse, remember the following Recording, also called documenting, is the written
guideline: “When in doubt, report.” It is best to share exchange of information between members of the health
your observations with the nurse and let the nurse care team. Recording takes place on various forms,
determine whether additional follow-up is needed. which are contained in the person’s medical record
(a legal document that details the person’s condition,
Remember that the members of the health care team the measures taken by the health care team to diagnose
who do not have the opportunity to spend as much and manage the condition, and the person’s response
time with the person as you do rely heavily on your to the care provided). Traditionally, medical records have
observations. When reporting, include as many accurate been kept on paper, but electronic medical records
details as possible, and focus on facts rather than your (kept on a computer) are becoming increasingly more
personal opinions. Look at the following examples: common (Figure 5-8).
Example 1. Mrs. Damon is recovering from a broken hip. When working with a person’s medical record, it
You are to help her stand three times a day. Usually she is very important to remember what you learned
is able to stand for 2 or 3 minutes each afternoon. Today, in Chapter 3 about maintaining the person’s
using your arm for support, Mrs. Damon stood for 5 minutes. confidentiality. Always return paper records to their
Helpful: “Mrs. Damon stood for 5 minutes this afternoon. proper location in the nurse’s station when you are
She leaned on my arm. In the past, she has only been finished using them. If electronic medical records
able to stand for 2 or 3 minutes at a time.” are in use, always log off the computer when you are
finished using it. Remember that only the members
Less helpful: “Mrs. Damon stood for longer than usual.” of the health care team who are directly involved in
providing care to the person need to have access to
Example 2. Since his stroke, Mr. Rivera has been working
the person’s medical record.
with an occupational therapist to relearn how to shave using
an electric razor. When he started therapy last week, he had
a hard time holding the razor and making his hand move Key forms
the right way. He got frustrated and asked you to finish The medical record contains many different forms.
the job. Today you notice that he shaved his whole face. There are three forms that are of particular interest to

52 | | Nurse Assistant Training

 and to make decisions about future care measures. Also,
it is important to understand that in facilities and agencies
that receive federal funding (for example, Medicare or
Medicaid payments), accurate documentation is essential
to ensure that the facility receives the proper payment for
services that were provided, and that the person continues
to receive services he is eligible for.
Whenever you record information in the person’s medical
record, include the date, the time and your initials or
signature. When documenting, usually a 24-hour clock
(also called military time) is used to express the time
(Figure 5-9). Other guidelines for proper documentation
are given in Box 5-2.

Figure 5-8 Electronic medical records are becoming more common.

the nurse assistant: the care plan, the flow sheet and
nursing notes.
■ Care plan. Each day, the first form you will refer to is
the person’s care plan. The care plan details the care
the person requires, and the methods, equipment
and frequency for providing that care. Because the
person’s condition may change, the care plan is
updated frequently, so you must check it every day.
The care plan may take the form of a computer
print-out, or it may be kept on a card in a file.
■ Flow sheet. A flow sheet is used to track changes
Figure 5-9 A 24-hour clock is usually used for documenting time in
in measurements (such as vital signs, intake and medical records. On a 24-hour clock, the hours between 1:00 a.m.
output, and weight) over a period of time. and 12:00 p.m. (noon) are the same as they are on a 12-hour clock.
■ Nursing notes. This form is used by the nursing To indicate a time in the afternoon, add “12” to the time on the
12-hour clock. For example, 3:00 in the afternoon would be expressed
staff to document the person’s condition, the nursing as “1500.” When using a 24-hour clock, the first two numbers indicate
care provided to the person, and any significant the hour and the last two numbers indicate the minutes (for example,
events that took place during the shift or visit. Some 3:19 a.m. = 0319).
employers allow nurse assistants to record certain
types of information in the nursing notes. Others will
While waiting for Mrs. Whitchurch’s test
require you to report your observations to the nurse
results to come back, the primary care provider
so that he or she can update the nursing notes.
started her on an antibiotic and asked the nursing
staff to measure Mrs. Whitchurch’s temperature at
Guidelines for recording
regular intervals throughout the day and night.
Depending on your employer’s policy, you may be
responsible for recording. For example, some employers What form will you use to record Mrs.
allow nurse assistants to record information on the flow Whitchurch’s temperature measurements?
sheet, but not the nursing notes. Others allow nurse
Why is it important to record Mrs. Whitchurch’s
assistants to document the care they provide and the
temperature measurements correctly and
observations they make in the nursing notes as well.
accurately?
If you are expected to record, it is important to do it
At the nursing home where you work, nurse
correctly and accurately. The medical record is a legal
assistants are allowed to document in the
document. As such, it is a formal accounting of the care
nursing notes. How would you document the
a person receives while in the facility, and can be used
observations that you made when you first
as evidence should a legal problem or dispute arise. In
suspected that Mrs. Whitchurch might have
addition, other members of the health care team rely on
a problem? What details would you include?
what is documented to evaluate the person’s condition (for
example, how well the person is responding to treatment)

Chapter 5 | Communicating with People | 53

 Box 5-2 Nurse Assistant DO’s and DON’Ts
Recording
DO make sure that you are recording DO record facts, not opinions. DON’T record care before you have
the information on the correct person’s actually provided it.
DO use black ink.
medical record.
DO record only care that you have
DON’T erase mistakes. Instead, follow
DO include the date, the time and your personally provided and observations that
your employer’s policy for correcting
initials or signature for every entry you have personally made.
mistakes. For example, your employer
you make.
may require you to draw a line through DO remember that, in a legal
DO use proper medical terminology the mistake and initial it. situation, care that was not recorded
and abbreviations, per your is considered care that was not
DO record promptly after providing care
employer’s policy. provided.
or making observations.

Using the Telephone pleasant tone of voice. If you have to put a caller on
hold, do it for only a short time. If the wait is going to
In your work, you may be required to use the telephone be longer than a minute, get back on the line to let
to receive or make calls (Figure 5-10). When using the the caller know, and offer to take a message.
telephone: ■ Take accurate messages. If you are asked to
■ Be professional. Know how to use the telephone take a message, write it down carefully and repeat
system to make outgoing calls, answer incoming it to the caller to make sure the information is
calls, put someone on hold, transfer a call and use correct. Include the date and time of the call on the
any other features. message, and sign your name. Make sure that your
■ Identify yourself. When you answer the telephone, message is complete. To make sure that you have
greet the caller and state your name, your title and not made any mistakes, check over what you have
the unit where you work, and ask how you can be written before you deliver the message. Put the
of assistance (for example, “Hello, this is Melissa message where the person is most likely to find it.
Schmidt, CNA, 3 West speaking. How can I help ■ Respect privacy. Callers may ask questions about
you?”). When you are placing a call, identify yourself someone’s health or may request other personal
as soon as the other person picks up. information. Be aware that even confirming that
■ Be courteous. Answer the telephone as soon a person is receiving care in the facility could be
as you hear it ring. Speak slowly and clearly, in a considered a breach of privacy. Do not provide
any information unless you are sure that your
employer permits it, and be sure that any information
you provide is correct. If you are unsure about
what information to provide to the caller, ask your
supervisor.

CHECK YOUR UNDERSTANDING

Questions for Review

1. When you are the sender, what should you do
after you deliver your message?
a. Expect the person to do what you told him.
b. Ask for confirmation that the message
was understood.
Figure 5-10 Answer the telephone promptly and pleasantly, state who
c. Communicate the next message.
you are and ask what you can do to help the caller. d. Look for written communication.

54 | | Nurse Assistant Training

2. When entering the room of a person who is c. Mr. Halladay’s blood pressure measurement is
blind, you should: 130/90 mm Hg.
a. Walk up quietly and touch the person on d. Mrs. Harper ate only 50% of her meal.
the back. 7. Which of the following observations should you
b. Knock on the door, wait for a response and report to the nurse?
introduce yourself.
a. Mrs. Zimmer is having difficulty having a
c. Knock on the door and go in.
bowel movement.
d. Talk in a low voice.
b. Mr. Thomas does not seem like himself today.
3. Mrs. James is deaf. What can you do to make c. Mrs. Nolan told you that she does not want to
sure she understands the information you have attend the group activity today.
just given her? d. All of the above
a. Get help from a translator. 8. Which document details the care the person
b. Write the information down for her. requires, and the methods, equipment and
c. Speak in the loudest voice possible. frequency for providing that care?
d. All of the above a. The electronic medical record
4. Mrs. Morgan’s daughter always watches b. The nursing notes
closely how you provide care to her mother, and c. The flow sheet
seems critical of some of the things you do. d. The care plan
What would be the best way for you to handle
9. It is 2:00 in the afternoon. How would you
this situation?
express this using the 24-hour clock?
a. Ask Mrs. Morgan to tell her daughter that she
a. 2 p.m.
likes the care you provide.
b. 0200
b. Tell Mrs. Morgan’s daughter that her mother likes
the care she is receiving. c. 1400
c. Tell Mrs. Morgan’s daughter that what you are d. 2 a.m.
doing is the right and only way to provide care. 10. Why is it important to record care and
d. Explain to Mrs. Morgan’s daughter what you observations accurately and correctly?
are doing and why you are doing it, and ask her
a. The medical record is a legal record of the
what care measures she found to be effective
care provided.
when she was caring for Mrs. Morgan at home.
b. Other members of the health care team rely
5. Mrs. Goldstein has recently been diagnosed with on the medical record to evaluate the person’s
diabetes and must eat meals at regular times. condition and make decisions about future care.
Today is a fasting day in her religion. She knows c. Federal reimbursement (payment) depends on
that she needs to eat because of her disease, accurate documentation of the services that
and she knows that her religion says that sick were provided.
people don’t have to fast. Yet when you serve d. All of the above
her food, she tells you that she feels funny about
eating. You could:
a. Tell her that she shouldn’t feel bad.
Questions to Ask Yourself
b. Avoid talking about religion and serve her food 1. Mrs. Alvarez has just been admitted to the
without saying anything. nursing home where you work. You can tell that
c. Tell her that she doesn’t really have to eat if she she is upset, and her family is worried. What
doesn’t want to. communication strategies will you use to help Mrs.
d. Tell her that you can understand that it must feel Alvarez and her family members feel better about
strange to eat on a fasting day and encourage this situation?
her to talk about it. 2. You are a home health aide. Today, while you were
changing Mr. Linkins’ bed linens, he tells you that
6. Which of the following is a subjective
he has decided to stop taking his blood pressure
observation?
medicine because it makes him have to use the
a. Mrs. Lyons tells you she feels sick to her stomach. bathroom too frequently. He asks you not to tell the
b. Mr. Upton has a red sore forming on his big toe. nurse, because she will get angry with him. How

Chapter 5 | Communicating with People | 55

 would you respond to Mr. Linkins? Would you the entrance to the dining room to his place at the
report Mr. Linkins’ comment to the nurse, despite table, a distance of about 15 feet. Today, Mr. Diaz was
the fact that he asked you not to? Why or why not? able to walk to his place at the table for lunch, but he
was too tired to try to walk the distance at dinner.
3. Mr. Diaz is recovering from a stroke. Per his care plan,
How would you phrase your report to the nurse?
you are to encourage him at each meal to walk from

56 | | Nurse Assistant Training

6
7
8
PROMOTING SAFETY

Controlling the Spread of Infection

Preventing Injuries
Responding to Emergencies
2
UNIT

Unit 2 | Promoting Safety | 57

 FPO

C HA P T E R
Controlling the Spread
6 of Infection
After reading this chapter, you will have the information needed to:
■ Understand how infections can be spread from one person to another.
■ Recognize the signs and symptoms of an infection.
■ Take measures to control the spread of microbes that can cause infection.
■ Apply standard precautions and transmission-based precautions.
Goals ■ Understand your role and your employer’s role in protecting you from exposure to
bloodborne pathogens on the job.
After practicing the corresponding skills, you will have the information needed to:
■ Wash your hands in a way that controls the spread of microbes that can cause infection.
■ Put on and take off personal protective equipment (PPE) correctly.
■ Open and close a trash bag correctly and double-bag contaminated trash and laundry.

58 | | Nurse Assistant Training

 Key Terms:
microbes health care–associated high-efficiency particulate human immunodeficiency
(microorganisms) infection air filter (HEPA) mask virus (HIV)

pathogens infection control standard precautions acquired

immunodeficiency
infection body fluids transmission-based syndrome (AIDS)
precautions
mucous membranes disinfectant hepatitis
sharps container
chain of infection sterilization occupational exposure
tuberculosis
contaminated personal protective
equipment (PPE) bloodborne pathogens

learning about what causes infections and how infections

During morning report at Metropolitan can spread.
Hospital Center, your supervising nurse tells you about
Microbes (microorganisms) are tiny living things that are
your new patient, Louise Wang, a 53-year-old woman
too small to see but are all around us. Microbes can only
who was admitted through the emergency room from
be seen using a microscope. Examples of microbes include
Morningside Nursing Home last night. Because she was
bacteria, viruses, fungi, yeasts and molds. Most microbes
diagnosed with highly contagious staph pneumonia, she
grow rapidly wherever they have warm temperatures,
is in isolation in Room 117. Last year, she had part of her
moisture, darkness and food. These characteristics make
bowel removed because of colon cancer, and she uses
the human body an ideal place for microbial growth! Some
an ostomy appliance (a bag worn on the outside of the
microbes are harmful to humans and some are not. Harmful
body) for the elimination of feces. The feces pass through
microbes that cause disease are called pathogens.
a surgically made opening in her abdomen and into the
A disease caused by a pathogen is called an infection.
ostomy appliance. In addition to assisting Mrs. Wang
with changing her ostomy appliance, you will need to Microbes are everywhere, even in and on our bodies. Many
help her with a complete bed bath and with transferring of the microbes that live in and on our bodies are harmless,
from the bed to the chair, because she is very weak. and some even perform useful functions. However, even
The nurse also tells you that Mrs. Wang is originally from microbes that are useful and necessary in certain areas
China but speaks and understands English very well. of the body can cause disease if they spread to another
part of the body where they are not normally found. For
You decide to visit Mrs. Wang immediately because
example, certain bacteria in the stomach and bowel help to
you think she might be afraid. Before going into her
digest food. But if these same bacteria are present in the
room, you wash your hands and put on a gown, mask
kidney or bladder, they can cause an infection.
and gloves. Outside her room, you notice the sign
posted on her closed door. The sign requests visitors The body has many natural defenses against infection.
to report to the nurses’ station. Healthy, intact skin and mucous membranes help to
prevent microbes from entering the body. Reflexes, such
You knock gently, then a little louder when you hear
as coughing and sneezing, help to expel microbes from
no response. When you finally hear a faint “Come in,”
the body. Finally, white blood cells carried in the blood
you open the door to see the back of a small woman
are able to destroy pathogens that enter the body. These
lying in bed. You walk toward the bed, gently calling
natural defense mechanisms help to keep us healthy. In
Mrs. Wang’s name and telling her who you are. When
addition, modern medicine has made other tools available
she turns toward you and sees your masked face, her
to help us fight and prevent infections, such as antibiotic
eyes open wide before she turns back to face the wall.
medications and vaccinations. Even though our bodies
have ways of protecting us from infection and there are
medications available to treat some infections, prevention
WHAT CAUSES INFECTION? is still the optimal goal. Some infections can be fatal,
especially in people who are not otherwise healthy, and
Louise Wang is in a room by herself because she has some infections cannot be treated with medication.
Staphylococcus pneumonia (staph pneumonia), a
disease that other people could catch from her. Colds
and flus also are diseases that people can get from
one another. Have you ever caught a cold or flu from
THE CHAIN OF INFECTION
someone? You can lessen your chances of getting sick Many infections can be passed from one person to
and avoid passing on an illness to someone else by another. However, for this to occur, six requirements must

Chapter 6 | Controlling the Spread of Infection | 59

be met. These six requirements are called the chain of blow your nose into a tissue, and someone else picks
infection (Figure 6-1). Eliminating just one link in the up the tissue to throw it away without wearing gloves,
chain can prevent an infection from spreading. Let’s take a that person can get your cold by indirect contact.
closer look at the six links in the chain of infection: The germs will spread from your nose secretions to
the tissue to the other person’s hand.
1. Pathogen. For an infection to occur, a microbe
capable of causing disease must be present. 5. Portal of entry. Just as the pathogen must have a
way of leaving the reservoir, it must also have a way of
2. Reservoir. Reservoir is a French word that means
gaining entry to a new reservoir. This is called a portal
“storehouse.” Here, we are using it to mean a place
of entry. In the case of person-to-person (or animal-
where microbes can grow and multiply. Possible
to-person) transmission, potential portals of entry
reservoirs for microbes include the bodies of people
include the respiratory tract, the digestive tract, the
and animals, bodies of water, and food.
genitourinary tract, the eye and breaks in the skin.
3. Portal of exit. Portal comes from the Latin word for
6. Susceptible host. Finally, the pathogen must enter
“gate.” For an infection to occur, the microbe must have a
a susceptible host, or a person who is capable of
way of leaving the reservoir, or a portal of exit. The portal of
becoming infected with that particular pathogen.
exit varies depending on the pathogen and the reservoir.
Some factors increase a person’s susceptibility to
When the reservoir is a human or animal body, the
infection, including very young or very old age, poor
portal of exit may be the respiratory tract, the digestive
general health, and the presence of medical devices
tract, the genitourinary tract or breaks in the skin.
that are placed in the body (such as urinary catheters).
4. Method of transmission. The way a pathogen gets Many of the people you will care for will have risk
from one person to another is called the pathogen’s factors that increase their susceptibility to infection.
method of transmission. The method of transmission
may be direct or indirect. In direct transmission, the
pathogen is passed from one person to another HEALTH CARE–ASSOCIATED
through close physical contact, such as touching,
kissing, having sex or breathing infected air. Indirect
INFECTIONS
transmission means that pathogens are spread by A health care–associated infection is an infection
way of a contaminated surface or object. Usually that a person gets while receiving care in a health
this situation occurs when an infected person care facility. You may also hear health care–associated
touches something and then someone else touches infections referred to as nosocomial infections. Health
that same object. For example, if you have a cold and care organizations that seek to provide quality care

Figure 6-1 The chain of infection. Breaking just one link in this chain can stop an infection from occurring.

60 | | Nurse Assistant Training

make it a priority to prevent health care–associated
infections from occurring. If a person develops an ▼ Box 6-1 Common Signs and
infection while in a health care facility, he may need Symptoms of Infection
to stay in the facility longer so that the infection can
be treated, delaying the person’s recovery and driving High body temperature Cloudy or smelly urine
up health care costs. In addition, developing a health
Red or draining eyes Joint pain
care–associated infection can put the person at risk for
serious complications and even death. As noted earlier, Stuffy nose Muscle ache
many people who are receiving care in health care Coughing Skin rash
facilities are more susceptible to developing infections, Headache Sores
and if they do develop an infection, it is harder for their Sore throat Redness around a wound
bodies to overcome it. In addition, some of the microbes or incision
Flushed face
that commonly cause health care–associated infections
Loss of appetite Drainage from a wound
are very difficult to treat. Over time, these microbes have
or incision
become resistant to the antibiotics (such as methicillin Nausea
and vancomycin) used to treat the infections they cause, Swelling
Stomach pain
which means that these medications are no longer Diarrhea
effective for eliminating the infection. Examples of these
Vomiting
hard-to-treat super bugs include the following:
■ Methicillin-resistant Staphylococcus aureus
(MRSA). Staph infections are spread by direct
contact, and can cause serious skin infections. If
the bacterium enters the body (for example, through signs and symptoms of infection vary according to the
a cut on the skin), the person can develop serious pathogen and the place in the body where the infection
infections of the blood, lungs, heart or bone. is occurring. If you notice that someone in your care has
■ Clostridium difficile, or C-diff. C. difficile is a one or more of the signs and symptoms in Box 6-1, report
microbe that is passed from the body in feces. Contact your observations to the nurse. By recognizing infections
with surfaces or hands contaminated by the microbe early, you help to ensure that the person receives prompt
spreads the infection to others. The bacteria invade the treatment, which in turn helps to prevent the spread of
bowel, causing diarrhea and abdominal pain. C. difficile infection to other people. Remember that not all people
produces spores that can live on hands and surfaces with infections will show common signs and symptoms of
for a long time. When a person is known to have infection. This is why it is important to practice infection
C. difficile infection, you must always wash your hands control with every person in your care, even when you do
with soap and water, because alcohol-based hand not observe any signs or symptoms of infection.
rubs are not effective for removing C. difficile from the
hands. In addition, a disinfectant containing bleach
ELDER CARE NOTE. In older adults, fever may
must be used to clean hard surfaces.
not be present even if an infection is present.
■ Vancomycin-resistant enterococcus (VRE). That’s because many older adults have other
This microbe can infect wounds, the intestinal tract chronic conditions, are taking medications, or
and the urinary tract. have changes in their immune system that can
The basic infection control measures that you will learn interfere with the body’s ability to produce a
about in this chapter are extremely effective for preventing fever. So be alert for other possible signs and
the spread of these very dangerous microbes, as well as symptoms in older adults, such as:
other microbes that can cause health care–associated ■ A new onset of confusion or increased
infections. The key is to use these infection control confusion (if the person is already
methods properly and consistently. confused).
■ Changes in eating or appetite.
■ New onset of the loss of bladder or bowel
HOW TO RECOGNIZE control or more frequent episodes
AN INFECTION of incontinence.
■ Loss of the ability to complete tasks the
An infection occurs when pathogens grow inside the
person is usually able to do.
body. Almost any part of the body can become infected.
You can recognize a possible infection in a person’s ■ Fatigue or lethargy.
body by certain signs and symptoms (Box 6-1). The ■ Flu-like symptoms.

Chapter 6 | Controlling the Spread of Infection | 61

 ▼ Box 6-2 General Actions That Help to Control the Spread of Microbes
■ Cleanse your hands frequently, using soap and bag in the person’s room before you carry the bag to the
water or an alcohol-based hand rub. laundry hamper outside the room. Place wet and soiled
■ Take care of your body. Eat well, exercise and get linens in a plastic or leakproof laundry bag.
enough rest to keep your immune system healthy. ■ Cover bedpans and urinals. To contain fluids when
■ Get vaccinated. Vaccines are available to prevent many carrying them from one place to another, always cover
infectious diseases, including influenza and hepatitis B. bedpans and urinals.
Receiving appropriate vaccinations and keeping them up ■ Prepare food carefully. When preparing food for
to date helps to protect you from getting these infectious yourself or for those in your care:
diseases. { Wash your hands first.
■ Stay home if you are sick. If you must report to work { Rinse off the tops of cans before opening them.
when you are not feeling well, be sure to discuss your { Wash fruits and vegetables before using them.
illness with your supervising nurse so that he or she can
{ Ensure that cooked foods (especially meat) reach the
make decisions about what tasks you can do and what
proper temperature.
care you can safely provide to others.
{ Wash, dry and store dishes and utensils after each use.
■ Recognize and report signs and symptoms
{ Wash cutting boards used to prepare meat and poultry
of infection. Be on the lookout for any signs of infection
and report any findings immediately to the nurse. with hot soapy water immediately after use. Use
■ Maintain cleanliness. Keep yourself, those in your care, separate cutting boards for cutting meat or poultry and
for cutting vegetables that are not going to be cooked.
and the environment clean.
■ Serve meals immediately. After food arrives from the
■ Ensure single use of personal equipment. Make
sure each person in your care has his or her own personal dietary department of a hospital or nursing home, or as soon
items such as bedpans, urinals, washbasins, emesis as you prepare food in a person’s home, serve it immediately.
■ Store foods carefully. Make sure people do not store
basins, toothbrushes, toothpaste, lotion and soap. These
items should never be shared. food in their rooms, unless the food is nonperishable and is
■ Handle linens properly. When handling bed linens, be stored in a tightly sealed container. If a person wants to save
sure to keep dirty linens away from your uniform. Avoid part of a meal for later, explain to her that unrefrigerated food
shaking dirty linens, because this can spread microbes can grow bacteria that can make her ill, and tell her that you
into the environment. Place dirty linens in the laundry will bring her a fresh serving of the food later, if she wants it.

HOW TO CONTROL THE SPREAD personal protective equipment (PPE) and taking isolation
precautions.
OF MICROBES
Health care workers take certain actions to control the Hand Washing
spread of microbes that can cause disease. This practice
is called infection control. Protecting those in your Washing your hands is the most important
care from infections is an important part of ensuring their thing you can do to control the spread of microbes
safety, one of the five principles of care. You probably (Figure 6-2). As a nurse assistant, you wash your
already practice some types of infection control in your
daily life without thinking much about it. If you cough or
sneeze, for example, do you cover your mouth with a
tissue or cough or sneeze into your elbow to control the
spread of germs? If someone you know has a cold or
flu, do you try to keep your distance from that person so
that you will not catch the cold or flu yourself? Do you
always wash your hands after using the bathroom? If you
do these things, you already are using infection control
methods. Box 6-2 summarizes general actions that can
be taken to help control the spread of microbes. Four
common methods of infection control used in health
care settings include hand washing (also called hand Figure 6-2 Washing your hands is the single most important thing you
hygiene), decontaminating objects and surfaces, using can do to protect yourself and others from infection.

62 | | Nurse Assistant Training

A B
Figure 6-3 An alcohol-based hand rub may be used as an alternative to washing with soap and water if your hands are not visibly soiled with blood
or other body fluids. To use an alcohol-based hand rub, (A) dispense the recommended amount of product into the palm of one hand, and (B) rub your
hands together, covering all surfaces, until the product dries.

hands in a special way to ensure that all surfaces are be the time you infect yourself or someone else with
clean. You should wash your hands whenever they are microbes from another person.
visibly soiled with dirt or body fluids, and at specific
times throughout the day (Box 6-3). Guidelines
for proper hand washing are given in Box 6-4. The Keeping Objects and Surfaces
specific procedure for hand washing is explained step
by step in Skill 6-1.
Clean
When you work in any health care setting, you can
When your hands are visibly soiled, you must wash
help control the spread of infection if you understand
them with soap and water. However, if your hands are
exactly what is meant by clean and what is meant by
not visibly soiled with dirt or body fluids, you may use
dirty. Clean items or surfaces are considered to be
an alcohol-based hand rub to decontaminate your
free of dirt and pathogens. Dirty items or surfaces
hands instead of washing with soap and water. When
are considered contaminated because they contain
using an alcohol-based hand rub, use the amount
dirt or pathogens. An unused item is considered
of product recommended by manufacturer. Rub it
to be clean until it comes in contact with a person
thoroughly over all surfaces of the hands, including the
or his environment. It is then considered dirty and
nails and between the fingers, until the product dries
cannot be reused for another person. In a hospital or
(Figure 6-3). nursing home, clean, unused supplies (such as linens
Sometimes you may think that hand washing is an and dressings) are stored in the clean utility room.
inconvenience when you have so much else to do. But Used supplies that must be cleaned or laundered are
the one time you decide to skip hand washing may returned to the dirty utility room. The dirty utility room
also has trash containers for disposing of disposable
supplies.

▼ Box 6-3 When to Wash As a nurse assistant, one of your responsibilities is

to help keep the person’s environment clean. You
Your Hands may also be responsible for cleaning some types of
■
equipment after you use it. Health care workers use
As you are coming on duty
■
many strategies to remove microbes from objects and
Before and after contact with a person in your care
surfaces. Simply washing the object or surface with
■ Before and after putting on gloves
soap and water will remove dirt and some microbes.
■ After using the bathroom
Or you can use disinfectant to kill microbes on the
■ After coughing, sneezing or blowing your nose object or surface (Figure 6-4). The facility will specify
■ After smoking which disinfectant solution to use, or you may make a
■ After handling dirty supplies or equipment disinfectant solution by mixing a solution of 1½ cups
■ Before handling food bleach to 1 gallon of water. When using a bleach
■ Before handling clean supplies or equipment solution, always ensure good ventilation and wear
■ Before going home gloves and eye protection. Let the disinfectant or bleach
■ Any other time you think it may be important solution stand on the surface for the recommended
amount of time (for example, 1 to 3 minutes for a

Chapter 6 | Controlling the Spread of Infection | 63

 Box 6-4 Nurse Assistant DO’s and DON’Ts
Hand Washing
DO keep your fingernails trimmed when artificial nails lift or nail polish DO push your watch above your wrist,
short and use a nailbrush or orange peels and cracks. put it in your pocket or pin it to your
stick to remove dirt and microbes from uniform. This enables you to wash your
DON’T wear rings to work. The tiny
underneath them. wrists along with your hands.
spaces in jewelry are difficult to clean
DON’T wear artificial nails or nail and can harbor microbes. In addition, DO apply hand lotion to help prevent the
polish. Microbes can be very difficult it is difficult to remove microbes from chapping and dryness that can occur with
to remove from the spaces created underneath the jewelry. frequent hand washing.

Figure 6-4 One of your responsibilities as a nurse assistant is to keep Figure 6-5 Personal protective equipment (PPE) helps to protect your
the person’s environment clean. Here, a nurse assistant is using a skin, mucous membranes and uniform from becoming contaminated
disinfectant solution to clean an over-bed table. with microbes.

disinfectant solution, 10 to 15 minutes for a bleach room. When it is necessary to put on multiple types
solution). When it is necessary to destroy all of the of PPE, items are put on in the following order:
microbes on an object or surface, sterilization is used. gown, mask, protective eyewear, gloves. When it is
Objects that are going to be placed inside a person’s necessary to remove the PPE, the order is as follows:
body (for example, indwelling urinary catheters) must gloves, protective eyewear, gown, mask. Removing
be sterile. Sterilization is achieved using gas, chemicals, PPE in the proper order helps to protect you from
dry heat or pressurized steam. In facilities, a special contaminating yourself or your uniform. Guidelines
department (often called Central Supply) is usually for the proper use of PPE are given in Box 6-5. Skill
responsible for sterilizing objects. In the home setting, 6-2 describes step by step how to put on and remove
boiling an object in water for 20 minutes is an effective each article of PPE.
means of sterilization.
Gloves
Using Personal Protective Disposable gloves are typically made of vinyl, nitrile or
latex. These gloves are meant to be worn once and then
Equipment discarded. Gloves should fit properly, and be free of rips
Personal protective equipment (PPE) is used or tears. Gloves are worn whenever there is a possibility
to prevent microbes from contaminating your uniform, that you will come in contact with a person’s blood or
skin or mucous membranes. Properly using PPE body fluids (Box 6-6). For example, you wear gloves
eliminates a portal of entry for potential pathogens, when you provide mouth care, perineal care or care for
and helps to keep you safe from infection. PPE someone who has a draining wound or open sores on
includes gloves, gowns, masks and eyewear the skin. You also wear gloves when there is a break in
(Figure 6-5). the skin on your own hands.
PPE is usually put on outside of the person’s room, You may need to change gloves several times during
and removed and discarded inside the person’s one procedure to avoid contaminating clean surfaces

64 | | Nurse Assistant Training

 Box 6-5 Nurse Assistant DO’s and DON’Ts
Using Personal Protective Equipment (PPE) Properly
DO choose gloves that fit your hands surfaces with dirty gloves, and always DON’T use gloves that have rips, tears or
properly. discard your gloves and wash your hands punctures, or that appear discolored.
when you have finished the procedure.
DON’T wear gloves as a “second skin” DO change masks and gowns if they
throughout the day. Replace your gloves DON’T wash or disinfect disposable become moist.
as often as necessary throughout a gloves for re-use. They are meant to be
DO put on and take off PPE in the proper
procedure to avoid contaminating clean worn once and discarded.
order.

by touching them with dirty gloves. Always wash your

hands after removing your gloves and before putting ▼ Box 6-6 When to Wear Gloves
on a new pair. When you are finished caring for one
■ When there is a possibility that you will touch blood or
person, always remove and discard your gloves and
wash your hands before leaving the room or assisting other body fluids
another person. ■ When you are providing care that requires you to touch
mucous membranes
Some people are allergic to latex, a material commonly ■ When the person in your care has broken skin, or you
used to make disposable gloves. If you or the person have broken skin on your hands
you are caring for develops skin redness, a rash, hives, ■ When you must handle items or surfaces soiled with
itching, a runny nose, sneezing, itchy eyes, a scratchy
blood or other body fluids
throat or difficulty breathing while you are providing care
using latex gloves, wash the area in contact with the
gloves immediately, and notify the nurse. In the future,
you will need to use disposable gloves made of vinyl or wear a mask when it is important to protect the person
nitrile when providing care. from pathogens you may exhale. The mask should fit
snugly over your nose and mouth. Use a mask only
once. Change your mask if it becomes moist, because
Recall that you will be responsible for helping moisture reduces the effectiveness of the mask.
Mrs. Wang with changing her ostomy appliance
and with bathing. There are two types of masks you may use. A surgical
(face) mask is most commonly used. These masks
Should you wear gloves when assisting are effective for providing a barrier that large droplets
Mrs. Wang with these activities? Why or why cannot pass through. When a person is known to
not? have a disease that is caused by very small droplets
suspended in the air (called aerosols) a high-efficiency
particulate air filter (HEPA) mask must be worn.
Gowns HEPA masks must be specifically fitted to the person
who will be wearing them. These masks actively filter the
A gown is worn to protect your clothes and body from
air to prevent aerosols from passing through.
splashes and sprays of blood and body fluids. The
gown must completely cover you from your neck to your
knees. A gown is worn only once and then is placed in Protective eyewear
a laundry hamper (if it is made of fabric) or thrown away Wear protective eyewear, such as goggles or a face
(if it is made of paper). Because a damp or wet gown shield, to keep body fluids from splashing into your eyes
will not protect you, you must change your gown if it when cleaning items or disposing of fluids. Protective
becomes wet. eyewear may be reusable or disposable.

Masks Taking Isolation Precautions

A mask covers your nose and mouth to protect you Isolation precautions are actions taken to isolate
from inhaling pathogens into your lungs. You may also pathogens to prevent them from spreading throughout

Chapter 6 | Controlling the Spread of Infection | 65

the facility. Isolation precautions are based on the precautions. The primary care provider decides which
pathogen’s method of transmission. The goal of these transmission-based precautions must be followed. This
precautions is to contain the pathogen and limit others’ decision is based on two things: the pathogen and
exposure to it as much as possible. There are two major how that pathogen spreads. When transmission-based
types of isolation precautions: standard precautions precautions are in effect, you will usually put on the
and transmission-based precautions. appropriate PPE before entering the person’s room, and
remove it at the doorway right before leaving the person’s
Standard precautions room. The three types of transmission-based precautions
Standard precautions (sometimes called universal are airborne precautions, droplet precautions and contact
precautions) are precautions that health care workers precautions.
take with every person to protect themselves and others ■ Airborne precautions are used when caring for a
from pathogens that are transmitted in body fluids. You person who is known or thought to have an illness
must practice standard precautions whenever you come that is transmitted through the air. For example,
into contact with body fluids, such as when assisting tuberculosis (Box 6-8) and measles are spread
with a medical procedure or when providing personal in this manner. Airborne pathogens (pathogens
care—even if you think the person in your care is not expelled into the air when an infected person
infected. Box 6-7 lists standard precautions. Memorize breathes, coughs or sneezes) can travel a long
these precautions and make them a way of life as you distance on air currents and through ventilation
work as a nurse assistant. systems. Therefore, airborne precautions include
placing the person in a private room and keeping the
Transmission-based precautions door closed, wearing a HEPA mask when providing
When a person’s primary care provider suspects or care, and having the person wear a mask when he or
confirms that the person has an infection that can she must leave the room.
be spread to others, you must take additional precautions ■ Droplet precautions are used when caring for a
to prevent the spread of the infection to other people. person who is known or thought to have an illness
These precautions are referred to as transmission-based that is transmitted by large droplets in the air, such

▼ Box 6-7 Standard Precautions

1. Wear disposable gloves whenever the possibility exists Never recap a sharp object before disposing of it, because
that you could come into contact with blood or body fluids. you could cut yourself while trying to replace the cap.
This includes when you are providing care and situations 5. Clean up blood or body fluid spills promptly, using
where you must handle items soiled with blood or other an approved disinfectant or a freshly mixed solution made
body fluids. Also wear gloves whenever you have broken by adding 1½ cups of bleach to 1 gallon of water. Be sure
skin on your hands. to wear appropriate PPE when cleaning up the spill.
2. Wash your hands and skin surfaces thoroughly and 6. Handle contaminated articles carefully. Put articles
immediately if your skin becomes soiled with blood or that have been contaminated with blood or body fluids into
other body fluids, or if you have handled potentially soiled a puncture-proof, labeled biohazard bag. Place a second
items. Also wash your hands after removing gloves, and bag over the first if the outside of the first bag may have
before putting on gloves. If your hands are not visibly become contaminated. Skill 6-3 describes step by step
soiled with blood or other body fluids, you may use an how to handle a plastic trash bag and how to double-bag
alcohol-based hand rub to decontaminate your hands after contaminated waste.
removing gloves and before putting on a clean pair. 7. Practice respiratory hygiene and cough etiquette.
3. Wear personal protective equipment (PPE) as Take measures to contain respiratory secretions that can
indicated by the situation. A gown must be worn whenever spread infections such as influenza. Encourage people who
the possibility exists that your uniform could be soiled by enter the facility with visible signs of a respiratory illness
the splashing of blood or other body fluids. Protective to cough or sneeze into a tissue to contain respiratory
eyewear, a mask, or both must be worn whenever the secretions, dispose of tissues properly and clean their hands
possibility exists that blood or other body fluids could with soap and water or an alcohol-based hand rub after
splash into your eyes, nose or mouth. sneezing, coughing or handling dirty tissues. People with
4. Handle sharp objects carefully. Protect yourself and signs of respiratory illness may also be provided with masks
others from injury caused by sharp objects that may be or physically separated from other people (for example,
soiled by blood or other body fluids (such as razors and in common waiting areas) to further limit the spread of
needles) by disposing of them in a sharps container. infections carried by respiratory secretions.

66 | | Nurse Assistant Training

 ▼ Box 6-8 Tuberculosis and the Health Care Worker
As a nurse assistant, you may care for people with tuberculosis, Because health care workers are at risk for exposure to the
a bacterial infection of the lungs that is spread through the air pathogen that causes tuberculosis, health care facilities
from one person to another. People with tuberculosis are most routinely screen employees for infection. Many states also
likely to spread the disease to people they spend time with require health care workers to be screened for tuberculosis
every day. The bacteria are put into the air when the person infection as a requirement for employment. Screening can
with tuberculosis coughs, sneezes or talks. be done using a skin test called the Mantoux test, which
involves placing a small amount of tuberculin (a protein
In most people who become infected with the pathogen that
made from the bacteria that causes tuberculosis) under the
causes tuberculosis, the body is able to fight the pathogen and
skin using a needle or tines. After a few days, the area will
keep it from growing and multiplying in the body. The pathogen
become red and swollen if the person is infected with the
becomes inactive, but remains alive in the body and can become
pathogen that causes tuberculosis. A blood test may also be
active later. Many people with tuberculosis infection never
used to screen for tuberculosis. Remember that a positive
develop active tuberculosis disease. However, in others, the
result on a screening test does not mean that you have
pathogen that causes tuberculosis becomes active later in life,
active tuberculosis. The pathogen that causes tuberculosis
and the person develops tuberculosis. Although tuberculosis
may be alive in your body, but inactive. If a screening test
primarily affects the lungs, it can affect the bones, brain, kidneys
indicates exposure to tuberculosis, other follow-up tests,
and other organs as well. If not treated, tuberculosis can be
such as sputum testing or chest x-rays, are ordered to rule
fatal. Treatment is complex and involves taking many different
out active tuberculosis.
medications over an extended period of time.

as a respiratory virus or meningitis. These droplets the transmission-based precautions are being taken,
are spread by sneezing, coughing, laughing, singing and stress that these precautions will help to speed
and talking. The droplets do not travel far. Droplet her recovery and prevent others from getting sick.
precautions are similar to airborne precautions, Explain the purpose of the PPE you are wearing.
except a surgical (face) mask can be worn instead This can help the person get used to seeing you in
of a HEPA mask. protective clothing. Make a special effort to check
■ Contact precautions are used when caring for a in on the person often, and take time to talk with
person who is known or thought to have an illness her. Spending time with the person and offering
that can be spread by direct or indirect contact. reassurance can help the person feel better about
Some types of wound infections and skin infections the time spent in isolation, and the need for the
can be spread in this way. Contact precautions transmission-based precautions.
include wearing a gown and gloves when providing
care, and containing and disposing of contaminated
items properly.
You know from the nurse’s report that droplet
When transmission-based precautions are in effect, precautions are in effect for Mrs. Wang because staph
a sign may be posted outside the person’s room so pneumonia is contagious. As you enter Mrs. Wang’s
that all health care workers and visitors (if permitted) room, she turns her face away and covers her eyes so
are aware of the precautions that must be taken. Make that you can’t see her tears.
sure visitors and other health care workers follow
these precautions. “Good morning, Mrs. Wang,” you say and then introduce
yourself. You explain that you will be taking care of her
Having transmission-based precautions in effect can today. Mrs. Wang looks at you and smiles sadly.
be very difficult for the person. How would you feel if
the door to your room had to be closed all the time for What might be bothering Mrs. Wang?
isolation? Perhaps you would feel as if no one wanted How could you provide emotional support
to be near you or that no one liked you. You might feel to Mrs. Wang, in addition to providing
lonely, angry, depressed, embarrassed, afraid or all of physical care?
these things! What if the people caring for you could
not come near you without wearing gowns, masks and What information would you give Mrs. Wang
gloves? Even though you must follow transmission-based about the transmission-based precautions
precautions as ordered, you can also be sensitive to the that are being used?
person’s feelings. Make sure the person knows why

Chapter 6 | Controlling the Spread of Infection | 67

 have been developed to help slow the progression of
BLOODBORNE PATHOGENS HIV infection, currently there is no cure.
AND WORKPLACE SAFETY ■ Hepatitis is inflammation of the liver, an organ that
performs many vital functions for the body. There are
As a nurse assistant, you are responsible for keeping
many different types and causes of hepatitis. Hepatitis
yourself and others safe from all infections. However,
B, hepatitis C and hepatitis D are caused by infection
some infections pose particular risk to you as a health care
with bloodborne viruses. Chronic infection with the
worker, because of their long-term effects on your health if
viruses that cause hepatitis B, C or D can lead to liver
you become infected. Many of the most serious infections
failure, liver cancer and other serious conditions. A
that health care workers may be exposed to are caused
vaccine is available to protect against hepatitis B virus
by bloodborne pathogens. Infection occurs when
(HBV). Vaccination for HBV also offers protection
blood from an infected person enters the bloodstream of
from hepatitis D virus (HDV). However, there is no
a person who is not infected. In the workplace, this could
vaccine to protect against hepatitis C virus (HCV).
happen if you stick yourself with a contaminated needle
(a “needlestick injury”) or cut yourself with broken glass You and your employer share the responsibility for
that has been soiled with blood. You could also become protecting you from occupational exposure to
infected through direct contact with another person’s blood bloodborne pathogens. Remember that the standard
if it comes in contact with your eyes, mucous membranes precautions we take with every person (see Box 6-7)
or an area of broken skin on your body. are designed to prevent accidental exposure to blood
and other body fluids. This is because you may not
Bloodborne diseases that pose particular risk to health
know whether a person is infected with a bloodborne
care workers are human immunodeficiency virus
pathogen or not, and it is important to protect yourself
(HIV) infection and hepatitis B, C and D.
and others from accidental exposure. To effectively
■ HIV is a virus that that invades and destroys the cells limit your risk for exposure to bloodborne pathogens
that help us to fight off infections. A person who is while you are on the job, you must practice standard
infected with HIV may look and feel healthy for many precautions consistently and correctly. Your employer
years. However, during this time, the virus is breaking also has responsibility for keeping you safe from
down the person’s immune system. Eventually, most bloodborne pathogens on the job by making sure you
people who are infected with HIV develop acquired have the equipment and training you need to lower
immunodeficiency syndrome (AIDS). A person your risk. Standards that employers must follow to keep
with AIDS is unable to fight off infections that a their employees safe from occupational exposures to
healthy person would be able to resist or control. The bloodborne pathogens are outlined in the Bloodborne
person dies from one of these infections, or another Pathogens Standard issued by the Occupational Safety
complication of HIV infection. Although medications and Health Administration (OSHA) in 2001 (Box 6-9).

▼ Box 6-9 Bloodborne Pathogens Standard

To protect health care workers from exposure on the job to ■ HBV vaccination. Employers must offer employees who
bloodborne pathogens, employers are required to adhere to have a risk of exposure to blood an opportunity to receive
the following standards: at no cost a vaccination that protects against hepatitis B.
■ An employee may refuse the vaccination, but if at any time
Exposure control plan. The facility must have a plan
the employee later decides to accept the vaccination, the
that outlines actions that will be taken if an employee is
employer must provide it.
exposed to blood or other body fluids on the job. The
■ Work practice controls. The employer is responsible
plan must be reviewed annually and made available to all
employees in written form. Employees are responsible for for establishing and enforcing procedures for handling
reporting exposure incidents so that proper follow-up (for contaminated waste, laundry and so on, and supplying
example, medical testing) can be provided. the equipment needed to follow these procedures. The
■ employer must also ensure that necessary systems are
Proper training. Employers must provide training about
installed and running to maintain a safe environment
risks associated with bloodborne pathogens and how to
(for example, ventilation systems).
minimize these risks to all employees who may be exposed
■ Engineering controls. The employer is responsible
to bloodborne pathogens on the job. Training usually
occurs during employee orientation and then at regular for making equipment available that limits the
intervals thereafter. employee’s risk for needle-stick injuries, such as
■ sharps containers.
Proper equipment. Employers are responsible for providing
personal protective equipment (PPE) for employee use.

68 | | Nurse Assistant Training

 6. Which of the following is a reason to place
CHECK YOUR UNDERSTANDING someone in isolation?
a. The person has a contagious disease.
Questions for Review b. The person had surgery.
c. The person is demanding and cannot get along
1. When you take dirty linens to the laundry hamper with others.
you should: d. The person wants the privacy of a single room.
a. Shake them first.
b. Hold them away from your uniform. Questions to Ask Yourself
c. Take only one sheet at a time to prevent
1. How can you control the spread of infection when
contamination.
you provide care for a person with an open wound?
d. Save steps by tossing them into the laundry
hamper from a short distance. 2. How can you spread infection if you have a cold?
3. In the past, how have you possibly spread
2. What is the most important thing you can do to
pathogens through direct and indirect contact?
control the spread of microbes?
Think of three ways.
a. Bag all contaminated linens.
4. What will you do in the future to avoid spreading
b. Wash your hands.
pathogens by direct and indirect contact? Think of
c. Always cover bedpans and urinals when carrying three ways.
them from place to place.
d. Eat a well-balanced diet and stay healthy. 5. Airborne precautions are in effect for Mr. Thompson.
You are changing Mr. Thompson’s linens when you
3. You should practice standard precautions: realize that you brought only one sheet instead of
two. How would you handle this problem? What
a. When you provide care for any person.
would you do first?
b. Only when you provide care for people infected
with HIV or HBV. 6. When you put on gloves to help Mr. Wilson with
c. Only when a person is in isolation. mouth care, he eyes the gloves and says, “I don’t
have AIDS, you know. Why are you wearing those
d. Only when you need to wash your hands.
things?” How should you respond?
4. What is one time when you must wear gloves? 7. Emma Jones, who works as a nurse assistant,
a. When you give someone a back rub became engaged over the weekend. She wants to
b. When you cough or sneeze wear her new engagement ring to work on Monday
c. When you serve meal trays so that she can show it off. What does she need to
consider when deciding whether to wear the ring?
d. When you touch blood or other body fluids
8. The nurse asks for your help to position a person
5. If you have a cut or open sore on your hand, on his side. The person has a large, open, draining
what must you do to protect yourself wound that needs cleaning. The nurse explains
from infection? to you that a great deal of solution will be used to
a. Avoid providing care for people with infections. clean the wound and that it is likely to splash. What
b. Stay away from work until the wound heals. personal protective equipment (PPE) should you put
c. Wear gloves while providing care. on and why?
d. Handle only clean items.

Chapter 6 | Controlling the Spread of Infection | 69

SKILLS

Skill 6-1
Hand Washing
PREPARATION 4. Put your hands under the running water to wet your
hands and wrists, keeping your hands and wrists
1. Gather your supplies: below the level of your elbows.
■ Soap 5. Apply soap from the dispenser.
■ Paper towels
6. Rub your hands together vigorously to work up a lather.
■ Orange stick or nail brush (optional)
7. Wash vigorously for at least 20 seconds
■ Lotion (optional) (Figure 1, A–D), paying particular attention to:
2. Remove your watch or push it up on your forearm. ■ The wrists (grasp and circle with your other hand).
If you are wearing long sleeves, push them up.
■ The palms and backs of your hands.
■ The areas between the fingers.
PROCEDURE ■ The nails (rub against the palms of your hands,
3. Turn on the water and adjust the temperature until it or use an orange stick or nail brush to clean
is comfortably warm. underneath them).

A B

C D
Figure 1A–D

70 | | Nurse Assistant Training

 SKILLS

8. Rinse your hands and wrists under the running 10. Use another clean, dry paper towel to turn off the
water, keeping your hands lower than your elbows faucets (Figure 4). Discard the paper towel in a
and the fingertips down (Figure 2). facility-approved waste container.

Figure 2 Figure 4

9. Using a clean, dry paper towel, dry your hands 11. Exit the hand-washing area by pushing the door
thoroughly, beginning at the fingertips and moving open with your shoulder and hip. If the door has a
back toward the elbow (Figure 3). Drying your hands handle, turn the handle using a paper towel to avoid
thoroughly keeps them from becoming chapped. contaminating your clean hands.
Discard the paper towel in a facility-approved 12. If desired, apply a small amount of hand lotion to
waste container. prevent chapping and dryness.

Figure 3

Chapter 6 | Controlling the Spread of Infection | 71

SKILLS

Skill 6-2
Using Personal Protective Equipment (PPE)

PREPARATION Putting on a Mask

1. Gather your supplies: 5. Put the mask over your mouth and nose.
■ Gown 6. Tie the top strings behind your head, then tie the
■
bottom strings or place the elastic loops around your
Mask
ears (Figure 2).
■ Protective eyewear
■ Gloves
2. Wash your hands.

PROCEDURE
Putting on a Gown
3. Slide your arms through the armholes, keeping the
opening of the gown in the back.
4. Fasten the ties at the back of your neck and at your
waist, making sure the edges of the gown overlap so
that your back is completely covered (Figure 1).
Figure 2

7. Adjust the mask for comfort. If necessary, bend the

nose wire to fit.

Putting on Protective Eyewear

8. Place the earpieces over your ears or the headband
around your head and adjust the fit.

Putting on Gloves
9. Inspect both gloves carefully for tears.

Figure 1
10. Put the gloves on carefully so that they do not tear.
Pull the gloves up over the gown cuffs (Figure 3).

Figure 3

72 | | Nurse Assistant Training

 SKILLS

Taking off Gloves cuff of the glove on your dominant hand, touching
only the clean inside of the glove (Figure 6).
11. Make a cuff on your dominant hand by grasping
the glove and pulling it partway down toward your
fingers (Figure 4). Do not touch the clean inside of
the glove.

Figure 6

14. Remove the glove by pulling it down so that the

other glove is contained inside (Figure 7).
Figure 4

12. Using the fingers of your dominant hand, pull the

glove on your non-dominant hand off by pulling it
inside out and rolling it into a ball. Be careful not
to let the outside (contaminated side) of the glove
touch your bare hand as you pull the glove
off. (Figure 5).

Figure 7

15. Discard the gloves in a facility-approved

waste container.

Taking off Protective Eyewear

16. Touch only the earpieces or the head band.
17. Place the eyewear in the appropriate container for
Figure 5 reprocessing, or discard in a facility-approved
waste container.

13. Continue to hold the glove that you have removed

in your dominant (still-gloved) hand. With your bare
non-dominant hand, place your fingers under the
Continued on next page

Chapter 6 | Controlling the Spread of Infection | 73

SKILLS

Skill 6-2
Using Personal Protective Equipment (PPE) Continued

Taking off a Gown 22. Fold the outer, contaminated surface inward and roll
up the gown (Figure 10).
18. Untie the neck and waist strings.
19. Pull off one gown sleeve by slipping your fingers
under the cuff and pulling the sleeve just over your
fingertips (Figure 8).

Figure 10

23. Discard the gown in a facility-approved waste

container, or place the gown in the laundry hamper,
Figure 8 if it is not disposable.
20. Grasp the other sleeve with the covered hand and
pull it off. Taking off a Mask
21. Continue holding that sleeve in your covered hand. 24. Untie the bottom strings and then the top strings, or
Grasp the inside of the first shoulder of the gown with pull the elastic loop from around one ear and then
your uncovered hand and pull the gown off the shoulder the other.
(Figure 9). Continue to bring the gown forward and 25. Hold the mask by the strings (Figure 11) and
turn it inside out as you pull it over your covered hand. discard it in a facility-approved waste container.

Figure 9 Figure 11

COMPLETION
26. Wash your hands.

74 | | Nurse Assistant Training

 SKILLS

Skill 6-3
Handling a Plastic Trash Bag

PREPARATION 7. Have your co-worker prepare a clean bag by folding

down a cuff at the top of the clean bag and labeling
Gather supplies: the bag “contaminated.” Have your co-worker hold the
■ Plastic trash bag(s) clean bag under the cuff and stand by the doorway.
8. Put the bag with contaminated items into the clean
PROCEDURE bag that your co-worker is holding under the cuff
Opening a Plastic Trash Bag (Figure 2).
1. Open the plastic trash bag and make a cuff around
the opened edge (Figure1).

Figure 2

Figure 1 9. Have your co-worker close the outside bag by

raising the cuffed area and tying a knot.
2. Put the opened bag on a clean surface within easy 10. Have your co-worker take the bag to the
reach of your work area. area designated for disposal or laundering of
contaminated items.
Closing a Used Plastic Trash Bag
11. Wash your hands.
3. Put your fingers under the cuffed edge of the used
plastic trash bag.
4. Pull the cuffed edges together and close the bag
by tying a knot. Touch only the outside of the bag
because the inside of the bag is contaminated.

Double-Bagging a Bag That Is

Contaminated with Body Fluids
5. Arrange for a co-worker to assist you at a
certain time.
6. Remove the bag from the trash or laundry container
inside the person’s room, close it and carry it to the
door of the person’s room.

Chapter 6 | Controlling the Spread of Infection | 75

C HA P T E R

7 Preventing Injuries

After reading this chapter, you will have the information needed to:
■ Use proper body mechanics and lifting technique to protect your body from injury on
the job.
■ Describe the safe use of equipment with moving parts.
■ Be aware of factors that place those in your care at risk for injury.
Goals ■ Take measures to prevent common accidents (such as falls, electrical shocks, burns
and poisoning) from occurring.
■ Ensure that proper follow-up takes place if an incident does occur.
■ Understand the hazards associated with restraint use, and describe alternatives to
restraint use.

76 | | Nurse Assistant Training

 ■ Describe the conditions that must be met before a restraint is applied, and describe
actions you must take to keep a person who is restrained safe.
Goals ■ Describe preparation and completion steps that are performed before and after every
procedure to protect yourself and the people in your care.

Key Terms:
body mechanics balance entrapment restraint

alignment coordination incident

Practicing Good Body Mechanics

During morning report, the nurse tells you
that a new resident will be arriving at Morningside When you practice good body mechanics, you use
Nursing Home today, and you are being assigned to your body in a safe and efficient way to accomplish
his care. The nurse tells you that the new resident’s tasks such as lifting, pushing and pulling. Good body
name is Mr. Victor Rivera, and he is 78 years old. He mechanics are all about alignment, balance and
is coming to live at the nursing home because he had coordination.
a stroke last month, and his wife is having a hard time
Alignment is good posture (Figure 7-1). If you have
caring for him because she also has health problems.
ever driven a car that is out of alignment, you know
Because of the stroke, Mr. Rivera is paralyzed on his
that it’s hard to steer, the tires wear down unevenly
left side and incontinent of urine and stool. The stroke
and it’s unsafe. Human bodies that are out of alignment
has also affected Mr. Rivera’s ability to speak. You
have similar problems. Body parts get pulled out of
nod, making a mental note of things you will need to
shape, which leads to discomfort and injury. Holding
do to help keep your new resident safe.
your body in alignment reduces strain on your joints
As you know from Chapter 1, safety is one of the five and muscles.
principles of care. If you are not safe, you cannot meet
■ Standing. To practice good alignment while
the needs of those in your care. If those in your care
standing, keep your knees slightly bent and
are not safe, they will not benefit from the care you
stand with your feet shoulder-width apart.
provide them.
Put your weight evenly on both legs. Keep your
shoulders straight and centered over your hips,
your stomach muscles tightened and buttocks
tucked under, your head up and your chin level
(see Figure 7-1, A).
PROTECTING YOUR BODY
■ Sitting. To practice good alignment while sitting,
FROM INJURY sit with your knees level with your hips, your back
As a nurse assistant, you lift and move people and straight, your stomach muscles tightened, and your
things all day long. This can place a great deal of strain shoulders straight and centered above your hips
on your muscles and joints, causing pain and injury. (see Figure 7-1, B).
Today, many employers have “no lift” or “safe patient Balance is stability achieved through the even
handling” programs, per Occupational Safety and distribution of weight. Having a wide base of support
Health Administration (OSHA) recommendations. These and keeping the heaviest part of your body (your center
programs seek to limit on-the-job injuries by providing of gravity) close to your base of support helps you to
equipment (such as mechanical lifts and powered stay balanced. When you are standing, your feet and
standing-assist devices), training and resources (such legs are your base of support, and your torso is your
as additional staffing) to make lifting and repositioning center of gravity. Therefore, spreading your legs apart
people easier and safer for the health care worker. and bending your knees to bring your torso lower helps
Always follow your employer’s policies and the person’s you to remain stable on your feet (Figure 7-2).
care plan when you are determining how to assist a
person with moving, and use the equipment that is Coordination is the use of direction and force for
available to you. Ask for help from co-workers when you purposeful action. For example, when you are moving a
need it. And learn and practice good body mechanics person up in bed, you will place one of your feet in front of
and lifting technique. the other. Shifting your weight from your back foot toward

Chapter 7 | Preventing Injuries | 77

 A B
Figure 7-1 Keeping your body in good alignment helps to relieve Figure 7-2 Widening your base of support and bringing your center of
stress and strain on joints and muscles. (A) When you are standing, gravity closer to your base of support helps you to maintain balance.
keep your shoulders straight and centered over your hips, your
stomach muscles tightened and buttocks tucked under, your head up
and your chin level. (B) When you are sitting, sit with your knees level
with your hips, your back straight, your stomach muscles tightened
and your shoulders straight and centered above your hips. broad base of support and helps you maintain your
balance.
4. Avoid bending over at the waist. Instead, bend your
knees and keep your back straight. Keeping the
your front foot gives you additional power and helps person or object close to your body, tighten your
you to move the person toward the head of the bed. stomach muscles and drive yourself upward, using
Coordination also means working with someone, the muscles of your legs and buttocks.
rather than against them. For example, when you are 5. To turn, pivot with your feet. Avoid twisting your body
repositioning a person, encourage the person to help you at the waist when your arms are loaded.
as much as possible. Similarly, if you are working with
another nurse assistant to reposition a person, you will
want to use good communication to make sure you are USING EQUIPMENT SAFELY
both performing the same movements at the same time.
This will give you twice the power and make the move As a nurse assistant, you use equipment that makes your
easier. job easier and helps to ensure the safety of the people
in your care. But because most equipment has moving
parts, you can cause serious injuries if you do not use it
Lifting Safely properly.
As a nurse assistant, you will be required to lift people Before using any piece of equipment, be sure you
and equipment frequently. If you don’t use proper understand how it works. Read the user’s manual and
technique when lifting, you put yourself at risk for injuring follow instructions exactly. (Instructions for use may
your back. Back injuries can be painful and difficult to also be located on a sticker or label attached to the
treat. They can prevent you from participating in activities equipment.) Before using the equipment with a person
that you enjoy, and they may even end your career in in your care, practice using the equipment by yourself.
health care. If you are not completely confident about using the
Proper lifting technique (Figure 7-3) involves using equipment, ask the nurse for help rather than risk injuring
the powerful muscles of your legs and buttocks to yourself or the person in your care.
drive yourself, and whatever you are lifting, upward. To
practice proper lifting technique: Equipment with Wheels
1. Plan your lift, and get help if you need it. Many pieces of equipment that you will use in the
2. Stand close to the person or object you are lifting. health care setting, such as beds, shower chairs and
Avoid leaning over or reaching. wheelchairs, have wheels. The brakes provided on
3. Place your feet about 12 inches apart, with one foot equipment with wheels prevent the equipment from
slightly in front of the other. This position provides a rolling. Imagine how unsafe and difficult it would be

78 | | Nurse Assistant Training

 Figure 7-3 Using proper lifting technique helps to protect your back.

to help someone into a piece of equipment that kept do not work properly, do not use the equipment. Report
moving. Before using a piece of equipment that has the equipment problem to the nurse. Guidelines for
wheels, try out the brakes (Figure 7-4). Make sure you transporting a person safely in a wheelchair are given
know how they work and that they work properly. If they in Box 7-1.

Side Rails
Beds used in health care facilities may be equipped with
side rails that can be raised to prevent the person from
falling out of bed. Some people may also use raised side
rails as an assistive device for repositioning themselves
in bed. Today, use of side rails is becoming less
common, because side rails are considered a form of
restraint (you will learn more about restraints later in this
chapter). In addition, side rails can cause serious injury.
A confused person may try to climb over the side rail and
fall. Entrapment is also a concern when side rails are
in use, especially with older people who are confused
or disoriented. In entrapment, the person’s head or
Figure 7-4 Know how to apply and release the brakes on equipment another body part gets trapped between, under, or on
with wheels. the side rails, or between the mattress and the side rail

Chapter 7 | Preventing Injuries | 79

 Box 7-1 Nurse Assistant DO’s and DON’Ts
Transporting a Person Safely in a Wheelchair
DO have the person rest his feet on DO enter and exit elevators backwards. This DO take care not to bump the person’s
the footrests. helps to prevent the small wheels on the arms or legs on the doorframe as you are
front of the wheelchair from getting stuck in passing through doorways.
DO walk on the right side of the hall.
the crack between the elevator and the floor.
DO lock the brakes whenever the
DO turn the chair around and walk down
DO use caution when walking past wheelchair is stopped.
wheelchair ramps backwards, with the
doorways and around corners and at
person facing uphill. This decreases the risk DO check with the nurse before leaving a
hallway intersections. This helps prevent
of tipping the chair and injuring the person. person unattended in a wheelchair.
you from bumping into other people.

(Figure 7-5). This can lead to suffocation (an inability to

breathe), serious injuries and death.
The person’s care plan will state whether the side rails
are to be lowered or raised when the person is in bed.
Always follow the person’s care plan! If side rails are in
use for a person in your care, make sure that the side
rails have been installed properly, and check the bed
frame, side rails and mattress to find areas where a A
person may become entrapped.

KEEPING THE PEOPLE IN YOUR

CARE SAFE
The key to safety is prevention, or trying to keep things
from going wrong by considering the things that
B
can go wrong and taking steps to avoid them. By
using common sense and your knowledge of the
person in your care, you can think about things that
might go wrong and take steps to prevent them
from happening.

Risk Factors for Injury

Many of the people in your care will have one or more
C
risk factors that put them at increased risk for injury.
Understanding each person’s risk factors for injury
will allow you to take steps to prevent injuries from
occurring.
■ Sensory impairment. Our five senses—sight,
smell, touch, hearing and taste—give us information
about our environment and help to keep us safe.
Think about how often you rely on your senses to
maintain your own safety. For example, you read a
D
label on a bottle to determine what is inside, and
Figure 7-5 A person can get caught (A) in the side rail, (B) underneath
you look both ways before you cross the street. the side rail, (C) between the side rail and the mattress, or (D) on the
You listen for alarms and other sounds that alert side rail, leading to suffocation and other serious injuries.

80 | | Nurse Assistant Training

 you to danger. A food’s odor or taste might tell you accidentally injured. Let’s take a closer look at common
that the food is spoiled. You test the water in the accidents that might occur.
shower before stepping in to see if it is too hot, or
not hot enough. A person with sensory impairment Falls
(for example, as a result of a stroke, complications Falls happen to all human beings. As people age,
of diabetes or advanced age) is at increased risk for factors such as declining eyesight, decreased
injuries because the sensory impairment affects his strength and increased difficulty moving can increase
ability to detect potential dangers in the environment. a person’s risk for falling. Certain disorders (such as
■ Confusion and disorientation. A person who Parkinson’s disease) and the effects of medications
is confused (for example, as a result of dementia, can also increase a person’s risk for falling. Falls
medication effects or being in an unfamiliar place) can cause serious, even fatal injuries. Because falls
is not able to make good, safe choices. The person can have such serious consequences, prevention
might try to stand up when it is not safe for her to is key.
do so. She might drink or eat something poisonous
because she confuses it for something that is The nurse is responsible for assessing the person to
safe to drink or eat. She might go outside without evaluate the person’s risk for falling when the person is
first putting on a coat to offer protection from bad admitted to the facility, and periodically thereafter. Many
weather. facilities use a fall risk assessment form, which assigns a
numerical value to risk factors the person has for falling.
■ Poor mobility. A person who is physically weak,
Strategies for addressing and minimizing the risk factors
unsteady on her feet, or paralyzed is more likely to
are then written into the person’s care plan. If the person
trip or fall. Disorders such as Parkinson’s disease
is at high risk for falling, a symbol (such as a falling leaf
or a stroke can cause a person to shuffle, which
or a falling star) may be placed next to the person’s room
increases the risk for tripping. A person who is weak
number or above the bed to alert all staff, even those
(for example, due to illness or advanced age) will tire
who do not have access to the person’s care plan, to the
easily when moving, which can cause her to fall.
person’s risk for falling.
Box 7-2 summarizes general actions you can take
Preventing Common Injuries to help prevent falls. In addition to following these
As a nurse assistant, there are many things you can general fall prevention guidelines, you can use your
do to prevent the people in your care from being specific knowledge of each person in your care to help

▼ Box 7-2 General Actions That Help to Prevent Falls

■ Keep doorways, floors and stairs free of clutter and ■ Make sure the person’s method of calling for help is within
tripping hazards, such as lamp cords or throw rugs. easy reach, and answer calls for help promptly. If the
■ Wipe up spills on the floor immediately. person must wait too long for help, he may try to get up
■ Ensure adequate lighting. Unless a person objects, make and solve the problem himself, risking a fall.
sure a nightlight is on at bedtime. If a nightlight causes ■ If the person uses a cane or walker, inspect the
confusing shadows, provide bright but indirect light. device from time to time to make sure the rubber tips
■ Encourage the person to use handrails (along hallways have not become worn and that the frame (on a
and staircases) and grab bars (in the bathroom) for walker) is tight.
support when walking, using the toilet or getting into the ■ Before helping a person into or out of a wheelchair, lock
bathtub or shower. Check these devices to make sure that the brakes and make sure the chair is secure. Also, before
they are tightly fastened to the wall. stepping away from a person who is in a wheelchair, make
■ If a person wears eyeglasses, make sure they are clean sure both wheelchair brakes are locked securely.
and that the person wears them when moving about. ■ Make sure the person’s clothing and shoes fit properly and
■ Take time to orient the person to his surroundings. This is are not tripping hazards. For example, make sure pants are
especially important when the person is confused, new to hemmed properly and not too long. Shoes should have
the facility or has poor eyesight. non-skid soles.
■ When the person is in bed, make sure the bed is lowered ■ When assisting a person who has been lying down to get
to the level specified in the person’s care plan and the out of bed, give the person a few minutes to sit on the
wheels are locked. Keep the side rails lowered or raised edge of the bed before standing up. This helps to prevent
according to the person’s care plan. dizziness that can lead to a fall.

Chapter 7 | Preventing Injuries | 81

prevent falls. The key to managing and preventing Electrical shocks
falls is to realize that a fall is nothing more than the
As you go about your daily routine, you will use
result of a motivated behavior. In other words, if the
many pieces of electrical equipment, from grooming
person does not get up, she won’t fall down! The key
appliances (hairdryers, curling irons, electric shavers)
then is to work to find out what the person wants
to furniture (adjustable beds, lamps). Always inspect
to do and then help her to do it safely. Use your
electrical devices before you use them to make sure
knowledge of the person to think about why she
that they are in good working order and that cords
might try to get up without help, or what might cause
are intact. A piece of equipment that is not working
her to fall. Then think about ways you can meet the
properly or that has a frayed cord can give the person
person’s need and reduce or eliminate the risk for
(or you) an electrical shock (Figure 7-6). Always follow
falling. For example:
the manufacturer’s directions for using the piece of
■ You know that Mrs. Williams will try to get up to equipment, and avoid getting the equipment near
get a book or magazine or other item that she water.
needs, rather than ask for help. To help reduce
Shocks can also occur at electrical outlets. Use care
Mrs. Williams’ risk of falling, you can make sure
when inserting and removing plugs, and advise those
the items she might want are within easy reach.
in your care to do the same. Use plastic outlet covers
This can be accomplished by moving the table
to prevent children or confused adults from sticking
closer to Mrs. Williams, rearranging the items on
their fingers or other objects into the outlet. Avoid
the table so that what she needs is within easy
overloading outlets. Use a surge protector if it is
reach, or providing her with a grabber she can
necessary to plug more than two items into a standard
use to reach the items.
outlet. Avoid using extension cords, except on a
■ Lately, Mr. McDaniels has been complaining of temporary basis.
feeling dizzy whenever he sits up. To help reduce
his risk of falling, you can make sure the nurse Burns
knows about the dizziness, so that the cause
A person can easily be burned if the water used for
can be determined and addressed. Details about
bathing is too hot. Turn hot water on last and off first,
the person’s dizziness—such as the level (mild
and check the temperature of the water coming out
to severe), the length of time it lasts (from a few
of the faucets. You can test the temperature of the
seconds to 5 minutes or more), and what the person
water using your wrist, but remember that a person
was doing when the dizziness occurred (for example,
with impaired sensation may not be able to tell if the
moving his head, trying to sit up or stand)—are also
water coming out of the faucet is too hot. Teach people
helpful to report.
with impaired sensation to use a thermometer to
■ Mrs. Jones has dementia. You know that because measure the temperature of the water before getting
of her memory loss, she has trouble understanding in the bathtub or shower. The temperature of hot
her environment. You also know from talking to tap water should be less than 115°F. If water
Mrs. Jones that she had dogs as pets up until she seems too hot, report this concern immediately to
came to live at the nursing home. Lately, Mrs. Jones the nurse.
has been trying to get up in the middle of the night
unassisted to “take the dog out.” To help reduce
Mrs. Jones’ risk for falling, you could look at pictures
of her dogs with her before she goes to bed to
bring back good memories, and reassure her that
her dogs are being well taken care of. This might
help her to feel calm and contented, and reduce her
tendency to get up in the middle of the night to take
care of the dog.
■ Mrs. Lukins is a very private person. You know
that she is embarrassed to ask for help using
the bathroom. You make it a point to check on
Mrs. Lukins frequently and ask her if you can help
her to the bathroom.
In each of these examples, your knowledge of the person
as an individual gives you information you can use to Figure 7-6 Small appliances can be hazardous if they do not work
help lower the person’s risk for falling. properly or if the cords are in bad condition.

82 | | Nurse Assistant Training

Foods and beverages that are too hot can also cause
burns. If food is steaming or a plate is too hot to
touch, wait until the food stops steaming or the plate
has cooled a little before serving the meal. Also make
sure hot beverages have cooled a bit before serving
them. If a person has trouble keeping a firm grip on
the cup, spills can occur, leading to burns. Serving
the beverage in a cup with handles and a lid can
help the person hold the cup more securely
(Figure 7-7).
Some people may use heating pads to promote comfort.
Place the heating pad in its cloth cover or wrap a towel
around it before placing it against the person’s skin. Set
the temperature according to the person’s care plan, and
avoid leaving the heating pad in place for longer than
20 minutes. Check the skin underneath the pad every
Figure 7-8 All containers should have a clear label stating what is
5 minutes for excessive redness or blisters. Do not allow inside. Keep cleaning supplies, medications and other potentially
the person to lie on top of the heating pad, because this poisonous substances in a locked cabinet or closet.
increases the likelihood of burns.

Poisoning
A poison is any substance that causes injury, illness
or death if it enters the body. Cleaning supplies, fluids It is 11:00 and your new resident, Mr. Rivera,
used for car and home maintenance, and certain has arrived with his wife. The admissions paperwork
plants can all cause poisoning if a person swallows has been completed and you’ve helped to get
them. Poisoning can also occur if a person takes the Mr. Rivera settled in his room and his belongings put
wrong medication, or too much of it. To reduce the away. You show Mr. Rivera how to use the call signal
risk for accidental poisoning, make sure all containers and ask him to please call you before he gets out of
are clearly and accurately labeled. Store all medicines, bed or the chair, so you can help him.
cleaning materials and other potentially poisonous
substances in locked cabinets and closets Knowing what you know about Mr. Rivera,
(Figure 7-8). what risk factors does he have for injury?

In addition to showing Mr. Rivera how to

use the call signal and reminding him to use
it whenever he wants to get up, what other
measures will you take to help keep
Mr. Rivera safe?

Reporting Incidents
An incident is something unusual that happens to a
person receiving care, a staff member or a visitor to the
facility and has the potential to cause harm. You must
verbally report all incidents, even those that do not result
in injury, to the nurse. In addition, you must complete a
written incident report, per your employer’s policy.
When reporting an incident and completing an incident
report, it is important to provide facts, not opinions. The
goal is not to assign blame. It is to provide a factual
account of what happened so that appropriate steps can
Figure 7-7 Take special precautions to prevent burns caused by spilling
be taken to prevent a similar incident from happening in
hot liquids or foods when a person has weak or unsteady hands. the future. Report the incident and complete the incident

Chapter 7 | Preventing Injuries | 83

 ■ What kind of assistance or first aid was given?
■ Were there witnesses to the incident? If so, who?
■ Did the person receive medical treatment?
Also include other information that would be a useful
part of the record or that is required by your employer.

A WORD ABOUT RESTRAINTS

A restraint is any device that inhibits a person’s
freedom of movement. Restraints can be physical or
chemical. A physical restraint is attached on or near a
person’s body to limit the person’s freedom of movement
or ability to reach part of her body. Examples of physical
restraints include wrist restraints, mitt restraints, jacket
restraints and vest restraints. Devices such as side rails
Figure 7-9 Following an incident, an incident report must be completed.
The incident report helps management identify trends and prevent and lap trays can also be considered physical restraints,
similar incidents from occurring in the future. if the person is not able to move them out of the way
independently. Chemical restraints are medications used
to subdue a person, so that the person is unable to
report promptly, while the details of what happened are function normally.
still fresh in your mind (Figure 7-9).
In the past, it was thought that restraints helped to keep
A complete incident report contains answers to the people safe by preventing them from getting up without
following questions: assistance and falling or wandering away from the
■ Who was the person involved in the incident? facility. However, now we know that restraints can cause
■ Was the person confused before or after very serious complications, and even death (Box 7-3).
the incident? In addition, the use of restraints can rob a person of
his or her dignity. As a result, restraint use is decreasing
■ Was the person alone?
in all health care settings. Today, many health care
■ What happened to the person? Was the person facilities, especially nursing homes, strive to be
injured? If so, describe the injury. restraint free. The Omnibus Budget Reconciliation
■ What caused the incident? (For example, was Act (OBRA) states that people receiving care in
water on the floor?) Remember to state only facts, nursing homes and in their own homes have the right
not opinions. to be free of restraints, and establishes strict guidelines
■ Where did the incident happen? for their use.
■ When did the incident happen (time, date)? Restraints must never be used as a convenience for
■ Who gave assistance or first aid? the nursing staff, or to punish or discipline a person.

▼ Box 7-3 Complications Associated with Restraints

■ Strangulation (cutting off the air supply) can occur with adverse mental effects include depression and loss
some types of restraints (such as vest restraints or seat of self-esteem.
belts) if they are not applied properly, or if the restraint ■ Complications of immobility. Not being able to
moves and gets tangled around the person’s neck. move freely puts the person at risk for pressure ulcers,
■ Entrapment and other serious injuries. A person contractures, blood clots, pneumonia, incontinence,
who struggles to get free from the restraint is at risk for constipation and loss of muscle tone and balance.
serious injuries, such as suffocation and broken bones. For ■ Tissue and nerve damage. A restraint that is applied
example, a person who tries to climb over side rails may too tightly can cut off the blood supply to the body part
become caught in the side rails (entrapment). Attempting to beyond the restraint, leading to tissue and nerve damage.
get up while restrained can cause the chair or wheelchair ■ Bladder and bowel elimination problems. If the
to tip over on the person, or the person may trip and fall. person is not offered the opportunity to use the bathroom
■ Mental effects. A person who is restrained may frequently enough, the person may become incontinent of
become more agitated and confused. Other urine, feces or both.

84 | | Nurse Assistant Training

 example, it may be necessary to apply a wrist restraint
to a hospitalized person who is confused and keeps
removing a medical device that is essential to his care,
such as an intravenous (IV) line. If restraints are in use in
the facility where you work and applying them is part of
your job description, your employer will teach you how
to properly apply the types of restraints that are in use
in the facility. If you are asked to apply a restraint, make
sure that the conditions listed in Box 7-4 have been met
first. Make sure you understand exactly how to use the
restraint, and use the right size for the person’s height
and weight. Follow your employer’s procedure and the
manufacturer’s instructions for securing the restraint.
After the restraint is applied, you must help keep the
person safe (Box 7-5).

Figure 7-10 Alternatives to physical or chemical restraints must always

be tried first. The better you know the person, the more able you will be to
predict the person's behavior and take measures to keep the person safe.
PERFORMING SKILLS SAFELY
This nurse assistant knows that this resident tends to try to get out of her In Unit 3, you will begin to learn the skills you will need
chair or bed when she is feeling lonely, so the nurse assistant decided to
bring the resident to the nurse’s station where she will feel less lonely and
to provide hands-on care. Completing all of the steps
the staff will be able to see her if she tries to get up unassisted. of a skill, correctly and in the correct order, is important
to protect those in your care, and yourself, from injury.
As a nurse assistant, you must seek ways to keep Although you may learn how to do these skills one way
the people in your care safe without using restraints. during your training, your employer may have specific
Providing company and distraction is one way to do ways of doing certain skills, which will be detailed in
this (Figure 7-10). Involve the person in meaningful a procedures manual. Always follow your employer’s
activities, such as exercise, games, hobbies or procedure manual.
musical entertainment. Activities provide gentle
There are certain steps that you should always take
physical and mental stimulation, help the person feel
before starting a skill and after completing the skill. In
useful and improve the person’s self-esteem. Ask
this book, we call these steps “Preparation Steps” and
family members or volunteers to sit with the person,
“Completion Steps.” Performing these steps routinely
or bring the person to the nurse’s station with you
promotes safety and efficiency, and helps to protect
while you complete paperwork. Check in on the
the person’s rights. These steps are summarized in Box
person very frequently, and offer a snack or beverage,
7-6. In addition, your instructor will give you a handout
or assistance using the bathroom. Getting to know
listing these steps, and you can keep this handout with
the person as an individual will help you think of
you when performing skills in this course. It is important
creative ways to keep the person safe without using
to memorize and perform these steps every time you
restraints.
provide hands-on care. Let’s take a closer look at
In some very specific situations and health care why each of the preparation and completion steps is
settings, it may be necessary to apply a restraint. For important.

▼ Box 7-4 OBRA Conditions That Must Be Met Before a Restraint

Can Be Applied
■ A primary care provider (doctor or advance practice nurse) ■ There must be a clear medical reason for the restraint.
must write the order for the restraint. The order must A restraint is never to be used for staff convenience or to
specify the type of restraint, the purpose of the restraint discipline a person.
and how long the restraint is to be used. ■ The person must be given an explanation of how the
■ All alternatives to physical or chemical restraint must be restraint works, why it is needed and how long it will be
tried and the person’s response to these alternatives must used. Family members must also be given this information
be documented before resorting to the use of a physical or if the person wants them to have it, or if the person is not
chemical restraint. able to make decisions about care independently.

Chapter 7 | Preventing Injuries | 85

 ▼ Box 7-5 Care for a Person Who is Restrained
■ Check on the person very frequently. She may need to Offer the person a snack or a drink. Release the restraints
be reassured that she hasn’t been abandoned. Many more often if the person seems to be anxious, needs to go
people injure themselves by trying to get out of restraints the bathroom or is in distress.
without assistance. ■ Observe the person carefully and report any changes
■ Release the restraints every 2 hours and help the person in behavior (such as increased agitation, drowsiness or
go to the bathroom, stretch, change positions and do decreased appetite) immediately to the nurse.
range-of-motion exercises. Inspect the person’s skin for ■ Report and record the care you provide and the
reddened areas and report any concerns to the nurse. observations you make.

Preparation Steps bed. Make sure the wheels on any equipment with
wheels are locked.
Before beginning any skill, always complete the
following steps: Completion Steps
■ Wash your hands. This is essential to prevent the When you are finished with a skill, always perform the
spread of infection. following steps:
■ Gather your supplies. Having everything you need
■ Ensure the person’s comfort and good
before you start promotes efficiency.
body alignment. Before leaving the person,
■ Knock, greet the person and ensure privacy. smooth the sheets on the bed, make sure he is
Before entering a person’s room, you must always warm enough, and make sure he can easily reach
knock and ask permission to enter. Greet the person items such as drinking water, the television remote
by name, and if you do not know him well, check or reading material. Make sure the person is in good
his identification photo or wristband to make sure body alignment to promote comfort and prevent
that the person you are speaking to is the person complications such as pressure ulcers.
who is supposed to receive the care that you are
■ Adjust equipment for safety. If you raised the
about to provide! Also tell the person who you are.
bed during the skill, return it to the level specified
It is especially important to introduce yourself if
in the person’s care plan to make it safer for him to
the person does not know you well, is confused
get out of bed independently. Check the wheels on
or has impaired vision. Shut the door to the room
any equipment again to make sure they are locked.
behind you and pull the privacy curtain to protect the
Place the person’s method of calling for help within
person’s privacy during the procedure.
reach. In many facilities, this will be the call light
■ Explain the procedure. Tell the person what control, but it may also be a small hand bell or other
you are there to do and how he can help you. way of making noise. If side rails are in place on the
Then, as you work through the skill, tell the person bed, lower or raise the side rails according to the
what you are doing and remind him of how he can person’s care plan.
help. Remember to explain the skill in a way that
■ Clean up your work area. Show respect for the
the person can understand. Also, be aware that a
person’s living space and prevent the spread of
person who is unconscious may still be able to hear
infection by cleaning up after every skill. Dispose of
you and may still be aware that someone is doing
disposable items. Place linens in the linen hamper
something to him, so it is important to perform this
for laundering. Clean and put away reusable
step with every person in your care.
equipment according to your employer’s policy.
■ Adjust equipment for body mechanics and Disinfect surfaces as required.
safety. Many of the skills you will do while the
■ Wash your hands. This is essential to prevent the
person is in bed. If the person is in an adjustable
spread of infection.
bed and will be staying in bed throughout the skill,
raise the bed to a comfortable working height to ■ Report and record. Reporting to the nurse lets
protect your back. If the person will be getting out the nurse know that you have completed
of the bed, lower the bed to the height specified the assigned task and gives you the chance
in the person’s care plan. This height will allow to update the nurse on any changes in the
the person to place both feet flat on the floor with person’s condition. Record your observations
the hips, knees and ankles at right angles, which and the care you provided according to your
will make it easier and safer for him to get out of employer’s policy.

86 | | Nurse Assistant Training

▼ Box 7-6 Preparation and Completion Steps
PREPARATION STEPS

Wash your hands.

Gather your supplies.

Knock, greet the person and ensure privacy.

Explain the procedure.

Adjust equipment for body mechanics and safety.

COMPLETION STEPS

Ensure the person’s comfort and good body alignment.

Adjust equipment for safety.

Clean up your work area.

Wash your hands.

Report and record.

The steps listed here represent general principles of good care and should be followed throughout your training.
However, your employer may have specific preparation and completion steps that you should follow; always check
your employer’s procedure manual.

Chapter 7 | Preventing Injuries | 87

 b. Ask the nurse or another nurse assistant to
CHECK YOUR UNDERSTANDING show you how to use the lift.
c. Help Mr. Thompson to get out of bed without
using the lift.
Questions for Review
d. Practice using the lift with another resident
before going to assist Mr. Thompson.
1. Which of the following is part of good
body mechanics? 7. All of the following are potential complications of
a. Independence restraints EXCEPT:
b. Communication a. Death.
c. Entrapment b. Low self-esteem and depression.
d. Alignment c. Nerve and tissue damage.
d. Drowning.
2. Which of the following moves increases
your stability? 8. You work in a hospital and the nurse
a. Moving your feet close together has asked you to apply a wrist restraint to
b. Bending at the waist Mrs. Schneider because she has repeatedly
c. Spreading your feet apart pulled her intravenous (IV) line out. Before
applying the restraint, you must make sure of
d. Relaxing your stomach muscles
all of the following EXCEPT:
3. Before using any equipment, you should: a. Mrs. Schneider is able to remove the device
a. Check to make sure it is working properly. independently.
b. Unplug it. b. The doctor or advance practice nurse has
c. File an incident report. written an order for the restraint.
d. Stand up straight. c. Mrs. Schneider understands the reason for
the restraint.
4. Mrs. Singer is a home health client. d. You have been properly trained in how to apply
Complications of diabetes have caused her the restraint, and applying restraints is part of
to lose feeling in her legs. Because of her your job description.
condition, what type of injury is Mrs. Singer
at high risk for? 9. Restraints must be released at least:
a. Poisoning a. Every shift.
b. Burns b. Every hour.
c. Entrapment c. Every 2 hours, and more often
d. Electrical shock if necessary.
d. Whenever a relative visits.
5. All of the following are risk factors for falling
EXCEPT:
Questions to Ask Yourself
a. Poor eyesight.
b. Being overweight. 1. Mrs. Kennedy has poor vision and uses a walker.
What special measures would you take to make
c. Poor mobility.
sure her room is safe?
d. Medication effects.
2. Mr. Lightfoot’s legs are unsteady when he gets up
6. You are a new employee and the nurse has quickly from his chair. Today, he is anxiously waiting
asked you to assist Mr. Thompson out of bed for a phone call from his daughter. What risk factors
using a mechanical lift device. Although you does Mr. Lightfoot have for falling, and what can you
have used mechanical lifts before, you are not do to help keep him safe?
familiar with the kind of mechanical lift used in 3. Mrs. Simpson, a resident at the nursing home
this facility. What should you do? where you work, has been wandering into other
a. Go to help Mr. Thompson. The lift probably residents’ rooms. The nurse tells you to strap her
works the same way the lifts you used at your into a wheelchair so that she can’t wander. What
previous place of employment did. should you do?

88 | | Nurse Assistant Training

 C H A PT E R
Responding to
Emergencies 8
After reading this chapter, you will have the information needed to:
■ Recognize and respond to common medical emergencies, including stroke, myocardial
infarction, choking, bleeding, shock, seizure, fainting and burns.
■ Prevent a fire emergency from occurring.
■ Keep people safe in the event of a fire emergency.
Goals ■ Keep people safe during weather emergencies and other events that disrupt the
facility’s ability to function normally.
After practicing the corresponding skills, you will have the information needed to:
■ Clear the airway of a conscious choking adult.

Chapter 8 | Responding to Emergencies | 89

 Key Terms:
emergency cerebrovascular accident automated external seizure
defibrillator (AED)
disaster myocardial infarction epilepsy
shock
first aid cardiopulmonary
resuscitation (CPR)

1. Recognize the emergency. Sometimes it will be

You have been caring for Mrs. Schulman, one obvious that a person is in distress. Other times,
of your home health clients, for 3 years. For as long as however, a medical emergency may only be signaled
you have known Mrs. Schulman, part of your duties
by a slight change in the person’s behavior or
appearance. As a nurse assistant, you will have
have been to help her get ready to go to the synagogue
in-depth knowledge of what is normal for each
with her daughter on Friday evenings. But this Friday person in your care. A change from normal could
afternoon, when you arrive at Mrs. Schulman’s house, signal an emergency and should be reported
she tells you she doesn’t feel like attending the service. immediately (Figure 8-1).
The only other time you can remember Mrs. Schulman 2. Check. Stay calm, and check the scene and the
missing Friday evening prayers was last winter, when person. First, make sure there is nothing that could
she was hospitalized for pneumonia. Mrs. Schulman hurt you or cause further injury to the person, such
asks you to please call her daughter and tell her not to as a downed wire in the area. Next, look for clues
come pick her up. She says, “I just feel really strange, that may help you understand what happened.
not like myself at all. My left leg feels numb … like I Finally, check the person: tap her shoulder or hand
might fall if I try to put weight on it. And my left arm
and shout to see if he or she is conscious.
feels weak and strange too. If you could just make me 3. Call. Next, call for help. In a hospital, there is usually
a cup of tea and help me get ready for bed, I think that a code you can dial to call for help from within the
might be best. I’m sure I’ll feel better in the morning.” facility. In other health care settings, you may be
You tell Mrs. Schulman that you are worried about
required to dial 9-1-1 or another emergency number.
Know your employer’s policies and procedures
her, and that you’d like to talk to someone else about related to calling for help in an emergency.
her symptoms and find out what you should do.
4. Care. Provide appropriate care (according to the
situation and your level of training) until help arrives.
Help the person rest comfortably, and provide
An emergency is a situation that arises suddenly
reassurance because the person is likely to be
and requires immediate action to keep a person safe. frightened and upset. In the sections that follow, we
Emergencies can be medical in nature, involving an will review basic first aid for some common medical
acute illness or injury that requires immediate attention emergencies. To expand your knowledge of how to
to prevent the person from dying or experiencing respond to emergencies, it is strongly recommended
permanent long-term effects. Emergencies can also that you take American Red Cross First Aid/CPR/
be environmental, involving changes to a person’s AED training in addition to the nurse assistant
training course.
environment that affect the person’s health and safety.
Examples of environmental emergencies include fires,
weather emergencies (such as snow storms, tornadoes
and hurricanes) and disasters (severe events that
cause widespread damage and destruction, affecting
many people and disrupting normal functioning of the
community). As a nurse assistant, you must know how
to respond in the event of an emergency to keep the
people in your care safe.

MEDICAL EMERGENCIES
Recognizing and Responding to
Medical Emergencies Figure 8-1 Your knowledge of what is normal for each person in your
care can help you detect when something is wrong. Sometimes the
The following steps guide your actions in an emergency only sign of a medical emergency is a slight change in the person’s
and ensure your safety and the safety of others. appearance or behavior.

90 | | Nurse Assistant Training

5. Report and record. Your observations about what The signs and symptoms of a stroke can vary from
happened before, during and after the emergency person to person. A person who is having a stroke may
are important to share with other members of the show any of the following signs and symptoms:
health care team. These observations should be
reported to the nurse and documented on the ■ Slurring of words
appropriate forms, per your employer’s policy. Note ■ Drooping of the features on one side of the face
whether the person complained of any symptoms (for example, the eyelid and the corner of the mouth)
before the event, the time the symptoms started
and how long the symptoms lasted. Be specific. For ■ Trouble seeing in one or both eyes
example, “She was breathing at a rate of 25 breaths ■ Weakness or numbness in an arm or leg
per minute” is more specific than “She was having
trouble breathing.” If you arrived on the scene to ■ A sudden, severe headache
find the person in distress and unconscious or ■ Dizziness or loss of balance
otherwise unable to tell you what happened, note ■ Confusion, or a loss of consciousness
anything unusual that you observed while you were
checking the scene and the person. Also report and ■ A generally ill appearance, or abnormal behavior
record exactly what you did to help the person (for The “FAST” check (Figure 8-2) is a quick way of
example, “I helped her to sit up and held her there.”) checking for signs of a stroke:
Face. Ask the person to smile. Is there weakness or
drooping on one side of the face?
Observations Into Action! Arm. Ask the person to raise both arms. Is there
In older people, the signs and symptoms of weakness or drooping of one of the arms?
an emergency may be very general and Speech. Ask the person to say a simple sentence or
non-specific, and they may be barely noticeable phrase. Does the person have trouble speaking, or is her
to someone who does not know the person well. speech slurred?
Because you will spend a lot of time with the people Time. If the person has difficulty performing any of these
in your care and you will get to know what is normal actions or shows other signs of stroke, call for help
for each of them, you will be in a good position immediately. Prompt medical attention may reduce the
to notice subtle changes that could be a sign of a amount of disability the person experiences as a result of
medical emergency. General signs and symptoms the stroke.
that could signal a medical emergency in an older If you think that a person is having a stroke, follow your
person include the following and should be reported employer’s procedure for calling for help. Stay with
to the supervising nurse right away! the person and provide reassurance until help arrives.
{ Headache Monitor the person’s breathing and check for any
{ A change in the person’s usual level of changes in his condition. If the person is drooling or
activity has trouble swallowing, place him on one side to keep
the airway clear. Note when the person’s symptoms
{ A change in mental status (such as
started. This is important information to report because
agitation, the new onset of confusion, or
some of the medications used to treat stroke are only
increased confusion in a person who is
effective within a certain time frame after the onset of
already confused)
symptoms.
{ Lethargy (extreme drowsiness or
sleepiness)
{ Difficulty sleeping You are concerned about the numbness and
weakness Mrs. Schulman is reporting on her left side.
You do the “FAST” test with Mrs. Schulman and see
that she is not able to raise her left arm. You suspect
Common Medical Emergencies that Mrs. Schulman has had a stroke, and decide to
call 9-1-1, per your employer’s policy. Then you call
Stroke Mrs. Schulman’s daughter.
A stroke, or cerebrovascular accident, occurs What information should you be ready to give
when blood flow to a part of the brain is interrupted, the emergency services dispatcher?
resulting in the death of brain cells. A stroke can
also be caused by bleeding into the brain tissue. Strokes What care will you provide to Mrs. Schulman
can cause permanent brain damage, but with quick while you are waiting for the ambulance
action, sometimes the damage can be stopped or to arrive?
reversed.

Chapter 8 | Responding to Emergencies | 91

 Figure 8-2 “FAST” recognition and reporting of stroke symptoms can help to minimize
the lasting effects of stroke.

Myocardial infarction ■ A cold sweat

A myocardial infarction, or heart attack, occurs when ■ A feeling of anxiety or doom
blood flow to part of the heart muscle (the myocardium) ■ Extreme fatigue (tiredness)
is blocked, causing the cells in that area to die. As a Although men most often have the classic signs of a heart
result, the heart’s ability to pump blood throughout the attack (for example, chest pain), women often have more
body can be affected. If a large area of the heart is subtle signs, such as a squeezing sensation in the chest,
damaged, the heart may stop beating (cardiac arrest). extreme fatigue, nausea, breaking out in a cold sweat,
Signs and symptoms of a heart attack vary from person dizziness or lightheadedness, and shortness of breath.
to person, and can be different in women than they are
in men. A person who is having a heart attack may show If you think a person in your care is having a heart attack,
any of the following signs and symptoms: stay with her and follow your employer’s procedure for
calling for help. Encourage the person to remain calm
■ Chest pain, discomfort, pressure, or squeezing that
and quiet while you are waiting for help to arrive.
lasts longer than 3 to 5 minutes and is not relieved
by resting, changing position, or taking nitroglycerin, If the person loses consciousness, stops breathing, or
or that goes away and then comes back has no pulse, the person is in cardiac arrest and will
■ Discomfort or pain that spreads to one or both arms, require cardiopulmonary resuscitation (CPR) and
the back, the shoulder, the neck, the jaw or the possibly defibrillation (delivery of an electric shock to the
upper part of the stomach heart muscle to restore a normal rhythm). An automated
■ Dizziness, lightheadedness or loss of consciousness external defibrillator (AED) is a portable electronic
device that delivers a defibrillation shock automatically
■ Trouble breathing, including noisy breathing, shortness or with a push of a button to help the heart restore an
of breath and breathing that is faster than normal effective pumping rhythm (Figure 8-3). The proper use
■ A heartbeat that is faster or slower than normal, or of an AED along with CPR has been shown to improve
irregular survival rates among people experiencing cardiac arrest.
■ Nausea You should know the location of AEDs in your facility,
■ Pale, ashen or slightly bluish skin because you may be asked to retrieve the AED in an

92 | | Nurse Assistant Training

 person is conscious, follow the procedure for giving
first aid to a conscious choking adult (see Skill 8-1).
If the person becomes unconscious, you must follow
a different procedure. The procedure for helping an
unconscious person who is choking is not taught as
part of this course. This skill is taught as part of the
American Red Cross First Aid/CPR/AED course,
which you are strongly encouraged to take in addition
to your nurse assistant training course.

Bleeding
Bleeding can be internal or external. Internal bleeding is
not immediately obvious, but external bleeding is. Severe
bleeding, whether it is internal or external, is life-threatening.
Figure 8-3 An automated external defibrillator (AED) is often used along To provide care for a person who is bleeding externally, first
with cardiopulmonary resuscitation (CPR) when a person is in cardiac
arrest. Know the location of the AED in your facility in case you need to take standard precautions by putting on gloves. If you think
retrieve it quickly. the blood might spray or splatter, you may need eye and
face protection as well. Control the bleeding by covering
the wound with a sterile dressing and firmly pressing
emergency while a coworker administers CPR. You against the wound with your gloved hand until the bleeding
should also know where CPR breathing barrier devices stops (Figure 8-4, A). Apply a pressure bandage over the
(used to protect both the person being resuscitated and dressing to maintain pressure on the wound and to hold
the rescuer from the spread of microbes in saliva, blood the dressing in place (see Figure 8-4, B). If blood soaks
and other body fluids) are kept so you can access them through the first dressing and bandage, continue to apply
in a hurry. The skills for administering CPR and using an pressure and add a second dressing and bandage. If the
AED are not taught as part of this course, but you are
strongly encouraged to take the American Red Cross
First Aid/CPR/AED course to learn these skills.

Choking
Choking occurs when the airway becomes either partially or
completely blocked by a foreign object. Many of the people
in your care will have risk factors for choking. For example,
neurological conditions, such as a stroke or multiple
sclerosis, can affect a person’s ability to swallow or clear
the airway through coughing. Dental problems or poorly
fitting dentures can affect a person’s ability to chew food
properly, putting him at risk for choking. Eating while talking
or laughing, or eating too fast, can also lead to choking.
If you are with a person who starts to choke, you will need A
to take quick action. First, ask the person to speak to you.
■ If the person can speak and is coughing forcefully,
stay with the person, have her sit up if she is lying
down, and encourage her to keep coughing. If the
person is not able to expel the object and clear the
airway quickly, call for help.
■ If the person cannot speak and is coughing weakly
or making a high-pitched sound while breathing,
the airway is partially blocked and the person
is not getting enough air. You must call for help
immediately and then follow the procedure for giving
first aid to a conscious choking adult (Skill 8-1).
■ If the person is unable to speak, cough or breathe, B
she will lose consciousness quickly unless the airway Figure 8-4 First aid for external bleeding. (A) Cover the wound with
a sterile dressing and apply pressure. (B) Apply a pressure bandage to
is cleared. Call for help immediately, and then, if the secure the dressing.

Chapter 8 | Responding to Emergencies | 93

bleeding does not stop, you must call for help. Stay with
person, and observe the person closely for signs that may
indicate that the person’s condition is worsening, such as
breathing that is faster or slower than normal, changes
in skin color and restlessness. Provide reassurance, and
keep the person calm. Remember to wash your hands
immediately after removing your gloves.

Shock
Shock is a condition in which the circulatory system
fails to deliver enough oxygen-rich blood to the body’s
tissues and vital organs. There are many causes of
shock, including massive blood loss, heart failure, severe
allergic reactions and severe infections that overwhelm
the body.
A person who is in shock may show any of the following Figure 8-6 Help a person who is in shock to lie down on his back, and
signs or symptoms: keep him from becoming too chilled or too hot.

■ Excessive thirst
■ Restlessness or irritability To provide first aid for a person who is in shock, first call
for help immediately. Take any measures that you can
■ Nausea or vomiting
to address the cause of the shock (for example, control
■ Altered level of consciousness external bleeding or assist the person with using an
■ Pale or ashen, gray, cool, moist skin auto-injector, if you have been trained to do so). Keep the
■ A blue tinge to lips and nail beds (cyanosis) person from becoming chilled or overheated, and help
■ Rapid breathing and rapid pulse the person to rest comfortably (Figure 8-6). Even though
the person is likely to be thirsty, do not give the person
The treatment for shock depends on the underlying anything to drink or eat. The person may need surgery,
cause. For example, if the shock is caused by severe which is safest when the stomach is empty. Comfort and
blood loss, the bleeding must be stopped. Shock that reassure the person until medical help arrives.
is caused by a severe allergic reaction is treated by
administering epinephrine. People who know they are Seizure
severely allergic to something may carry epinephrine
A seizure is the result of abnormal electrical activity
with them in the form of an auto-injector (Figure 8-5).
in the brain, which leads to temporary and involuntary
You can learn how to assist someone with using an
changes in body movement, function, sensation,
auto-injector in the American Red Cross First
awareness or behavior. Seizures can have many different
Aid/CPR/AED course.
causes. Some people may have epilepsy, a chronic
seizure condition that can often be controlled with
medication. Other causes of seizures include fever,
infection and injuries to the brain tissue.
Although usually we think of a seizure as involving
convulsions (uncontrolled body movements caused by
contraction of the muscles) and loss of consciousness,
sometimes a person having a seizure will just become
very quiet and have a blank stare. A person with epilepsy
may experience something called an aura (an unusual
sensation or feeling) before the onset of a seizure.
Most seizures last only a few minutes. Your main goal is to
protect the person from injury during the seizure. Remove
nearby furniture or other objects that the person could
accidentally hit during the seizure. Do not try to hold or
restrain the person, or put anything in the person’s mouth
Figure 8-5 A person who is at risk for anaphylactic shock as a result or between the teeth to prevent the person from biting
of a severe allergy may carry an auto-injector like this one with her.
The auto-injector contains epinephrine, a medication used to treat his tongue. When the seizure is over, place the person
life-threatening allergic reactions. Photo courtesy of Dey Pharma, L.P. on one side (Figure 8-7) to prevent him from choking on

94 | | Nurse Assistant Training

 prevent her from choking. The person will usually recover
quickly with no lasting effects; however, she should
receive a medical evaluation after the fainting episode.

Burns
Burns are injuries to the skin and possibly the underlying
structures (for example, bone and muscle) as a result of
exposure to heat, radiation, an electric shock or chemicals.
Burns can range in severity from minor (for example, a
sunburn) to life-threatening. If a person is burned, you
should always call 9-1-1 when:
■ The burn is causing the person to have trouble
breathing, or there are signs of burns around the
Figure 8-7 When the seizure is over, place the person in the recovery mouth and nose.
position. Turning the person onto his side helps to prevent him from
choking on fluids (such as saliva or vomit) that may pool in the mouth. ■ The burn covers more than one body part or a large
area of the body.
secretions that may have pooled in the mouth. The person ■ The person’s head, neck, hands, feet or genitals
may be drowsy and disoriented or unresponsive for a are burned.
period of time. He may be very tired and want to rest. Stay ■ The burn involves underlying structures (for example,
with the person until he is fully recovered from the seizure muscles or bone) and the person is younger than
and aware of his surroundings. 5 years or older than 60 years.
■ The burn was caused by exposure to chemicals, an
Fainting explosion or electricity.
Fainting is a temporary loss of consciousness caused by a
While waiting for help to arrive, first try to remove the source
sudden decrease in the blood supply to the brain. Fainting
of the burning. For a burn caused by heat, cool the burn
may be a sign of a serious medical issue, such as a heart
with large amounts of cold running water. For a chemical
condition, but it can also be caused by factors such as
burn, remove the chemical from the skin by flushing the
hunger, being too hot, standing for long periods of time,
area with large amounts of running water (if the chemical
medication side effects, fatigue or strong emotions. A
is liquid) or brushing the chemical off using gloved hands
person who is about to faint often becomes pale, begins
and then flushing the area with water. Be careful not to get
to sweat, and then loses consciousness and collapses.
the chemical on yourself, or on another area of the person’s
The person may feel weak or dizzy. A fainting spell might
body. If the burn was caused by an electrical shock, turn
be prevented by having the person lie down or sit with her
off the power at its source before attempting to assist the
head level with her knees (Figure 8-8). If the person does
person. If you cannot turn the power off at the source, do
begin to faint, lower the person to the floor using good
not touch the electrical wire or the person.
body mechanics, and position her flat on her back. Loosen
tight clothing, such as a tie, collar or scarf. Make sure the Cover the burned area loosely using a sterile, dry
person is breathing. Do not give the person anything to dressing. Provide reassurance, and monitor the person
eat or drink. If the person vomits, turn her onto one side to for the development of shock.

FIRE EMERGENCIES
A fire in a health care facility can be devastating. Many
people who are receiving health care have limitations in
mobility, hearing, vision or understanding—all of which
interfere with their ability to successfully react to a fire.
As a nurse assistant, you must know how to prevent a
fire from occurring, and what to do if a fire does occur.

Preventing Fire Emergencies

For a fire to occur, the following must be present: fuel
(something that burns), heat (something to ignite the
Figure 8-8 A person who feels faint may be able to prevent the fainting fuel) and oxygen (Figure 8-9). Removing any one of
episode by sitting down and placing her head near her knees. these elements will stop a fire from increasing.

Chapter 8 | Responding to Emergencies | 95

 Figure 8-10 Knowing what to do in the event of a fire can save your life
and the lives of others.

Figure 8-9 Three elements must be present for a fire to start: fuel
(something to burn), heat (something to ignite the fuel) and oxygen. others are exposed to poisonous gases, heat or flames,
the safer everyone will be. Box 8-1 describes how to
Remember that many people who receive health care move people to safety in the event of a fire emergency.
require oxygen therapy, which increases the risk for fire. ■ Alarm. Activate the nearest fire alarm pull station
Take the following precautions to help prevent fires: (if applicable). Call 9-1-1 (or another number, per
your employer’s policy) to report the location and
■ Supervise the people in your care whenever
current extent of the fire.
they smoke.
■ Contain. Close all doors and windows that you can
■ Follow your employer’s rules about smoking. If you
safely reach to contain the fire. As you leave an area,
provide care for people who smoke, make sure
close the door behind you.
they smoke only in appropriate places and safely
extinguish their smoking materials. Make sure the ■ Extinguish. Only attempt to extinguish the fire if it is
person uses any protective equipment (such as a safe for you to do so. If the fire is relatively small and
smoking apron) per your employer’s policy. contained, you may be able to put it out using
a fire extinguisher.
■ Keep materials such as matches and lighters in
a secure place, out of reach from children and Generally, to use a fire extinguisher, pull the safety
confused people. pin out, aim the hose at the base of the fire, squeeze
■ Never permit smoking around a person who is the handle, and spray using a side-to-side sweeping
using oxygen. motion (Figure 8-11). There are three major types of
fires, classified as type A, B or C (Table 8-1). Most fire
■ Report any electrical equipment that is not working extinguishers are ABC fire extinguishers, which means
properly or is not well-maintained to your supervisor.

Responding to Fire Emergencies

If a fire does break out, you must know how to respond.
Your facility will have a fire emergency plan, which
will specify the method used to alert others to fire (for
example, a phone number to call or the location of fire
alarm pull boxes). The fire emergency plan will also specify
when and how to evacuate the people in the building, as
well as any special measures to take to prevent a fire from
spreading. Be familiar with your facility’s fire emergency
plan and participate in the periodic drills that are held to
practice putting the plan into action (Figure 8-10).
The word “RACE” can help you to remember how to
react to a fire emergency:
■ Rescue. Stop what you are doing and remove anyone
in immediate danger from the fire to a safe area. Get out Figure 8-11 If you need to use a fire extinguisher, remember the word
“PASS”: Pull the pin out, Aim the hose at the base of the fire, Squeeze
as safely and quickly as possible. The less time you and the handle, Spray in a side-to-side motion.

96 | | Nurse Assistant Training

 ▼ Box 8-1 Removing People to Safety in a Fire Emergency
■ Touch doors with the back of your hand before you open ■ Move people who cannot walk in their beds or in
them. If the door is hot, do not open it. Leave the area wheelchairs.
another way. If the door is cool, stand to one side and ■ People may be frightened and confused. Help to
open it slowly. If you see heavy smoke on the other side, reassure them by remaining calm and explaining what
close the door. is happening. Reassure people that you will help move
■ Stay low. Smoke rises, and it is easier to breathe when you them to a safe area. After people are moved to a safe
are closer to the floor. place, make sure a staff member remains with them to
■ Use stairs, not an elevator. keep them from wandering into dangerous areas. The
■ If your clothing or that of another person catches fire, stop, presence of a staff member is especially important for
drop (to the ground), and roll over and over (to extinguish people who have impaired vision or hearing or who
the flames). are confused.

Table 8-1 Types of Fires and Fire Extinguishers

Type Description How to Put the Fire Out
A A fire that uses ordinary dry materials as fuel, Type ABC fire extinguisher, or Type A fire extinguisher,
such as wood, paper or leaves or water.

B A grease fire (kitchen fires are often grease fires) Type ABC fire extinguisher, or Type B fire extinguisher, or
smother the fire by sprinkling baking soda over it or
putting the lid on the pan and removing the pan from
the heat source.
NEVER USE WATER!

C An electrical fire, such as one caused by Type ABC fire extinguisher, or Type C fire extinguisher.
frayed wiring NEVER USE WATER!

they are effective against all types of fires. In the event be caused by man (such as bombings, chemical leaks
that an ABC fire extinguisher is not available, you must and nuclear accidents).
use an extinguisher specific to the type of fire, or take
As a nurse assistant, you must be prepared in the event
other measures as summarized in Table 8-1.
of a weather emergency or disaster. Know what types of
weather emergencies are common in the area where you
live, and familiarize yourself with actions you should take to
WEATHER EMERGENCIES, keep yourself and others safe should such an emergency
arise. Box 8-2 summarizes actions you take in the event
DISASTERS AND OTHER EVENTS of some common weather emergencies. You can learn
WITH WIDESPREAD IMPACT more about other weather emergencies that may be more
common in your area by visiting the American Red Cross
Environmental events can occur that put people in
website or your local American Red Cross chapter.
immediate danger and affect the ability of the facility to
function normally, resulting in an emergency situation. Your employer will have a disaster preparedness plan that
For example, weather emergencies such as ice or specifies the actions the staff should take in the event of a
snow storms can result in power outages, an inability disaster. Make sure you know your role and responsibilities.
to receive supplies for an extended period of time, Often, when a major event such as a hurricane is predicted
and staffing shortages. When this occurs, the facility’s and there is time to prepare, the disaster preparedness
ability to follow normal routines to provide care may plan will specify that patients or residents are to be
be disrupted, and an emergency exists. When an evacuated to another facility. The disaster preparedness
event affects many people and causes widespread plan will also specify measures that should be taken to
damage and destruction in the community, it is called cope with the event if it occurs suddenly, there is no time
a disaster. Disasters can be caused by natural events to evacuate, and the normal functioning of the facility will
(such as tornadoes, hurricanes or floods), or they may be affected for an extended period of time.

Chapter 8 | Responding to Emergencies | 97

 ▼ Box 8-2 Weather Emergencies
General Precautions on the lowest level of the building is the next
■ best option.
Listen for weather reports on the radio or television. In a
■ Close the doors to rooms and close fire doors.
hospital or nursing home, know which staff members are
■ Make sure doorways to halls, fire doors and exits are
assigned to listen to the reports.
■ Have a flashlight, a battery-operated radio and fresh not blocked.
■ Follow evacuation procedures if necessary.
batteries available.
■ Make sure you have access to a supply of fresh water. A tornado warning means a tornado has been sighted or
indicated on weather radar in the area. If a tornado warning is
Hurricanes. A hurricane occurs when the winds of a large
issued in your area:
tropical storm (that is, a storm that begins over warm ocean
water) increase to 74 miles per hour or more. ■ Immediately move yourself and others to the basement of
the building or a windowless room on the lowest level of
A hurricane watch means a hurricane is possible in your area the building.
within the next 48 hours. If a hurricane watch is issued in your
Earthquakes. An earthquake occurs when the plates
area:
that make up the Earth’s surface move against each other,
■ Prepare for a possible evacuation, per your employer’s causing the Earth to shake. This activity in the Earth may
disaster preparedness plan. cause buildings to shake, windows to shatter and objects to
■ Check outdoor areas: remove or secure loose objects and shift or fall. It also can cause fires to start and can generate
prepare to board up windows. large ocean waves. Earthquakes can occur in most states,
A hurricane warning means hurricane conditions are expected and they may occur at any time without warning. If you are
within 36 hours. If a hurricane warning is issued in your area: inside when an earthquake occurs, stay inside and protect
yourself and others from falling or shifting objects by taking
■ Follow your employer’s disaster preparedness plan for
cover under a large, heavy object (such as a desk or table)
evacuating patients or residents to another facility (if an
and holding on. If you are outside when an earthquake occurs,
evacuation order is issued).
stay outside but move away from buildings, trees and
■ If you are not told to evacuate, move people into interior overhead wires.
rooms or hallways. Keep people away from windows. If
a person cannot easily get of bed, move the person in After the earthquake:
his bed into a hallway, or push the bed against the wall. ■ Be prepared for aftershocks (smaller quakes that occur
Assign a staff member to stay with people who have after the first tremor).
been moved to safety. ■ Check yourself and others for injuries. Never try to move
■ Cover people with blankets or bedspreads to protect seriously injured people unless they are in danger of
them from flying glass in case windows break. further injury.
■ Close the doors to rooms and close fire doors. ■ Do not use equipment or services requiring electricity, gas,
■ Make sure doorways to halls, fire doors and exits are not water or sewage disposal because these systems may be
blocked. damaged. If you smell gas or see a broken line, shut off the
■ Monitor weather conditions carefully. main valve or inform the person responsible. Do not try to
Tornadoes. A tornado is a spinning, funnel-shaped turn utilities back on.
■ Never smoke or light candles. Earthquakes can create gas
windstorm that moves along the ground. Tornadoes can arise
very suddenly. leaks, and an open flame from a match or cigarette lighter
can cause an explosion.
A tornado watch means that weather conditions are favorable ■ Use the telephone only in a life-threatening emergency.
for a tornado in your area. If a tornado watch is issued in ■ Watch for fallen power lines.
your area: ■ Listen to a battery-operated radio for updated information
■ Be alert to weather conditions (for example, dark or greenish about the emergency.
clouds, funnel clouds), blowing debris and the sound of an ■ Clean up spilled medicines, drugs, flammable liquids and
approaching tornado. A tornado often sounds like a freight other materials.
train. Inform other staff members if you see or hear anything. ■ Open cabinets and closet doors cautiously. The items
■ Move people to the basement of the building. If inside may have shifted and could fall on you when you
the building has no basement, a windowless room open the door.

98 | | Nurse Assistant Training

In the event of a disaster, you will play a very 2. If your clothing catches fire, you should:
important role in helping to reassure and calm the a. Run, cover and cool.
people in your care. Many of the people in your
b. Stop, drop and roll.
care will have characteristics that make them more
vulnerable during times of crisis. For example, a c. Call the fire department.
person who has recently experienced an upsetting d. Blanket, bathe and bandage.
event (such as separation from or loss of a loved one)
3. Which of the following could be a sign of
might be less able to cope with the emotional impact
a stroke?
of the disaster. A person who is dependent on
others for care will understandably be very frightened a. Profuse sweating
during an event that disrupts the normal routine of b. Convulsions
the facility. A person with dementia will not be able to c. Fainting
understand what is happening, and will become very d. Drooping on one side of the face
upset by the change in the normal routine. People
who speak a language other than English may fear 4. You are helping a person to eat when he begins
that they will not be able to communicate their needs. to choke. He is making a high-pitched wheezing
By staying calm, knowing what to do and offering sound, and it is difficult for him to answer you
reassurance, you can help the people in your care to when you ask if he needs help. What should
feel safe. you do?
In a disaster situation, staff members who are on duty a. Perform cardiopulmonary resuscitation (CPR).
may be required to stay at the facility for longer than one b. Call for help immediately, and then begin
shift because conditions outside may make it unsafe or administering back blows and abdominal thrusts.
impossible for people to travel to and from the facility. c. Watch him carefully for a minute to see if he is
If you are on duty and a disaster occurs, your primary able to cough up the object on his own.
responsibility is assisting the people in your care. d. Call for help immediately, and then provide
However, naturally, you will be concerned about the reassurance until help arrives.
health and safety of your own family while you cannot be
with them. Developing a home disaster preparedness 5. You are with a group of residents in the day
plan that describes what family members should do if room when suddenly one of the residents loses
they are away from home or apart from each other when consciousness and slumps over in her chair.
a disaster occurs can give you peace of mind. Review What should you do?
the plan frequently with family members so that you are a. Call for help immediately.
confident everyone knows what to do. Also, make sure b. Splash water on the resident’s face to revive her.
you are prepared in the event that you must remain in
c. Move furniture out of the way to protect her from
the facility for longer than one shift. For example, if you
further injury.
require medication to manage a chronic condition, make
sure you have enough on hand to see you through the d. Administer cardiopulmonary resuscitation (CPR).
emergency. 6. How should you position a person who has had
a seizure after the seizure is over?
a. Flat on his back
b. On his side
CHECK YOUR UNDERSTANDING c. Seated, with his head between his knees
d. On his stomach

Questions for Review 7. One of your co-workers has cut herself with
a knife while cutting up fruit for a smoothie-
1. What should you do if a fire alarm sounds while making activity with the residents, and she is
you are at work? bleeding quite heavily. What is the first thing you
a. Leave the building and go home. should do?
b. Ask another nurse assistant what to do. a. Call 9-1-1 and monitor her for shock.
c. Follow your employer’s policies for responding b. Put on a pair of gloves and then go to her aid.
to a fire alarm. c. Put a dressing over the cut and apply pressure
d. Ignore the fire alarm, because it is probably only to stop the bleeding.
a fire drill. d. Rinse the cut with water.

Chapter 8 | Responding to Emergencies | 99

8. You are a home health nurse on duty and a Questions to Ask Yourself
tornado watch has been issued for your area.
Which area in the client’s home would be the 1. You enter Mr. Lee’s room and see flames shooting
best place to move the client to safety? out of the trash can. What should you do?
a. The dining room, which has large windows 2. You are alone at Mrs. Jones’s house and she begins
b. A windowless bathroom on the ground floor to choke on a piece of hot dog. What should
c. The client’s room you do?
d. The front hall
3. You are with Mr. Smith in the bathroom and you
9. Which of the following could by a sign of a notice that he is sweating profusely, clutching his
myocardial infarction? chest and gasping for air. What do you do?

a. Blurred vision 4. You are caring for Mr. White in his home and he
b. Nausea begins to have a seizure. What should you do?
c. Aura 5. You wake Mrs. George and notice that the left side
d. Shock of her mouth is drooping. What should you do?

100 | | Nurse Assistant Training

 SKILLS

Skill 8-1
First Aid for a Conscious Choking Adult

1. Check the scene and the person.

■ Ask the person if he or she is choking.
■ Identify yourself and ask the person if you
can help.
■ If the person is coughing forcefully, encourage
continued coughing. Otherwise:
2. Call, or have someone else call 9-1-1 (or follow your
employer’s procedure).
3. Give five back blows. Position yourself behind
the person, lean him forward and strike him firmly
between the shoulder blades using the heel of your
hand (Figure 1).

Figure 2

Figure 1

Figure 3
4. Give five abdominal thrusts. Still standing behind
the person, wrap your arms around his waist. Place 5. Continue giving back blows and abdominal
the thumb side of your fist just above the person’s belly thrusts until:
button. Clasp your fist with your other hand and give
quick, upward thrusts into the abdomen (Figure 2). ■ The object is forced out.
■ The person becomes unconscious.
Note: If the person is pregnant or too big for you
■ The person can breathe or cough forcefully.
to reach around, you will need to give chest thrusts
instead of abdominal thrusts. To give chest thrusts, 6. Document your observations and actions per your
place the thumb side of your fist over the center employer’s policy. Be aware that the person will
need to receive a medical evaluation after the
of the person’s breastbone instead of above the
emergency has passed.
person’s belly button, grab your fist with your other
hand and give quick, upward thrusts (Figure 3).

Chapter 8 | Responding to Emergencies | 101

9
10
11
12
13
14
15
16
17
PROVIDING CARE

Measuring Vital Signs, Weight and Height

Maintaining a Comfortable Environment
Providing Restorative Care
Assisting with Positioning and Transferring
UNIT

Assisting with Personal Cleanliness and Grooming

Assisting with Meals and Fluids
Assisting with Elimination
Promoting Comfort and Rest
Assisting with Admissions, Transfers and Discharges
3
102 | | Nurse Assistant Training
 C H A PT E R
Measuring Vital Signs,
Weight and Height 9
After reading this chapter, you will have the information needed to:
■ Discuss the importance of measuring vital signs accurately.
■ Describe factors that can affect each of the four vital signs: temperature, pulse,
respirations and blood pressure.
■ Describe equipment used to measure each of the four vital signs.
Goals ■ Discuss considerations related to measuring each of the four vital signs safely
and accurately.
■ Describe when weight and height measurements are obtained.
■ Discuss considerations related to measuring weight and height accurately.

Continued on next page

Chapter 9 | Measuring Vital Signs, Weight and Height | 103

 Continued from previous page

After practicing the corresponding skills, you will have the information needed to:
■ Use an electronic thermometer to measure a person’s oral, rectal, axillary or
tympanic temperature.
Goals ■ Evaluate a person’s radial and apical pulse.
■ Evaluate a person’s respirations.
■ Measure a person’s blood pressure.
■ Measure a person’s weight and height.

Key Terms:
vital signs hypothermia dyspnea hypertension

fever stethoscope hypotension sphygmomanometer

As a nurse assistant, you will be responsible for

Mrs. Parker, a resident of Morningside measuring and recording the vital signs of those in
Nursing Home, is 82 years old and came to live at your care. These measurements are always taken when
Morningside after her husband died and severe a person is first admitted to a health care facility, at
arthritis and other health problems made it difficult regular intervals throughout the person’s stay at the
for her to manage on her own. You always enjoy facility (for example, every day or every week), and
seeing Mrs. Parker. Usually you can find her in the before the person is discharged from the facility. When
common area, chatting to anyone who will listen. She a person first starts receiving care, you may be asked
knows all of the staff and other residents by name and to take the person’s vital signs frequently because
always remembers something special about everyone. these frequent readings help the health care team
Whenever she sees you, she always asks about your determine what is normal (or baseline) for that person.
son, and how he is doing playing basketball for the After the baseline is established, the person’s primary
high school team. care provider (that is, the doctor or advanced practice
nurse) may order the person’s vital signs to be taken
Today, however, you discover Mrs. Parker in bed, with
on a less frequent but regular basis. The frequency
a dry, hacking cough. When she tries to talk to you, she
varies from one person to another. You may also take
coughs even more. Between coughs she manages to tell
a person’s vital signs on an “as-needed basis,” such
you that she aches all over. Her face looks flushed, and
as when you notice a change in the person’s usual
when you touch her, she feels warm and dry. You tell
condition, or when the nurse asks you to. For example,
Mrs. Parker you would like to take her vital signs. Her
it may be necessary to measure a person’s blood
vital signs are as follows: temperature, 99.3°F (orally);
pressure before the nurse gives the person certain
pulse, 110 beats/min and weak; respirations, 26 breaths/
types of medications.
min and shallow; and blood pressure, 134/94 mm Hg
(higher than Mrs. Parker’s usual blood pressure). Accuracy when measuring vital signs is extremely
important. Vital sign measurements often affect
decisions that are made about the person’s medical
care. The importance of these readings to the person’s
VITAL SIGNS care makes it essential that you measure these signs
accurately, record them correctly and report any changes
In health care, there are four basic measurements that
in them promptly to the nurse. The other members of
can tell us a great deal about how a person’s body is
the health care team are depending on you to give them
functioning. These four measurements—temperature,
accurate information in a timely manner.
pulse, respirations and blood pressure—are called
vital signs because they represent functions that are When you are measuring a person’s vital signs,
essential for life (“vital” comes from the Latin word remember that although obtaining these measurements
for “life”). Health care workers often use their own may be a routine task to you, having these
language for talking about vital signs. They talk about a measurements taken may carry special significance for
person’s TPR, which stands for temperature, pulse and the person receiving care. Some people will be worried
respiration; and BP, which stands for blood pressure. about what the measurements will reveal about their

104 | | Nurse Assistant Training

health status. Many people will be embarrassed by ELDER CARE NOTE. In older people, the body
having a rectal temperature taken. Always observe the temperature may decrease, or only slightly
five principles of care when you measure a person’s vital increase, in response to an infection. Always
signs, and be sensitive to the person’s feelings about report even slight variations in an older person’s
having these measurements taken. temperature, whether they are higher or lower
than what is normal for the person.

You find your supervising nurse on the unit We use a range of numbers to describe temperatures
and say, “Nancy, I’m worried about Mrs. Parker. that are considered normal for most people. The normal
She’s developed a dry, hacking cough; her skin is range varies both according to where on the body the
hot and dry to the touch; she tells me that she aches temperature is measured, and the age of the person
all over; and she barely feels like talking! I took her (Figure 9-1):
vital signs, and her temperature is a little high. Her
pulse rate and respiratory rate are also high, and her ■ Site. Common places to measure a person’s
pulse is weak and her breaths are shallow. Her blood body temperature include the mouth (an oral
pressure is higher than it normally is, too. I have the temperature), rectum (a rectal temperature), ear
measurements written down, but can you go check (a tympanic temperature) and armpit (an axillary
on Mrs. Parker?” The nurse thanks you for providing temperature). Because of the variation that occurs
such a thorough report and says, “I’ll go right away to from site to site, it is very important to note the site
check on her.” where you obtained the temperature, in addition to
the actual measurement! Follow your employer’s
A short time later, while you are giving Mrs. Parker policy regarding how to note the site. A common
some juice, Nancy returns with a medication to lower practice is to write an “O” after the measurement
Mrs. Parker’s temperature. Shortly after Mrs. Parker if the temperature was taken orally, an “R” if the
takes the medicine, the doctor arrives, examines her temperature was taken rectally, a “TY” if the
and orders an antibiotic and a medication to help temperature was taken in the ear, and an “A” if the
control the cough. temperature was taken in the armpit.
You could have just reported your ■ Age. Body temperature is usually higher in
observations about Mrs. Parker’s condition, newborns and lower in older adults.
but instead you decided to obtain Mrs. Body temperature is measured in degrees. Degrees
Parker’s vital sign measurements and can be measured on two different scales, Fahrenheit
include them in your report as well. How did (°F) or Celsius (°C). In the United States, the Fahrenheit
taking Mrs. Parker’s vital signs help you to scale is used most commonly. Table 9-1 summarizes
communicate more effectively with the nurse? normal temperature ranges and average temperatures in
How did Mrs. Parker benefit from your degrees Fahrenheit and degrees Celsius for each of the
actions? What could have happened if you major sites where temperature can be measured. The
delayed reporting your observations, or if the ranges and averages given in Table 9-1 are for adults
vital sign measurements you took were younger than 65 years. Remember that in adults older
not accurate? than 65 years, the body temperature is normally 1 to 2
degrees lower than the ranges and averages shown in
Table 9-1.

Temperature
Body temperature indicates the amount of heat
produced by the body. Normally the body maintains a
fairly constant temperature. A special area in the brain
regulates the body temperature and makes adjustments
as needed to keep it within the normal range. A person’s
temperature usually moves up and down within the
normal range, depending on factors such as the time of
day, the person’s level of activity, the person’s emotional
status and the temperature of the surrounding air.
Fever is a temperature above the normal range and is
Figure 9-1 Normal temperature ranges vary according to the site where
a common response to infection. Hypothermia is a the temperature was measured and the age of the person. (Data taken
temperature below the normal range. from the Welch Allyn website.)

Chapter 9 | Measuring Vital Signs, Weight and Height | 105

 Table 9-1 Normal Range of Body Temperatures in Adults Younger Than
65 Years*
Site (ºF) (ºC)
Normal Range Average Normal Range Average
Oral 97.6–99.6 98.6 36.4–37.5 36.9

Rectal 98.6–100.6 99 37–38.1 37.5

Axillary 95.3–98.4 96.8 35.2–36.9 36

Ear 96.6–99.7 98.1 35.9–37.6 36.7

*In adults older than 65 years, the normal temperature ranges and averages are typically 1° to 2° lower than those given here.
Data taken from the Welch Allyn website.

Observations Into Action!

The following may be signs of a medical problem
and should be reported to the nurse right away.
{ A temperature that is higher than normal for
the person
{ A temperature that is lower than normal for
the person Figure 9-2 Glass thermometers vary slightly in appearance, depending
on their use.

Equipment used to measure use a rectal thermometer to take an oral or axillary

temperature temperature.
A thermometer is used to measure temperature. Several
Glass thermometers are fragile and can break easily.
different types of thermometers are used in health
The mercury that many glass thermometers contain is
care settings.
highly toxic and must be cleaned up and disposed of
properly. If you break a glass thermometer, do not touch
Glass thermometer the mercury, and prevent others from doing so as well.
A glass thermometer contains mercury or a mercury- Notify the nurse so that the proper procedures can be
like substance in a thin glass tube with a bulb on the followed for cleaning up the broken glass and disposing
end (Figure 9-2). The glass tube is marked with a of the mercury. Even if the thermometer contains a non-
scale in degrees Fahrenheit or degrees Celsius toxic, mercury-like substance, broken glass still presents
(Figure 9-3). When the bulb is placed in the person’s a hazard to you and to others. Because of the hazards
mouth, rectum or armpit, the person’s body heat associated with mercury and broken glass, many health
causes the substance inside the thermometer to care facilities no longer use glass thermometers. You
expand and move up the tube, indicating the person’s can learn more about the proper care and use of a glass
body temperature. To obtain an accurate temperature, thermometer in Appendix D, Skills D-1 and D-2.
the glass thermometer must be left in place for 3 to
10 minutes, depending on where the temperature is Electronic thermometer
being measured.
An electronic thermometer is a battery-operated
Glass thermometers for oral and rectal use differ in device with a heat-sensitive probe that is placed in
the colors of their tips (see Figure 9-2). The oral glass the person’s mouth, rectum or armpit to measure the
thermometer, which is used for taking oral and axillary temperature (Figure 9-4). The probe is covered with
temperatures, has a blue tip. Rectal thermometers a disposable cover (sheath) before use. As with glass
have a red tip. (Remember “Red for Rectal.”) Never thermometers, the probe is color-coded according to

106 | | Nurse Assistant Training

 A

Figure 9-3 Glass thermometers are marked in either degrees Fahrenheit (F) or degrees Celsius (C). The column on a glass thermometer is marked with
a series of long and short lines extending from 94º to 108º Fahrenheit, or from 34º to 43º Celsius. On a Fahrenheit thermometer (A), each long line on
the thermometer represents 1 degree, and each of the four shorter lines between the long lines represents 0.2 degree. On a Celsius thermometer (B),
each long line represents 1 degree, but each shorter line in between represents 0.1 degree.

its intended use (blue for oral or axillary use, and red Skill 9-1 to learn how to use a tympanic thermometer to
for rectal use). Never use a rectal probe to take an oral measure a person’s tympanic temperature.
or axillary temperature! When the device is finished
measuring the person’s temperature (usually in less Ensuring safety and accuracy when
than 1 minute), it beeps and displays the measurement obtaining a temperature
on a screen. Skill 9-1 describes how to use an Obtaining an accurate temperature measurement safely
electronic thermometer to measure a person’s oral, requires you to use the right equipment in the right
rectal or axillary temperature. way. It also requires you to consider conditions the
person may have that make one method of obtaining a
Tympanic thermometer temperature preferable over another one.
A tympanic thermometer is a special type of electronic
thermometer that uses a specially designed probe Equipment considerations
to measure heat waves given off by the eardrum ■ Glass thermometers. Before using a glass
(Figure 9-5). (The medical term for the eardrum is thermometer, always inspect the thermometer to
tympanic membrane.) The probe is covered with a make sure that it is not chipped, cracked or broken. To
disposable cover and inserted into the person’s ear prevent the spread of infection, wash the thermometer
canal. The device beeps and displays the temperature with cool water and soap before and after using it.
measurement on a screen within a few seconds. See (Never use hot water to wash a glass thermometer
because this can cause the thermometer to break.)
Before inserting the thermometer, move the mercury
or mercury-like substance into the bulb by “shaking
down” the thermometer with a quick downward
flick of your wrist (Figure 9-6). The mercury or
mercury-like substance must start below the 94° F
mark on a Fahrenheit thermometer or the 34° C

Figure 9-4 An electronic thermometer. Figure 9-5 A tympanic thermometer.

Chapter 9 | Measuring Vital Signs, Weight and Height | 107

 electronic thermometer is giving faulty readings (for
example, a temperature that is extremely high or
extremely low, or the same temperature for every
person), report the problem to the nurse so that the
device can be taken out of service and repaired.
Electronic thermometers are used for many people, so
always practice proper infection control procedures.
Remember not to put the thermometer down on dirty
surfaces, and if the thermometer has a cord, keep the
cord in your hand and make sure that the only part of
the device that contacts the person or his surroundings
is the probe cover. To ensure an accurate measurement,
be sure to place the thermometer probe properly, and
leave it in place for the specified amount of time.

Person-specific considerations
The method used to take a person’s temperature
depends on several factors. Using the wrong method
to take a person’s temperature can affect the person’s
safety, the accuracy of the measurement or both.

Figure 9-6 “Shake down” a glass thermometer before use by holding it

■ Oral method. Generally, the oral method is
firmly by the stem and snapping your wrist in a quick downward motion. the preferred way to measure a person’s body
temperature because it is easy, causes the person
mark on a Celsius thermometer in order to give an minimal discomfort and embarrassment, and gives
accurate temperature reading. Be sure to place the a measurement that accurately reflects the internal
thermometer properly, and leave it in place for the body temperature. Situations that may make taking
specified amount of time. an oral temperature unsafe or result in inaccurate
■ Electronic thermometers. Make sure the electronic measurements, and what to do in these situations,
thermometer is fully charged. If you notice that the are summarized in Table 9-2.

Table 9-2 Obtaining Accurate Temperature Measurements Safely

Situation Avoid Do This Instead
The person has consumed food or The oral method, because the Wait 15 minutes before taking the oral
a beverage or smoked a cigarette temperature of the food, fluid or cigarette temperature, or use another method
within the past 15 minutes. smoke can influence the temperature if allowed.
inside the mouth, resulting in an
inaccurate reading.

The person has had recent mouth The oral method, because the Take temperature using rectal, axillary or
surgery or has a mouth disease. thermometer may cause injury. tympanic method.

The person is confused. The oral method with a glass Take temperature orally using an electronic
thermometer, because the person may thermometer, or use rectal, axillary or
bite down on the thermometer and break tympanic method.
it, causing injury.

The person is unconscious or The oral method, because the person may Take temperature using rectal, axillary or
paralyzed on one side of the body. not be able to keep the mouth closed tympanic method.
around the thermometer, resulting in an
inaccurate temperature reading.

The person has trouble breathing The oral method, because the person will Take temperature using rectal, axillary or
or breathes through mouth, or the not be able to keep the mouth closed tympanic method.
person has a tube in the nose and around the thermometer and still breathe.
cannot keep the mouth closed.
Continued on next page

108 | | Nurse Assistant Training

Table 9-2 Obtaining Accurate Temperature Measurements Safely continued

Situation Avoid Do This Instead

The person is receiving oxygen. The oral method, because oxygen cools Take temperature using rectal, axillary or
the temperature inside the mouth, tympanic method.
resulting in an inaccurate reading.

The person has a blocked rectum The rectal method, because the Take temperature using oral, axillary or
or hemorrhoids, or has recently had thermometer may cause injury. tympanic method.
rectal surgery.

The person has diarrhea. The rectal method, because this method Take temperature using oral, axillary or
can be uncomfortable for the person. tympanic method.

The person has certain The rectal method, because placing the Take temperature using oral, axillary or
heart conditions. thermometer in the rectum may stimulate tympanic method.
the urge to strain and may increase the
workload of the heart.

■ Rectal method. The rectal method for measuring ■ The pulse rate. When you count the number of
a person’s body temperature also accurately times you feel a person’s pulse beat in a minute,
reflects internal body temperature, but it can you know how fast the person’s heart is beating.
cause the person embarrassment and discomfort. This number is called the heart rate or pulse
A rectal temperature is obtained when taking an
oral temperature might cause injury or inaccurate
results. Situations that would make taking a rectal
temperature unsafe or that could result in inaccurate
measurements are summarized in Table 9-2.
■ Axillary method. The axillary method is the
least accurate way to measure a person’s body
temperature. Take an axillary temperature only
if the person cannot tolerate having an oral or a
rectal temperature taken. To ensure that the results
obtained are as accurate as possible, pat the armpit
dry with a tissue before placing the thermometer
(moisture can affect the measurement), and make
sure the person stays seated or lies down while the
temperature is being measured.

Pulse
Each time the heart beats, it pushes blood through the
arteries, vessels that carry blood away from the heart and
throughout the body. The heartbeat creates a wave of
blood, which you can feel pass through the artery if you
put your fingers over certain places on the body where
the artery lies close to the surface of the skin (Figure 9-7).
Between beats, the heart rests. Then it beats again,
causing another wave that you can feel. The wave that
you can feel is called the pulse.

Characteristics of the pulse

The pulse provides information about how a person’s
heart is working. When you evaluate a person’s pulse,
you note several things: Figure 9-7 Pulse points.

Chapter 9 | Measuring Vital Signs, Weight and Height | 109

Table 9-3 Normal Resting Pulse an apical pulse differs from the technique used to
measure the pulse at the wrist and other pulse points.
Rates
■ Radial pulse. The radial pulse is evaluated by
Normal Resting placing your fingers over the radial artery, on the
Age Group Pulse Rate inside of the wrist, and counting the number of
pulsations that you feel in 1 minute. In addition to
Adults and children older 60 to 100 beats/min* counting the number of pulsations, you also note
than 10 years the rhythm and force of the pulse. Be sure to press
Children between the 70 to 130 beats/min
lightly against the wrist. If you press too hard, you
ages of 1 and 10 years
can flatten the artery and you will not be able to feel
anything. Skill 9-2 describes step by step how to
Infants between the ages 80 to 120 beats/min evaluate a person’s radial pulse.
of 1 and 11 months ■ Apical pulse. When evaluating an apical pulse, you
place a stethoscope over the apex of the heart and
Newborns between the 100 to 150 beats/min
count each pulse beat by listening to it rather than
ages of 1 and 30 days
feeling it. (Box 9-1 describes the parts and use of
*In well-trained athletes, the normal resting pulse rate may be a stethoscope.) The apical pulse is evaluated when
between 40 and 60 beats/min. the person has a very weak or irregular pulse that
Data from National Institutes of Health. is difficult to detect at the radial artery, and when
the person has certain heart conditions. The apical
method is also used for infants and young children.
rate. Activity, pain, fever, significant blood loss, Skill 9-3 describes how to evaluate a person’s
and emotions such as anger, fear, agitation or apical pulse.
excitement can cause the pulse rate to increase.
Sleep, some medications, and conditions such as Ensuring accuracy when evaluating
depression can cause the pulse rate to decrease. the pulse
In adults, the pulse rate is normally between 60 and
To ensure accuracy when measuring a person’s pulse,
100 beats/min (Table 9-3).
evaluate factors that could increase the person’s pulse
■ The pulse rhythm. When you describe the pulse rate before beginning. For example, if the person has just
rhythm, you describe how regular the pulse is. come back from physical therapy or undergone a painful
A pulse that comes at regular intervals (like the procedure, or if the person is emotionally upset, it might
ticking of a clock) has a regular rhythm. If the be best to give the person time to rest and relax before
length of time between pulses is uneven, the checking the pulse. When you are taking a radial pulse,
rhythm is irregular. make sure the person’s arm is resting comfortably on the
■ The pulse force. If the pulse is easy to feel, it is bed (or on her lap if she is seated). Avoid placing your
described as a full or strong pulse. A bounding thumb over the person’s radial artery (when taking a radial
pulse is a pulse that seems to push up against your pulse) or holding the diaphragm of the stethoscope with
fingertips. A thready pulse is a weak pulse that is your thumb (when taking an apical pulse) because your
very difficult to feel. thumb has its own pulse, which you might confuse for the
person’s pulse. Wait until the second hand gets to the
Observations Into Action! “12” before you count starting, and count for 1 full minute.

The following may be signs of a medical problem

and should be reported to the nurse right away:
{ A pulse rate that is less than 60 beats/min Mrs. Parker’s pulse rate was high (110 beats/
or greater than 100 beats/min min). What factors could be responsible for
her increased pulse rate?
{ A pulse that is irregular
{ A weak (thready) or bounding pulse

Sites for evaluating the pulse Respirations

Most of the time, you will evaluate the person’s pulse at Respiration is the process of breathing. When we
her wrist. This is called a radial pulse. In some situations, breathe, we take oxygen into the body and expel carbon
you may evaluate the person’s pulse over her heart. This dioxide (a waste product) from the body. Both of these
is called an apical pulse. The technique used to evaluate functions are vital to life.

110 | | Nurse Assistant Training

 ▼ Box 9-1 Using a Stethoscope
Earpieces A stethoscope allows the user to listen to sounds produced
inside the body. The stethoscope consists of an amplifying
device (used to make sounds louder), tubing (used to conduct
the sound to the user’s ears), and two earpieces. The amplifying
Tubing device has a large flat side, called the diaphragm, and a small
rounded side, called the bell. The diaphragm is used to listen
to high-pitched sounds, such as a heartbeat or blood passing
through the arteries. The bell is better for listening to low-
pitched sounds. Depending on your needs, you can rotate the
amplifying device to use either the diaphragm or the bell side.

Before using a stethoscope, check the tubing for cracks or

holes that could distort the sounds. Wipe both the earpieces
and the amplifying device with an alcohol wipe before and
after each use. Fit the earpieces into your ears with the tips
Diaphragm
facing forward (toward your nose). You will know they are in
place correctly if you cannot hear any outside sound. Next,
tap on the amplifying device to check your ability to hear
through the stethoscope. If you do not hear the tap, rotate the
Bell amplifying device and tap again. When you are able to hear
the tap, the stethoscope is ready to use.

Characteristics of respirations Observations Into Action!

When you are evaluating a person’s respirations, as
when you are evaluating the person’s pulse, you note Difficult, irregular or noisy breathing is considered
several things: abnormal. Report the following signs of abnormal
breathing to the nurse right away:
■ The respiratory rate. This is the number of
respirations that occur in 1 minute. You count { A respiratory rate that is greater than 20
respirations by observing the person’s chest breaths/min or less than 15 breaths/min
rise (inhalation, or taking the breath in) and fall { A respiratory rhythm that is irregular
(exhalation, or letting the breath out). One inhalation { Respirations that are shallow or deep
plus one exhalation equals one respiration. The same { Respirations that are strained or difficult (dyspnea)
factors that can increase the pulse rate also can { Respirations that do not cause both sides
increase the respiratory rate (for example, exercise,
of the chest to rise and fall together
fever, pain, significant blood loss, and emotions such
as anger, fear, agitation or excitement). Likewise,
the same factors that decrease the pulse rate can
Ensuring accuracy when evaluating
decrease the respiratory rate (for example, sleep, respirations
certain medications, and certain conditions such as Respiration is the one vital function that we can control
depression). In adults, the normal respiratory rate to a certain extent. Although we breathe without having
is between 15 and 20 breaths/min. In infants and to think about it, we do have some control over whether
children, the normal respiratory rate is faster. our breaths are deep or shallow, and whether they
are fast or slow. We also have the ability to interrupt
■ The respiratory rhythm. This is the regularity with
the normal pattern of breathing, by holding our breath.
which the person breathes. In normal breathing, the
Because just knowing that you are evaluating her
breaths are evenly spaced.
breathing can cause a person’s breathing to change,
■ The respiratory depth. A person’s respirations it is best to evaluate respirations without the person
may be described as deep or shallow. being aware that you are doing it. Usually, you evaluate
Normally, a person breathes quietly and easily. The breaths a person’s respirations after evaluating her pulse. If you
seem effortless and are evenly spaced. Both sides of the keep your fingers on the person’s wrist (as if you are
chest rise and fall equally. Dyspnea is the medical term for still checking the pulse), the person may not be aware
breathing that is difficult or seems like it takes a lot of effort. that you are evaluating her respirations, which can

Chapter 9 | Measuring Vital Signs, Weight and Height | 111

lead to a more accurate evaluation. Count the person’s At times, you may be asked to measure the person’s
respirations for 1 full minute, counting one rise and one blood pressure first in one arm and then the other, or
fall of the chest for each respiration. Skill 9-4 describes to obtain a series of blood pressure measurements (for
step by step how to evaluate a person’s respirations. example, with the person lying flat, then sitting up and
then standing). Follow the nurse’s instructions or the
person’s care plan.
Mrs. Parker’s respiratory rate was
26 breaths/min. What factors could have Equipment used to measure
contributed to her increased respiratory rate?
blood pressure
The traditional way of measuring a person’s
blood pressure is with a stethoscope and a
Blood Pressure sphygmomanometer. The sphygmomanometer has
Blood pressure measures the pressure of the circulating three parts: a cuff that is placed around the person’s
blood on the walls of the arteries. Each time the heart arm, a bulb that is squeezed to fill the cuff with air, and a
beats, it pumps blood into the arteries. The pressure of manometer, a gauge for measuring the blood pressure
the blood against the walls of the arteries when the heart (Figure 9-8). There are two styles of manometers. A
pumps is called the systolic pressure. The pressure of the mercury manometer is an upright gauge that contains a
blood against the walls when the heart relaxes is called the column of mercury. The level of the mercury shows the
diastolic pressure. The systolic pressure is always higher pressure readings. An aneroid manometer shows the
than the diastolic pressure. A blood pressure reading pressure readings on a round dial with an arrow that
consists of these two numbers, which are written like a points to the numbers. Although there is no mercury in
fraction. The larger systolic reading goes on the top, and an aneroid manometer, the unit of measure is still mm Hg
the smaller diastolic reading goes on the bottom. For (millimeters of mercury).
example, in the reading 118/78 mm Hg, 118 is the systolic The fabric cuff contains a rubber bladder, which is
pressure, and 78 is the diastolic pressure. Blood pressure connected by tubing to the bulb. A valve at the base of
is measured in “millimeters of mercury,” or mm Hg. the bulb opens and closes to control the flow of air into
In adults, the healthy range for blood pressure is less the bladder. The valve is controlled by a screw. If you turn
than 120/80 mm Hg. Hypotension is the word used the screw to the left or down, it opens the valve and lets
to describe low blood pressure, and hypertension is the air escape from the bladder, deflating the cuff. If you
the word used to describe high blood pressure. A blood turn the screw to the right or up, it closes the valve so that
pressure that remains high over time can damage the when you pump air into the bladder with the bulb, the valve
arteries and place strain on the heart. keeps the air inside the bladder, making the cuff tight.

It is important for you to know what blood pressure is

considered normal for each of the people in your care. Manometer
Men frequently have higher blood pressures than women,
and some ethnic groups tend to have higher blood
pressures than others. In addition, blood pressure tends
to increase with age. When you are measuring a person’s
blood pressure, be aware that it is normal for the blood Fabric-covered
pressure to vary throughout the day, within a relatively bladder/cuff
narrow range. For example, blood pressure is usually
higher late in the day, as compared with the morning. It is
higher when a person is sitting or standing, as compared
with when the person is lying down. Emotional stress can
also cause blood pressure to increase.

Observations Into Action!

The following may be signs of a medical problem
and should be reported to the nurse right away: Value
{ A blood pressure that is significantly higher
Bulb
than the person’s normal blood pressure
{ A blood pressure that is significantly lower
than the person’s normal blood pressure Figure 9-8 A sphygmomanometer is used to measure blood pressure.

112 | | Nurse Assistant Training

When you take a person’s blood pressure, you use the Ensuring safety and accuracy when
stethoscope to listen for changes in blood flow through measuring blood pressure
the brachial artery of the arm. Inflating and then deflating
Guidelines for ensuring safety and accuracy
the cuff that is wrapped around the person’s arm allows
when measuring a person’s blood pressure are given
you to cause these changes in blood flow, which are
in Box 9-2.
used to identify the systolic and diastolic pressures. As
you pump air into the cuff, the cuff pressure increases
until it is high enough to stop the blood flow through the
brachial artery. At this point, you do not hear anything Throughout the rest of your shift, you measure
through the stethoscope. As you turn the valve to deflate and record Mrs. Parker’s vital signs every 4 hours.
the cuff and release the pressure on the brachial artery, After you leave for the day, the nurse assistant caring
the cuff pressure eventually matches the systolic blood for Mrs. Parker continues to measure and record her
pressure. At that point, you will begin to hear pulse vital signs every 4 hours. The next morning, the doctor
sounds through the stethoscope. The reading on the calls and asks the nurse for an update on Mrs. Parker’s
manometer at the time that you hear the first pulse condition. The nurse looks at Mrs. Parker’s chart and
sound is the systolic pressure. As the cuff pressure reports that Mrs. Parker’s temperature has decreased
drops to equal the diastolic pressure in the artery, the overnight.
sounds that you hear change. The last sound that you Why is it significant that Mrs. Parker’s
hear before the pulse sounds fade away is the diastolic temperature has decreased overnight?
pressure. Skill 9-5 describes how to measure a person’s
blood pressure using a sphygmomanometer and How did regularly obtaining and recording
a stethoscope. Mrs. Parker’s vital sign measurements help
to promote efficient communication among
An electronic sphygmomanometer measures and members of the health care team? How does
displays the person’s blood pressure automatically after efficient communication benefit Mrs. Parker?
you place the cuff on the person’s arm. Some electronic
models are completely automatic, while others require
you to inflate the cuff. It is not necessary to use a
stethoscope with an electronic sphygomomanometer.

Box 9-2 Nurse Assistant DO’s and DON’Ts

Measuring Blood Pressure
DO position the person comfortably in shoulder. Using a cuff that is too big paralyzed or weak arm, or an arm with
the bed or chair with the arm supported or too small can result in an inaccurate a dialysis shunt. These conditions can
at heart level. If the person is seated in reading. affect circulation in the arm, which can
a chair, make sure his feet are flat on cause an inaccurate reading. In addition,
DON’T place the cuff over the person’s
the floor. you could injure the person when you
clothing. This can result in an inaccurate
decrease circulation by inflating
DO allow the person to sit quietly for at reading and make it difficult to hear the
the cuff.
least 5 minutes before measuring the pulse sounds.
blood pressure. DO give the vessels in the arm time
DO wrap the cuff smoothly and snugly.
to relax between blood pressure
DO select the correct cuff size. Different This helps to ensure an accurate
measurements. If you make a mistake
cuff sizes include “average adult,” “small reading.
or cannot hear the pulse sounds clearly
adult,” “large adult,” “adult thigh” (used
DO position the cuff correctly, with the and need to try again, deflate the cuff
when blood pressures cannot be taken
arrow over the brachial artery. This is completely and wait 1 minute before
in the arms), and “bariatric” (for obese
necessary to ensure an accurate reading. attempting to measure the blood pressure
adults). Cuffs also come in a range of
again. Trying to take the pressure
sizes for children. You can determine the DON’T place the cuff on an arm with a too soon can result in inaccurate
correct cuff size by using a tape measure cast or an intravenous (IV) line, on an arm measurements, in addition to causing the
to measure around the person’s upper that is on the same side as a mastectomy person discomfort.
arm, halfway between the elbow and (surgical removal of the breast), on a

Chapter 9 | Measuring Vital Signs, Weight and Height | 113

WEIGHT AND HEIGHT
Although they are not vital signs, weight and height
measurements also provide important information
about a person’s health status. A person’s height is
usually only measured on admission to the health
care facility, but weights are obtained periodically.
As with a person’s vital signs, the frequency with
which a person’s weight is measured varies from
person to person. Also as with vital signs, accuracy
is extremely important. For people with certain
medical conditions, such as heart failure, changes in
weight are used to help monitor the person’s
condition, and even small changes can be significant.
Also, medication dosages are sometimes based
on weight.

Equipment Used to Measure

Weight and Height
Depending on the situation, a person’s height and weight
can be measured in different ways:
■ When a person can stand independently long
enough to be weighed, an upright scale A
(Figure 9-9, A) is used. The upright scale is also
used to measure the person’s height. Skill 9-6
describes step by step how to measure a person’s
weight and height using an upright scale.
■ When a person is able to get out of bed but is not
able to stand long enough to be weighed using
an upright scale, a chair scale (see Figure 9-9, B)
may be used to weigh the person. Some chair
scales have a seat mounted on the scale and you
simply help the person to sit in the seat. Other
chair scales are designed to be used with a
wheelchair. When using this type of chair scale,
you first weigh the empty wheelchair, and then you
B
weigh the wheelchair with the person in it. The
person’s weight is the difference between the two Figure 9-9 Depending on the situation, different types of scales may be
used to weigh a person. (A) An upright scale. (B) A chair scale.
measurements.
■ If the person is unable to get out of bed at all, a sling
scale is used to weigh the person. The person’s weight varies throughout the day, a consistent
height can be measured while the person lies in bed, process and technique can help to ensure that the
using a tape measure. weights you obtain are accurate, and make weight
comparisons more reliable. For example, always
use the same scale in the same place. Weigh the
Ensuring Accuracy When person at approximately the same time of day each
time, and have the person wear the same type and
Measuring Weight amount of clothing. Consistently give the person
Weight measurements can be used to evaluate a an opportunity to use the bathroom before obtaining
person’s medical condition or nutritional status over the weight measurement. Finally, make sure the
time. For example, you may be asked to obtain a scale is balanced (it should read “0” without any
person’s weight every day, or every week. Since weight on it.)

114 | | Nurse Assistant Training

 7. What equipment is needed to evaluate a
CHECK YOUR UNDERSTANDING radial pulse?
a. Sphygmomanometer
Questions for Review b. Stethoscope
c. Watch with a second hand
1. Temperature, pulse, respirations and blood d. All of the above
pressure usually are taken together and are
referred to as: 8. Mrs. Wilson’s pulse is very weak. How would you
describe her pulse?
a. Life measurements.
b. Vital signs. a. Shallow
c. Routine measurements. b. Thready
d. Monitoring. c. Bounding
d. Irregular
2. Mrs. Tyler has just been admitted to the nursing
home. What measurements will you obtain? 9. Which of the following factors can affect a
person’s vital sign measurements?
a. Blood pressure, temperature, respiratory rate,
pulse rate a. Illness
b. Height b. Emotions
c. Weight c. The time of day
d. All of the above d. All of the above

3. What instrument is used to listen to sounds 10. The nurse has asked you to measure Mr. Simon’s
when obtaining a blood pressure or an apical temperature rectally. What equipment will
pulse measurement? you use?
a. Stethoscope a. A tympanic thermometer
b. Diaphragm b. An axillary thermometer
c. Sphygmomanometer c. An electronic thermometer with a blue probe
d. Thermometer d. An electronic thermometer with a red probe

4. Mr. Rollins is receiving oxygen therapy. You could

use any of the following methods to take his Questions to Ask Yourself
temperature EXCEPT the: 1. You are getting ready to assist Mrs. Perkins to
a. Oral method the bathroom when she tells you that she feels
b. Axillary method very dizzy. You decide to take her vital sign
c. Rectal method measurements, which are as follows: temperature,
d. Tympanic method 97° F (oral); pulse, 80 beats/min; respirations,
15 breaths/min; and blood pressure, 90/52 mm Hg.
5. Which of the following measurements is outside Which of these measurements is significant
of the normal range for an adult? and why?
a. Temperature, 99° F 2. When you go into Mrs. Clement’s room to take her
b. Respirations, 13 breaths/min oral temperature, you notice a cup of coffee on her
c. Pulse, 63 beats/min over-bed table. What should you consider, and what
d. Blood pressure, 107/70 mm Hg should you do?
3. When you take Mr. Wilson’s pulse at 8:00 a.m.,
6. Where is the brachial pulse located? the rate is 72 beats/min and the rhythm is regular.
a. The inside of the elbow When you take it again at 9:00 a.m., the rate is
b. At the top of the heart, just under the left nipple 56 beats/min and irregular. What should you do?
c. On the inside of the wrist at the base of 4. Mrs. O’Neill wants to talk with you while you are
the thumb trying to measure and record vital signs. How
d. On the inside of the groin where the thigh meets should you handle this situation? What should you
the hip say to her?

Chapter 9 | Measuring Vital Signs, Weight and Height | 115

SKILLS

Skill 9-1
Using an Electronic Thermometer to Measure a
Person’s Temperature

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Oral or axillary temperature:
{ Electronic thermometer with blue probe
{ Probe cover
{ Tissues
{ Pen and paper
■ Rectal temperature:
{ Electronic thermometer with red probe
Figure 1
{ Probe cover
■ head of the bed elevated) or the supine position
{ Lubricating jelly
(lying on the back).
{ Gloves ■ Rectal temperature: Help the person lie on
{ Tissues one side with his back toward you and the top
{ Pen and paper knee flexed.
■ Tympanic temperature: ■ Tympanic temperature: Position the person in
Fowler’s position.
{ Tympanic thermometer
9. If taking a rectal temperature, lubricate the tip of the
{ Probe cover probe by placing a small amount of lubricating jelly
Pen and paper
{ on a tissue and dipping the tip of the probe in it. Put
3. Knock, greet the person and ensure privacy. on the gloves.

4. Explain the procedure. 10. Place the thermometer.

■ Oral temperature: Put the probe under the
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. person’s tongue and slightly to one side
Make sure the wheels are locked. (Figure 2A). Ask the person to close his lips
around the thermometer.
PROCEDURE
6. Turn the thermometer on by removing the probe
from the location in the machine where it is stored
(electronic thermometer) or by pushing the button
(tympanic thermometer).
7. Place the probe cover on the probe. For an electronic
thermometer, insert the probe into the probe cover by
pushing firmly until you feel the cover snap into place
(Figure 1). For a tympanic thermometer, place the
probe cover over the cone-shaped probe.
8. Position the person appropriately.
■ Oral or axillary temperature: Position the
person in Fowler’s position (sitting up with the
Figure 2A

116 | | Nurse Assistant Training

 SKILLS

■ Rectal temperature: Adjust the top covers

and the person’s clothing as necessary to expose
the buttocks. Lift the person’s upper buttock and
insert the probe into the anus no more than 1 inch
in an adult or 1/2 inch in a child (Figure 2B). Stay
with the person and hold the probe in place.

Figure 2D

11. When the thermometer beeps, remove the probe and

read the temperature measurement on the screen.
12. Eject the probe cover into a facility-approved waste
Figure 2B
container and return the probe to its home. (Be
aware that returning the probe to its home clears
■ Axillary temperature: Expose the person’s the display screen, so be sure to make note of the
underarm and pat the skin dry with a tissue, if temperature measurement first.)
necessary. Put the probe in the middle of the 13. Help make the person comfortable.
person’s underarm and then bring the person’s
■ Rectal temperature: Wipe the lubricating jelly
arm across his chest to hold the probe in place
from the person’s buttocks with a tissue and discard
(Figure 2C).
the tissue in a facility-approved waste container.
Adjust the person’s clothing to cover the buttocks.
■Axillary temperature: Adjust the person’s
clothing to cover the underarm area.
14. Remove and dispose of your gloves. Wash your hands.
15. Write down the person’s name, the time, the
temperature measurement, and the method used to
obtain the temperature (O for oral, R for rectal, A for
axillary or TY for tympanic).
16. Continue obtaining other vital sign measurements, or
follow the completion steps.

COMPLETION
Figure 2C 17. Ensure the person’s comfort and good body alignment.
18. Adjust equipment for safety: Lower the bed to the
■ Tympanic temperature: Grasp the top of the level specified in the person’s care plan. Make sure
person’s ear and pull up and back (in an adult) or the wheels on the bed are locked. Place the person’s
down and back (in a child younger than 3 years) method of calling for help within reach. Lower or raise
to straighten the ear canal. Insert the probe into the side rails according to the person’s care plan.
the ear canal, pointing it down and forward, 19. Clean up your work area.
toward the person’s nose (Figure 2D). 20. Wash your hands.
21. Report and record.

Chapter 9 | Measuring Vital Signs, Weight and Height | 117

SKILLS

Skill 9-2
Evaluating a Person’s Radial Pulse

PREPARATION 8. Look at your watch. When the second hand reaches

the “12,” begin counting the pulse. Continue
1. Wash your hands. counting for 1 full minute.
2. Gather your supplies: 9. Note the rhythm and force of the pulse.
■ Watch with a second hand 10. Write down the person’s name, the time, and the
■
pulse rate, rhythm and force.
Pen and paper
3. Knock, greet the person and ensure privacy. 11. Continue obtaining other vital sign measurements,
or follow the completion steps.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety: COMPLETION
Raise the bed to a comfortable working height.
12. Ensure the person’s comfort and good
Make sure the wheels on the bed are locked.
body alignment.
13. Adjust equipment for safety: Lower the bed to
PROCEDURE the level specified in the person’s care plan. Make
sure the wheels on the bed are locked. Place the
6. Position the person appropriately:
person’s method of calling for help within reach.
■ In bed: Position the person in Fowler’s position Lower or raise the side rails according to the
(sitting up with the head of the bed elevated) or person’s care plan.
the supine position (lying on the back). Position 14. Clean up your work area.
the person’s arm so that it is resting comfortably 15. Wash your hands.
on the bed or the person’s lap.
16. Report and record.
■In a chair: Have the person sit with both feet
flat on the floor. Position the arm so that it is
resting comfortably on the arm of the chair or the
person’s lap.
7. Gently press your first, second and third fingers
over the person’s radial artery (located on the inside
of the wrist on the same side as the thumb)
(Figure 1).

Figure 1

118 | | Nurse Assistant Training

 SKILLS

Skill 9-3
Evaluating a Person’s Apical Pulse

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Watch with a second hand
■ Stethoscope
■ Alcohol wipes
■Pen and paper
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. Figure 1
Make sure the wheels on the bed are locked.

PROCEDURE 11. Look at your watch. When the second hand reaches
6. Position the person appropriately: the "12," begin counting the pulse. Continue
counting for 1 full minute.
■ In bed: Position the person in Fowler’s position
12. Note the rhythm and force of the pulse.
(sitting up with the head of the bed elevated) or
the supine position (lying on the back). Position 13. Write down the person’s name, the time, and the
the person’s arm so that it is resting comfortably pulse rate, rhythm and force.
on the bed or the person’s lap. 14. Continue obtaining other vital sign measurements,
■ In a chair: Have the person sit with both feet or follow the completion steps.
flat on the floor. Position the arm so that it is
resting comfortably on the arm of the chair or the
COMPLETION
person’s lap. 15. Ensure the person’s comfort and good
7. Clean the earpieces and diaphragm of the body alignment.
stethoscope with an alcohol wipe. Discard the wipe 16. Adjust equipment for safety: Lower the bed to
in a facility-approved waste container. the level specified in the person’s care plan. Make
8. Adjust the top covers and the person’s clothing as sure the wheels on the bed are locked. Place the
necessary to expose the apical pulse site (located person’s method of calling for help within reach.
about 2 to 3 inches to the left of the breastbone, Lower or raise the side rails according to the
below the left nipple). person’s care plan.
9. Put the earpieces of the stethoscope in your ears 17. Clean up your work area.
with the tips facing forward (toward your nose). 18. Wash your hands.
10. Warm the diaphragm of the stethoscope by holding 19. Report and record.
it in your hand. Place the diaphragm over the apical
pulse site (Figure 1). Hold the diaphragm in place
with your fingers, not your thumb.

Chapter 9 | Measuring Vital Signs, Weight and Height | 119

SKILLS

Skill 9-4
Evaluating a Person’s Respirations

PREPARATION 8. Note the rhythm and depth of the respirations, and

whether the person seems to be having any
1. Wash your hands. difficulty breathing.
2. Gather your supplies: 9. Write down the person’s name, the time, and the
■
respiratory rate, rhythm and depth.
Watch with a second hand
■
10. Continue obtaining other vital sign measurements,
Pen and paper
or follow the completion steps.
3. Knock, greet the person and ensure privacy.
4. Explain the procedure. COMPLETION
5. Adjust equipment for body mechanics and 11. Ensure the person’s comfort and good
safety: Raise the bed to a comfortable working body alignment.
height. Make sure the wheels on the bed
12. Adjust equipment for safety: Lower the bed to
are locked.
the level specified in the person’s care plan. Make
sure the wheels on the bed are locked. Place the
PROCEDURE person’s method of calling for help within reach.
6. Hold the person’s wrist as if taking a radial pulse. Lower or raise the side rails according to the
person’s care plan.
7. Look at your watch. When the second hand reaches
the “12” and you see the person’s chest rise, begin 13. Clean up your work area.
counting the respirations. Remember that one 14. Wash your hands.
respiration equals one rise and one fall of the chest.
Continue counting for 1 full minute. 15. Report and record.

120 | | Nurse Assistant Training

 SKILLS

Skill 9-5
Measuring a Person’s Blood Pressure

PREPARATION 10. Place the cuff on the person’s arm, over bare skin,
with the arrow directly over the brachial artery. The
1. Wash your hands. bottom edge of the cuff should be about 1 inch
2. Gather your supplies: above the person’s elbow. Wrap the cuff around
the person’s arm snugly and smoothly and secure
■ Sphygmomanometer with the correct-size cuff the cuff. Make sure it is snug enough to stay in
■
place, but not uncomfortably tight (Figure 2).
Stethoscope
■ Alcohol wipes
■Pen and paper
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Position the person appropriately:
■ In bed: Position the person in the supine position
Figure 2
(lying on the back). Position the person’s arm so
that it is resting comfortably, palm up, on the bed. 11. Place your fingers on the person’s radial pulse, on
■ In a chair: Have the person sit with both feet the wrist.
flat on the floor. Position the arm so that it is fully 12. Turn the screw to the right so that the cuff inflates
supported and level with the person’s heart. when you pump the bulb. Inflate the cuff by pumping
the bulb until you can no longer feel the radial pulse.
7. Clean the earpieces and diaphragm of the Look at the gauge and note the reading, which is an
stethoscope with an alcohol wipe. Discard the wipe estimate of the systolic pressure. Let the air out of
in a facility-approved waste container. the cuff quickly by turning the valve to the left.
8. Turn the screw to the left (down) and squeeze all of 13. Put the earpieces in your ears with the tips facing
the air out of the cuff. Adjust the person’s clothing as forward (toward your nose). Place the diaphragm
necessary to expose the upper arm. of the stethoscope firmly over the person’s brachial
9. Locate the person’s brachial pulse, on the inside of pulse (Figure 3).
the elbow (Figure 1).

Figure 3
Figure 1
Continued on next page
Chapter 9 | Measuring Vital Signs, Weight and Height | 121
SKILLS

Skill 9-5
Measuring a Person’s Blood Pressure Continued
14. Turn the screw to the right (up) and pump the bulb COMPLETION
to inflate the cuff to 30 mm Hg above the estimated
systolic blood pressure. 19. Ensure the person’s comfort and good body
alignment.
15. Turn the screw to the left (down) and let the air
out of the cuff slowly (about 2 to 4 mm Hg per 20. Adjust equipment for safety: Lower the bed to
second). The reading when you first hear the the level specified in the person’s care plan. Make
pulse sound is the systolic pressure. Remember sure the wheels on the bed are locked. Place the
this number and continue letting the air out slowly. person’s method of calling for help within reach.
Lower or raise the side rails according to the
16. The reading when the pulse sound stops or changes person’s care plan.
is the diastolic pressure. Remember this number and
quickly let out the rest of the air. 21. Clean up your work area.
17. Write down the person’s name, the time and the 22. Wash your hands.
blood pressure measurement. 23. Report and record.
18. Remove the cuff from the person’s arm.

122 | | Nurse Assistant Training

 SKILLS

Skill 9-6
Measuring a Person’s Weight and Height Using an Upright Scale

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Upright scale
■ Paper towels
■Pen and paper
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety.

PROCEDURE
6. Check the balance of the scale by moving the
weights all the way to the left (zero). The pointer
should be centered evenly between the top and
bottom bars (Figure 1). If the scale is not balanced,
notify the nurse.

Figure 2

9. The bottom bar is marked in units of 50 pounds.

Move the large weight on the bottom bar to the
weight that is closest to the person’s estimated
weight in units of 50 pounds, without exceeding the
person’s estimated weight. For example, if you think
the person weighs about 190 pounds, you would
move the bottom weight to the “150” mark.
Figure 1 10. The top bar is marked in units of 1 pound and
¼ pound. Move the small weight on the top bar until
7. Put a paper towel on the scale platform. the pointer is centered evenly between the top and
bottom bars.
8. Assist the person to step onto the scale platform,
facing the balance bar (Figure 2). 11. Add the weight on the top bar to the weight on
the bottom bar. This is the person’s weight.
12. Write down the person’s name, the time and the
weight.
13. If you are measuring the person’s height as well,
assist the person to turn around so that she is facing
away from the balance bar.
14. Slide the height scale all the way up and pull out
the height rod.
Continued on next page

Chapter 9 | Measuring Vital Signs, Weight and Height | 123

SKILLS

Skill 9-6
Measuring a Person’s Weight and Height Using an Upright Scale
Continued

15. Slide the height rod down until it touches the top 16. Write down the person’s height next to her weight.
of the person’s head, and read the number on the
17. Assist the person to step off the scale.
height scale (Figure 3). This is the person’s height.
COMPLETION
18. Ensure the person’s comfort and good
body alignment.
19. Adjust equipment for safety: Lower the bed to
the level specified in the person’s care plan. Make
sure the wheels on the bed are locked. Place the
person’s method of calling for help within reach.
Lower or raise the side rails according to the
person’s care plan.
20. Clean up your work area.
21. Wash your hands.
22. Report and record.

Figure 3

124 | | Nurse Assistant Training

 C H A PT E R
Maintaining a Comfortable
Environment 10
After reading this chapter, you will have the information needed to:
■ Understand the importance of personal items to the person receiving health care.
■ Describe environmental conditions that affect a person’s comfort, and understand the
nurse assistant’s role in maintaining an environment that is special, comfortable and
safe for the person.
Goals ■ Describe equipment that is commonly used to furnish a person’s room in a health care
setting.
■ Explain how a properly made bed can contribute to a person’s comfort and health.

Continued on next page

Chapter 10 | Maintaining a Comfortable Environment | 125

 Continued from previous page

■ Describe the linens and other supplies that may be used to make a bed.

Goals ■ Explain measures that are taken when making a bed to prevent the spread of infection.
After practicing the corresponding skills, you will have the information needed to:
■ Make an unoccupied and an occupied bed.

Key Terms:
miter closed bed open bed surgical bed

Agnes Ryan shares a room with Louise Wang One day as you are helping Mrs. Ryan get ready
at Morningside Nursing Home. Mrs. Ryan’s part of the for physical therapy, you ask her when she started
room has become home to her. A glass display case collecting cat figurines. Mrs. Ryan points to a black cat
filled with cat figurines hangs on the wall near her in the center of the top shelf and says, “Do you see that
bed. A quilt, which Mrs. Ryan made many years ago, little black cat? It all started with him. My husband,
is folded neatly at the foot of her bed. Mrs. Ryan likes Gerard, gave him to me on Halloween, right after we
to change the quilt according to the season, so every started dating. He said that contrary to popular belief,
few months she exchanges the quilt on her bed for he felt the black cat would bring us luck. I guess he was
another one in her collection. A little stack of books, a right, since we got married the next year and spent
pad of paper and pen, an arrangement of silk flowers 67 happy years together! After that, Gerard added
and a collection of family photos decorate the top of to my collection over the years. That little calico cat
Mrs. Ryan’s bedside table. She likes to keep these playing with the ball of string next to Blackie? Well,
things arranged in a particular way so that she knows Gerard brought that one back for me from Europe
just where they are. when he came home from the war. Oh, there’s a story
behind each one of them! My collection used to be
much larger, you know. When I came to live here,
I had to choose my favorites, because there just wasn’t
THE PERSON’S SPACE room to bring them all. I gave the rest away to family
members and friends who I thought would enjoy
them. It was hard to part with them because each one
Emotional Factors That Affect reminded me of Gerard, and I felt like I was giving
Comfort away a little piece of our life together each time.”

Think about the word home. What do you picture in Think about your own home. How do the items
your mind when you think of home? Do you think of a you keep and display there reflect who you
favorite, comfortable chair where you sit down after are? Has a visitor to your home ever shown an
a long, hard day? Do you picture a display of family interest in something that was special to you?
photographs on the wall, or a special gift that someone How did that make you feel?
gave to you?
Mrs. Ryan said that she had to make hard
Home is your personal space. It is where you live, decisions about what to bring to her new
and where you feel safe and comfortable. For people home. Have you ever had to make a decision
who are receiving health care, the health care setting like that? Was it difficult for you?
becomes their home, either temporarily or permanently.
In a hospital, the person’s “home space” is usually As a nurse assistant, how might taking an
just part of a room. For a nursing home resident, the interest in a person’s personal belongings
person’s home space would include her room and help to strengthen your relationship with
common areas, such as the dayroom and dining room. that person, and provide better care?
Sometimes the person’s own home is modified to
become a health care setting, as in home health care.
Whether home is a person’s own home, a nursing home Just as your home and belongings are important to you,
or a hospital, you help maintain that place so that it is the homes and belongings of the people in your care are
special and personal. important to them (Figure 10-1). A person in your care

126 | | Nurse Assistant Training

 Figure 10-1 Treat the person’s personal items with the same care you Figure 10-2 A clean, neat environment is essential for controlling
would treat your own valued possessions. infection and odors.

is sensitive about who touches her belongings or comes the person’s personal space is kept neat and clean (for
into her personal space. Show that you respect the example, by disposing of disposable items and cleaning
person, her home and her belongings by always: and putting away non-disposable equipment after you
complete a procedure). You also help maintain cleanliness
■ Knocking and asking permission to enter before
by ensuring that the person has fresh linens on the bed.
entering the person’s room.
■ Treating the person’s personal belongings with the Odor control
same care you would treat your own.
Minimizing bad smells, such as those of urine, feces,
■ Taking care to put items back where you found them vomit and body odor, is essential for promoting a
if you must move them (for example, to clean). pleasant environment. Maintaining a clean environment
■ Asking the person where to place an item if you are helps to stop odors from developing. Always empty and
unsure about where it belongs. clean bedpans, urinals and emesis basins promptly. Also,
■ Asking the person about her preferences regarding keep the lids on linen hampers and trash cans closed.
how her space should be kept. Odors can also develop when a person’s body, clothing
or linens are not clean. These sorts of odors can be
Physical Factors That Affect prevented by routinely assisting the people in your care
with personal care, and replacing the linens on the bed
Comfort whenever they become wet or soiled, and according to
Displaying personal items that hold special meaning your employer’s policy.
helps us to feel more comfortable and at home in
our surroundings. However, physical factors, such as Temperature control
room temperature, lighting and cleanliness, also affect We cannot be comfortable if we are too hot or too cold.
how comfortable we are in a place. To help ensure a Loss of body fat is a normal part of aging. As a result, older
comfortable environment for people receiving care, people tend to become chilled more easily than younger
health care facilities establish policies to maintain certain people. People who are ill may also feel chilled. Many
environmental standards. health care facilities have individual room-temperature
controls. You may find the temperature in the room to
Cleanliness be warm because you are busy and moving around, but
As you learned in Chapter 6, cleanliness is essential for remember, the temperature is set for the comfort of the
preventing the spread of infection. Maintaining a clean person receiving care. You may still need to provide the
environment also helps to prevent odors. All members of person with an extra blanket for the bed, a lap blanket or a
the health care team share the responsibility for ensuring a sweater to help ensure that he is warm enough.
clean environment (Figure 10-2). The housekeeping staff
takes care of routine deep cleaning, such as mopping Noise control
the floors and emptying waste containers. However, as a Health care facilities can be quite noisy. Equipment
nurse assistant, you are responsible for making sure that beeps. Telephones ring. Staff members, visitors and

Chapter 10 | Maintaining a Comfortable Environment | 127

people receiving care talk to one another. Televisions the mattress at the hips so that the person can sit up in
are turned on. In any busy place, a certain amount of bed. You can also raise the mattress under the person’s
noise is unavoidable. However, an environment that is knees, to help prevent the person from sliding down
too noisy can increase stress levels and make it difficult in the bed while he is sitting up (Figure 10-3, A). The
for people to rest and sleep. Because of the impact mattress should only be raised under the person’s knees
noise can have on the health and well-being of those for a short period of time (for example, while the person
receiving care, the noise levels in a facility are often eats) because being in this position for an extended
considered when evaluating the quality of care provided period of time can lead to complications such as
by the facility. pressure ulcers. The mattress platform on an adjustable
bed also allows the entire mattress to be tilted up or
You can help to minimize noise by speaking in a
down without bending the person at the waist, so that
normal tone of voice and being mindful of where
the person’s head is lower than her feet, or vice versa
conversations take place. For example, try to avoid
(see Figure 10-3, B and C). The person’s primary care
having conversations with other staff members right
provider (a doctor or advanced practice nurse) may
outside of a person’s room. Answer telephones promptly.
order these special positions, called Trendelenburg’s
If you notice that a piece of equipment is squeaky or
noisy, make arrangements to have the equipment sent
for repair or maintenance.

COMMON FURNISHINGS IN
HEALTH CARE SETTINGS
A person’s room in a health care setting often contains
standard furnishings designed to make it easier to
provide care. In a home health setting, the person
may rent some of these furnishings, or you may need
to make do with furnishings and other items that are
already in the home.

Bed
In home health and long-term-care settings, the person
may use his own bed, rather than an adjustable bed or a
specialty bed.

Adjustable beds
Adjustable beds, or hospital beds, are often used in
health care settings because they can be adjusted in
different ways to make it easier and safer to provide
care, and to promote the comfort of the person in the
bed. On an adjustable bed, the entire bed frame can be
raised or lowered in relation to the floor. When you are
providing care for a person in the bed, you will usually
raise the bed to a comfortable working height so that
you do not have to bend or stoop. This helps to protect
your back. When you are finished providing care, you
will lower the bed to the level specified in the person’s
care plan. When the person sits on the edge of the bed,
he should be able to put his feet flat on the floor. This
makes it easier and safer for the person to get in and out
of the bed. Figure 10-3 The mattress of an adjustable bed can be positioned
many different ways. (A) Breaks at the hips and knees raise the head
Adjustable beds also have mattress platforms with of the mattress and the person’s knees to prevent the person from
sliding down in the bed while sitting up. (B) In Trendelenburg’s position,
“joints” that allow the mattress to be positioned in the entire mattress is tilted so that the head is lower than the feet.
different ways. For example, you can raise the head of (C) Reverse Trendelenburg’s position.

128 | | Nurse Assistant Training

position and reverse Trendelenburg’s position, supplies for a procedure, be sure to remove all of your
respectively, for people with certain medical conditions. supplies and clean the over-bed table when you are
finished with the procedure.
Many adjustable beds in use today are adjusted using
an electric control panel. Because the control panel
normally is located within the person’s reach, the person Storage
usually can operate the bed without your assistance.
Equipment and supplies used for personal care, such
Some adjustable beds are manual, meaning that a series
as washbasins and toiletries, are often stored in the
of cranks is used to change the position of the bed or
bedside table. The person’s room will typically contain
mattress. If you are using a bed with hand cranks, make
a closet, wardrobe or dresser where he can store
sure to return the cranks to their correct position after
clothing and other personal items. Remember to ask the
using them. If left out, a person could trip over them or
person’s permission before accessing his storage area
accidentally walk into them, causing injury.
or removing anything from it.
Specialty beds
Specialty beds may be used, depending on the person’s Privacy Curtains
specific needs. If you are caring for a person in a Rooms that are shared will have a privacy curtain
specialty bed, make sure the nurse shows you how to suspended from a track on the ceiling that can be
operate and care for the bed, if these tasks are within pulled to separate one half of the room from the other.
your scope of practice. Examples of specialty beds You should pull the privacy curtain whenever you are
include: assisting a person with care.
■ Air-fluidized bed. This bed has a mattress filled
with ceramic beads. A current of air keeps the beads Communication Devices
in constant wave-like motion, which helps to relieve
pressure on any one area of the body. Air-fluidized Every person in your care must have a way to call
beds may be used for people at high risk for pressure for help. Most health care facilities have a call signal
ulcers. (Pressure ulcers are discussed in more detail system. A call signal is attached to the bed, within the
in Chapter 12.) person’s reach. Pushing the button causes a bell to ring
and a light to come on over the person’s door and at
■ Alternating-pressure bed. The mattress of this
the nurse’s station, alerting the staff. A similar device is
bed has channels that are connected to a pump that
located in the bathroom.
alternately fills and empties the channels with air.
This type of bed is useful for preventing pressure Make sure that the person understands how to use the
ulcers and for stimulating circulation. call signal system and can operate it. Many of the people
When caring for a person in a specialty bed, be aware you will care for will have some degree of memory loss
that the edges of the mattresses used on these beds and will not be able to remember how to use the call
are usually soft and rounded. A person positioned on signal. Reminding the person over and over simply
the edge of the mattress can easily slide off. When the makes the person anxious, because short-term memory
person is in bed, always make sure she is lying in the is what the person is lacking. Setting up an alternative
middle of the mattress (not close to the side). When the way for the person to let you know she needs you is very
person is getting out of the bed, avoid having her sit on important. This could be as simple as having the person
the very edge of the mattress (make sure the person has verbally call out to you, or giving the person a small hand
complete support under her thighs). bell or hotel bell to ring. These alternative methods of
calling for help also work well in settings that may not
have a call signal system, such as the home setting.
Over-Bed Table
The over-bed table fits over a bed or a chair to provide
a work surface. Wheels allow it to be moved easily
from one place to another, and the height is adjustable.
BEDMAKING
The over-bed table is useful for serving meals and for A clean, fresh bed is important to almost everyone. It
keeping items such as eyeglasses, the television remote, is especially important to people who spend most of
or a water pitcher and glass within the person’s reach. their time in bed. Nurse assistants are responsible for
You may also use the over-bed table as a place to set up ensuring that the people in their care have clean, dry
your supplies before carrying out a procedure. Because linens at all times. The frequency with which you change
the over-bed table is considered a clean area, never bed linens depends on how much time the person
put dirty items, such as soiled linens or a urinal, on it. spends in bed, and it also depends on your employer’s
If you use the over-bed table as a place to set up your policies. In most facilities, linens are routinely changed

Chapter 10 | Maintaining a Comfortable Environment | 129

in the morning, after bathing, grooming and dressing Fitted mattress pads have elastic edges that fit
are completed. But the time of day for changing linens over the mattress to hold the mattress pad in
also varies according to the needs of the person in your place.
care. One universal rule to follow: Change all linens ■ Sheets. A bottom sheet and a top sheet are used
immediately if they are wet or soiled, because wet, soiled to make the bed. Often, in health care facilities,
linens can cause skin irritation that can lead to pressure both sheets are flat, although the bottom sheet
ulcers. may be fitted. When a flat sheet is used as a
bottom sheet, you must miter the corners to hold
Supplies Used in Bedmaking the sheet in place (Figure 10-4).
■ Blanket. A blanket is a heavier layer that is added to
Linens provide additional warmth.
The following types of linens are used to make a bed: ■ Pillowcase. A pillowcase is used to cover the
■ Mattress pad. The mattress pad is a thick, pillow and protect it from becoming soiled.
absorbent pad that is used to cushion the ■ Bedspread. A bedspread is the finishing layer. It
mattress. Because the mattress pad is absorbent, covers and protects the linens underneath when the
it also protects the mattress from becoming bed is not being used, and provides another layer for
soiled. The mattress pad may be flat or fitted. warmth when the person is in the bed.

Figure 10-4 Mitering is a way of folding linens to secure them to the bed. To miter a corner: (A) Tuck the sheet under the bottom edge of the mattress.
(B) Face the head of the bed with your side next to the bed. With the hand that is next to the bed, lift the edge of the sheet at the side of the bed about
12 inches from the top of the mattress, making a triangle. (C) Lay the triangle on top of the bed, holding the top of the triangle firmly. Tuck the hanging
portion of the sheet under the mattress. (D) Bring the sheet back down over the mattress.

130 | | Nurse Assistant Training

 Figure 10-5 A draw sheet may be placed over the bottom sheet. Draw sheets are used when repositioning a person in bed. The draw sheet should
extend from the person’s shoulders to his thighs.

Other supplies the person to get out of the bed when one of these
pads is in place, because of the tendency of the
Depending on the procedure you are performing and the
pad to slip. When the pad becomes soiled, it must
needs of the person, you may need additional supplies
be cleaned according to facility policy or replaced.
for bedmaking as well.
■ Alternating-pressure pad. These pads, which
■ Bath blanket. A bath blanket is a lightweight are placed over a standard mattress, operate in
flannel sheet that is used to provide privacy and much the same way as an alternating-pressure bed.
warmth when performing personal care procedures An alternating-pressure pad may be used when a
(such as a bed bath or linen change with the person person is at high risk for developing pressure ulcers.
still in the bed). The bath blanket is draped over the If an alternating-pressure pad has been ordered
person to minimize exposure during the procedure. for one of the people in your care, the nurse will
■ Draw (lift) sheet. A draw (lift) sheet is a half-sized show you how to set it up. Just as with a foam pad,
sheet that is placed over the middle of the bottom there is an increased danger of slipping when an
sheet and used to assist with repositioning the alternating-pressure pad is in place.
person in bed. The draw sheet extends from the ■ Foot board. A foot board is a padded board that
person’s shoulders to her thighs (Figure 10-5). In a is placed against the person’s feet when she is in
home setting, you can make a draw sheet by folding bed to keep her feet at right angles to the legs, with
a top sheet in half widthwise. the toes pointed upward (Figure 10-6, A). The foot
■ Bed protector. A bed protector is an absorbent board is used to maintain a position that will prevent
pad that wicks moisture away from the person’s “foot drop,” a condition that occurs when the toes
body. A bed protector may be placed on top of the point downward for an extended period of time and
bottom sheet when a person is incontinent of urine, the muscles become weak, making it impossible for
has a heavily draining wound or is perspiring heavily. the person to bring the foot up into a normal position
■ Foam pads. Solid foam pads or eggcrate foam for walking. Be sure the nurse shows you how to
pads may be placed over the mattress for comfort. properly position the foot board if one has been
These pads can be dangerous, however, because ordered for a person in your care.
they tend to slip. When making the bed of a person ■ Bed cradle. A bed cradle is a frame that keeps
who uses a foam pad, be sure to cover the pad the top bed linens from rubbing against and putting
with a sheet and tuck the edges of the sheet in pressure on the tops of the person’s legs, feet and
tightly to reduce slipping. Use extra caution when toes. The top linens are placed on the bed over the
moving the person around in the bed or assisting bed cradle (see Figure 10-6, B).

Chapter 10 | Maintaining a Comfortable Environment | 131

A B
Figure 10-6 Special equipment may be used to lower the person’s risk of developing pressure ulcers. (A) A foot board. Image courtesy of Posey
Company; Arcadia, California. (B) A bed cradle.

How to Make a Bed taken into a person’s room, they cannot be used for
another person, and they have to be laundered, even
Although you may already be familiar with making beds in if they were not used.
your own home, making beds in a health care setting is ■ Keep clean linens on a clean surface, such as the
different from the way you perform this task at home. You over-bed table or a chair. Never place clean linens
will make many more beds at work than you do at home, on the floor.
so working efficiently and in a way that reduces strain on
your back is important. You must also take infection control ■ Put soiled linens directly in the linen hamper. Never
measures when making beds in a health care setting. place soiled linens on the floor.
■ Remove and replace linens carefully, without shaking
When making beds in a health care setting, you can save them. Shaking linens causes air currents that may
time and energy by: spread dust and microbes around the room.
■ Gathering and stacking bed linens in the order in which ■ Keep linens (clean and soiled) away from your uniform.
you use them, so that the mattress pad is on the top. ■ Wear gloves when removing soiled linens from the
■ Folding reusable linens, such as blankets and bed. After removing your gloves, wash your hands
spreads, and putting them in a clean place, such as before touching the clean linens.
over the back of a chair, until you are ready to put Another difference between making your own beds at
them back on the bed. home and making beds in a health care setting is that
■ Checking the bed for personal items, such as sometimes the person will not be able to get out of
eyeglasses and dentures, before removing the the bed while you change the linens. In this situation, you
linens from the bed. change the linens with the person still in the bed. This is
■ Making one side of the bed at a time. called making an occupied bed. When you are making
an occupied bed, never leave the person alone. Because
In addition to saving time, working on one side of the
the person will be turned on her side facing away from
bed at a time helps prevent you from reaching across
you as you make the first side of the bed, make sure there
the bed, which is important for good body mechanics.
is something or someone for the person to hold onto on
Raise the bed to a comfortable working height so that
the side of the bed opposite where you are working. This
you do not have to stoop and bend. In a home setting,
will prevent you from rolling the person onto the floor by
the bed may be low, and you may not be able to raise
accident while you are working. If the bed has side rails,
it. In such situations, you may have to squat or kneel,
you can raise the side rail on the opposite side of the
keeping your upper body erect, to make the bed.
bed. If the bed does not have side rails, you will need to
Remember that linens can spread infection. To practice get a co-worker to help you, or you could place sturdy
infection control when making a bed, be sure to follow high-backed chairs along the opposite side of the bed to
these precautions: give the person something to hold on to.
■ Take only the linens you need into the person’s room. Bedmaking is an opportunity for you to spend some time
In a hospital or nursing home, once linens have been in conversation with the person in your care. In addition

132 | | Nurse Assistant Training

 You have been on vacation, and another nurse
assistant was filling in for you while you were away.
Today is your first day back at work, and you are
changing Mrs. Ryan’s bed linens. Mrs. Ryan watches
you carefully take her quilt off the bed and fold it over
the back of the chair, and then she says, “Can you
believe that the young lady who was filling in for you
put my quilt on the floor while she was making my
bed? She didn’t even fold it first!”

Why do you think Mrs. Ryan was upset

about the way the other nurse assistant
handled her quilt?

What other reasons can you think of for

A folding the quilt neatly and placing it over
the back of a chair?

What should you do with the information

Mrs. Ryan has given you about the care she
received in your absence?

Preparing the Bed for the Person

After you make the bed, you need to prepare it for the
person who will be using it. If the person will not be getting
back into the bed right away, you may prepare a closed
bed (Figure 10-7, A). A closed bed is simply a bed that
is made, but not occupied. The bedspread is pulled up to
cover the linens, protecting them from becoming soiled,
B and giving the bed a neat appearance. When you know
a person will be getting into the bed soon (for example,
in the evening before bedtime, or in preparation for a
new admission), you will “open” the bed. An open bed
is one where the bedspread, blanket and top sheet have
been folded back toward the bottom of the bed, making
it easier for the person to get into the bed (see Figure
10-7, B). Folding the linens back on themselves is called
“fanfolding” the linens. A surgical bed is a special type of
open bed that is prepared for a person who will be arriving
on a stretcher. To prepare a surgical bed, the bedspread,
blanket and top sheet are fanfolded to the side of the bed,
instead of to the bottom (see Figure 10-7, C).

C
CHECK YOUR UNDERSTANDING
Figure 10-7 Preparing the bed. (A) A closed bed. (B) An open bed.
(C) A surgical bed.
Questions for Review
to providing a clean, comfortable bed for her, you 1. When making a person’s bed, you should:
can use this time to show her that you think she is an
important and special person. Skill 10-1 describes how a. Make the bed when it is convenient for you, to
to make an unoccupied bed, and Skill 10-2 describes improve your efficiency.
how to make an occupied bed. b. Shake the clean linens to get the wrinkles out.

Chapter 10 | Maintaining a Comfortable Environment | 133

 c. Check for personal items left in the bed before 6. One of the people in your care is incontinent of
removing the soiled linens from the bed. urine. When you are changing her bed linens, in
d. Place the soiled linens on the floor after addition to the standard linens used to make a
removing them from the bed. bed, you might also gather:
a. A bed protector.
2. When making a bed in a health care setting, you
should do all of the following except: b. An extra bedspread.
c. A foot board.
a. Make one side of the bed at a time.
d. A draw sheet.
b. Carry linens for all of the beds you will be
changing that morning with you, so that 7. What measures can you take to minimize noise
you do not have to go back and forth to the in a health care setting?
linen cart.
a. Be sure to speak loudly so that you do not have
c. Wash your hands before handling clean linens. to repeat yourself.
d. Hold linens away from your uniform. b. Ask people to turn off televisions and radios.
3. What can a nurse assistant do to minimize bad c. Use personal cell phones instead of the
odors in a health care setting? telephone at the nurse’s station.
d. Respond to call signals promptly.
a. Open the windows.
b. Assist people in their care with personal care, 8. A draw sheet is used to:
and ensure that they have clean clothes and
a. Cushion the mattress.
linens at all times.
b. Provide privacy during personal care
c. Encourage people in their care to wear perfume
procedures.
or cologne.
c. Protect the linens from soiling.
d. Nothing; bad odors are unavoidable in health
care settings. d. Assist with repositioning a person in bed.

4. When a person is receiving health care, the 9. When making an occupied bed:
health care facility becomes the person’s home. a. Lower the bed to the lowest position.
How do you show respect for the person’s b. Take precautions to prevent the person from
home? rolling out of bed on the side opposite where
a. By arranging the person’s personal items in you are working.
a way that you find pleasing c. Raise the side rails on both sides of the bed.
b. By handling the person’s personal items d. Raise the head of the bed.
carefully
c. By encouraging the person to store personal Questions to Ask Yourself
items so that they do not get broken or stolen 1. Mrs. McDay keeps a large, framed picture of her
d. All of the above daughter on her bedside table. While making her
bed, you need to move the picture to avoid knocking
5. A person is too ill to get out of bed for meals, so
it over. What must you remember to do before
her meals are brought to her room. Which piece
leaving the room?
of equipment will you use during the meal to
make it easier for the person to eat? 2. Mrs. Ross cannot get out of bed, and you have to
a. An over-bed table change her bed linens. What will you do to keep
Mrs. Ross safe while you change the linens?
b. A bed cradle
c. A bedside table 3. You notice that one of the new nurse assistants on
d. A foot board your unit is gathering linens for all of the beds she
is assigned to make at once, and taking the linens
from room to room with her. What should you do?

134 | | Nurse Assistant Training

 SKILLS

Skill 10-1
Making an Unocccupied Bed

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Pillowcase
■ Top sheet
■ Draw sheet (if needed)
■ Bottom sheet
■ Mattress pad
■ Gloves
3. Knock, greet the person and ensure privacy.
Figure 1
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety: 15. Put the clean bottom sheet on the bed. If you are
Raise the bed to a comfortable working height. Make using a fitted sheet, fit the elastic corners over the
sure the wheels on the bed are locked. edges of the mattress. If you are using a flat sheet:
PROCEDURE a. Put the flat sheet on the bed with the center
fold in the center of the bed and the bottom
Task 1: Remove the Dirty Linens edge even with the foot of the mattress.
6. Lower the head of the bed so that the bed is flat. Make sure the sheet is positioned so that
when you unfold it, the rough side of the
7. Put on the gloves.
hem stitching at the top of the sheet will be
8. Check the linens for items the person may have left against the mattress. Unfold the sheet.
in the bed. If items were left in the bed, move them
to a safe place. b. Tuck the top of the sheet underneath the
mattress at the head of the bed.
9. Moving around the bed, loosen all of the bed linens.
c. Miter the top corner. With your palms
10. Remove the pillowcase from the pillow, and place it in facing up, continue tucking in the sheet on
the linen hamper. Place the pillow on a clean surface.
the side, all the way to the foot of the
11. Remove the bedspread. If it is clean and can be mattress (Figure 2).
reused, fold it and place it on a clean surface. Do the
same with the blanket, if it can be reused.
12. Remove the rest of the linens from the bed, rolling
them toward the center of the bed so that any soiled
areas are contained inside (Figure 1). Place the dirty
linens in the linen hamper.
13. Remove and dispose of the gloves. Wash your hands.

Task 2: Place Clean Linens on the

First Side of the Bed
14. Put the clean mattress pad on the bed with the
center fold in the center of the bed. Unfold the
mattress pad. If you are using a fitted mattress pad,
fit the elastic corners over the edges of the mattress.
If you are using a flat mattress pad, make sure the
top edge is even with the head of the mattress. Figure 2

Continued on next page

Chapter 10 | Maintaining a Comfortable Environment | 135

SKILLS

Skill 10-1
Making an Unocccupied Bed Continued
16. If a draw sheet is to be made into the bed, put the Task 4: Change the Pillowcase and
draw sheet across the middle of the mattress with
the center fold in the center of the bed. Unfold the
Open or Close the Bed
draw sheet. With your palms facing up, tuck the draw 28. Hold the pillowcase at the center of the bottom
sheet under the mattress, tucking in the middle third seam.
first, then the top third and then the bottom third. 29. Turn the pillowcase inside out, back over the hand
17. Put the top sheet on the bed with the center fold in that is holding the bottom seam.
the center of the bed and the top edge even with 30. With the hand that is holding the pillowcase,
the head of the mattress. Make sure that the sheet is pick up the pillow at the center of one of the
positioned so that when you unfold it, the rough side short ends and bring the pillowcase down
of the hem stitching at the top of the sheet will face over the pillow using your other hand (Figure 3).
up. Unfold the sheet. Fit the corners of the pillow into the corners of
18. Put the blanket on the bed with the center fold the pillowcase.
in the center of the bed and the top edge about
6 inches below the head of the mattress. Unfold
the blanket.
19. Put the bedspread on the bed with the center fold in
the center of the bed. Unfold the bedspread.
20. Together, tuck the top sheet, blanket and bedspread
under the foot of the mattress. Miter the corner at
the foot of the bed to hold the top sheet, blanket and
bedspread in place.

Task 3: Secure the Linens on the

Second Side of the Bed
21. Move to the opposite side of the bed.
22. Secure the mattress pad. If you are using a fitted Figure 3
mattress pad, fit the elastic corners over the edges
of the mattress. If you are using a flat mattress pad, 31. Place the pillow at the head of the bed, with
unfold it the rest of the way and make sure it is the open end of the pillowcase facing away from
aligned properly. the door.
23. Secure the bottom sheet. If you are using a fitted 32. If the person will be returning to bed shortly, open
sheet, fit the elastic corners over the edges of the the bed by fanfolding the top linens to the foot of the
mattress. If you are using a flat sheet, tuck the top of bed. If the person will not be returning to bed soon,
the sheet underneath the mattress at the head of the close the bed by folding the top of the bedspread
bed, miter the top corner and, with your palms facing back over the pillow.
up, tuck in the sheet on the side, all the way to the
foot of the mattress. COMPLETION
24. Secure the draw sheet (if used), tucking in the
33. Ensure the person’s comfort and good body
middle third first, then the top third and then the
alignment.
bottom third.
34. Adjust equipment for safety: Lower the bed to the
25. Together, tuck the top sheet, blanket and bedspread
level specified in the person’s care plan. Make sure
under the foot of the mattress. Miter the corner at
the wheels on the bed are locked. Place the person’s
the foot of the bed to hold the top sheet, blanket and
method of calling for help within reach.
bedspread in place.
35. Clean up your work area.
26. Fold the top of the bedspread down far enough to
allow room to cover the pillow. 36. Wash your hands.
27. Fold the top sheet down 6 inches over the blanket’s 37. Report and record.
edge on each side of the bed to form a neat cuff.

136 | | Nurse Assistant Training

 SKILLS

Skill 10-2
Making an Occupied Bed

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Pillowcase
■ Top sheet
■ Draw sheet (if used)
■ Bottom sheet
■ Mattress pad
■ Bath blanket
■ Gloves
3. Knock, greet the person and ensure privacy. Figure 1
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
Task 1: Remove and Replace Linens
on the First Side of the Bed
6. Lower the head of the bed so that it is as flat as the
person can tolerate.
7. Put on the gloves.
Figure 2
8. Remove the bedspread. If it is clean and can be
reused, fold it and place it on a clean surface. 11. Adjust the pillow under the person’s head for
Do the same with the blanket, if it can be reused. comfort. Ensure good body alignment and make
9. Loosen the top sheet at the foot of the bed. Cover sure the person is covered with the bath blanket.
the person and the top sheet with the bath blanket (to 12. Check the linens on the side where you are working
provide privacy and warmth). Ask the person to hold for items the person may have left in the bed. If items
the edge of the bath blanket (or tuck the edges under were left in the bed, move them to a safe place.
the person’s shoulders) while you remove the soiled
top sheet and place it in the linen hamper (Figure 1). Continued on next page
10. Help the person roll toward you, onto his side.
Raise the side rail and move to the opposite side of
the bed (Figure 2).

Chapter 10 | Maintaining a Comfortable Environment | 137

SKILLS

Skill 10-2
Making an Occupied Bed Continued
13. Loosen the dirty mattress pad, bottom sheet and 17. If a draw sheet is to be made into the bed, put the
draw sheet. Fanfold the dirty linens toward the person draw sheet across the middle of the mattress with
and tuck them against and slightly under his back the center fold in the center of the bed. Unfold
(Figure 3). If the linens are soiled with body fluids, the draw sheet. With your palms facing up, tuck
tuck a bed protector under the dirty linens and fold it the draw sheet under the mattress, tucking in the
back over them and the person’s back to prevent the middle third first, then the top third and then the
clean linens from becoming contaminated. bottom third.
18. Fanfold the opposite side of the clean linens toward
the person.
19. Flatten the fanfolded linens as much as possible.
Help the person roll toward you, over the fanfolded
linens.
20. Adjust the pillow under the person’s head for
comfort. Ensure good body alignment and make
sure the person is covered with the bath blanket.
21. Raise the side rail and move to the opposite side of
the bed.

Task 2: Remove and Replace Linens

Figure 3 on the Second Side of the Bed
22. Lower the side rail on the side where you are working.
14. Remove and dispose of your gloves. 23. Put on a clean pair of gloves.
15. Put the clean mattress pad on the bed with the 24. Check the linens on the side where you are working
center fold in the center of the bed. Unfold the for items the person may have left in the bed. If items
mattress pad. If you are using a fitted mattress were left in the bed, move them to a safe place.
pad, fit the elastic corners over the edges of the
25. Loosen and remove the soiled linens and place them
mattress. If you are using a flat mattress pad, make
in the linen hamper.
sure the top edge is even with the head of the
mattress. 26. Remove and dispose of your gloves.
16. Put the clean bottom sheet on the bed. If you are 27. Pull the clean, fanfolded mattress pad toward you
using a fitted sheet, fit the elastic corners over the until it is completely unfolded. If you are using a
edges of the mattress. If you are using a flat sheet: fitted mattress pad, fit the elastic corners over the
edges of the mattress. If you are using a flat mattress
a. Put the flat sheet on the bed with the center pad, make sure it is aligned properly.
fold in the center of the bed and the bottom
edge even with the foot of the mattress. 28. Pull the clean, fanfolded bottom sheet toward you
until it is completely unfolded. If you are using a
Make sure the sheet is positioned so that fitted sheet, fit the elastic corners over the edges of
when you unfold it, the rough side of the the mattress. If you are using a flat sheet, tuck the
hem stitching at the top of the sheet will be top of the sheet underneath the mattress at the head
against the mattress. Unfold the sheet. of the bed, miter the top corner, and with your palms
facing up, tuck in the sheet on the side, all the way
b. Tuck the top of the sheet underneath the to the foot of the mattress.
mattress at the head of the bed.
c. Miter the top corner. With your palms facing
up, continue tucking in the sheet on the side,
all the way to the foot of the mattress.

138 | | Nurse Assistant Training

 SKILLS

29. Pull the clean, fanfolded draw sheet toward you until Task 4: Tuck in the Top Linens
it is completely unfolded. With your palms facing up,
tuck the draw sheet under the mattress, tucking in
and Make a Toe Pleat
the middle third first, then the top third and then the 39. Put the blanket on the bed with the center fold in the
bottom third (Figure 4). center of the bed and the top edge about 6 inches
below the head of the mattress. Unfold the blanket.
40. Put the bedspread on the bed with the center fold in
the center of the bed and the top hem even with the
head of the mattress. Unfold the bedspread.
41. Together, tuck the top sheet, blanket and bedspread
under the foot of the mattress. Miter the corners at
the foot of the bed to hold the top sheet, blanket and
bedspread in place.
42. Fold the top of the bedspread down far enough to
allow room to cover the pillow.
43. Fold the top sheet down 6 inches over the blanket’s
edge on each side of the bed to form a neat cuff.
44. Standing at the foot of the bed, grasp both sides
of the top covers about 18 inches from the foot of
Figure 4 the bed. Pull the top covers up and toward the foot
of the bed, making a 3- to 4-inch fold (called a toe
30. Help the person roll onto his back in the center of pleat) across the foot of the bed (Figure 5).
the bed. Adjust the pillow under the person’s head
for comfort. Ensure good body alignment and make
sure the person is covered with the bath blanket.
31. Put the top sheet over the person with the center
fold in the center of the bed and the top edge even
with the head of the mattress. Make sure that the
sheet is positioned so that when you unfold it, the
rough side of the hem stitching at the top of the
sheet will face up.
32. Have the person hold the clean top sheet in place
while you remove the bath blanket from underneath.
Place the bath blanket in the linen hamper.

Task 3: Change the Pillowcase

33. Remove the pillow from under the person’s head. Figure 5
34. Remove the pillowcase from the pillow, and place it
in the linen hamper.
35. Hold the clean pillowcase at the center of the COMPLETION
bottom seam.
45. Ensure the person’s comfort and good body alignment.
36. Turn the pillowcase inside out, back over the hand
46. Adjust equipment for safety: Lower the bed to the
that is holding the bottom seam.
level specified in the person’s care plan. Make sure
37. With the hand that is holding the pillowcase, pick the wheels on the bed are locked. Place the person’s
up the pillow at the center of one of the short ends method of calling for help within reach. Lower or raise
and bring the pillowcase down over the pillow using the side rails according to the person’s care plan.
your other hand. Fit the corners of the pillow into the
47. Clean up your work area.
corners of the pillowcase.
48. Wash your hands.
38. Place the pillow under the person’s head, with the
open end of the pillowcase facing away from the door. 49. Report and record.

Chapter 10 | Maintaining a Comfortable Environment | 139

C HA P T E R
Providing Restorative
11 Care
After reading this chapter, you will have the information needed to:
■ Explain the goals of restorative care.
■ Describe the nurse assistant’s role in providing restorative care.
■ Promote independence and self-care.
■ Help a person to be active.
Goals After practicing the corresponding skills, you will have the information needed to:
■ Help a person walk with and without a cane, crutches and a walker.
■ Help a person with passive range-of-motion exercises.

140 | | Nurse Assistant Training

 Key Terms:
restorative care atrophy ambulation transfer (gait) belt
(rehabilitation nursing)
contracture range-of-motion exercises
immobility

work. However, if you work in a facility that receives

Today you arrive for your shift at Morningside Medicare funding, providing restorative care is a
Nursing Home promptly at 6:45 a.m. After clocking particularly important part of your job. To meet Omnibus
in and putting your personal belongings in your Budget Reconciliation Act (OBRA) requirements, the
locker, you report to the supervising nurse to find out health care staff must identify each person’s risk factors for
which residents you will be caring for today. Your first functional decline (loss of abilities), and take appropriate
responsibility will be to help your residents with early steps to maintain the person’s existing abilities and prevent
morning care in preparation for breakfast. You decide any future loss of abilities from occurring. Providing
to start with Mrs. Winnie Steele and Mrs. Dorothy restorative care is essential to achieving these goals.
Winesap, roommates in Room 120. Mrs. Steele, who
is 72 years old, has chronic heart failure. Because her
weak and damaged heart struggles to pump oxygen-
rich blood throughout her body, Mrs. Steele becomes THE NURSE ASSISTANT’S
tired and short of breath very easily. As a result, she ROLE IN PROVIDING
must stop what she is doing frequently to rest and
catch her breath. However, you know that Mrs. Steele
RESTORATIVE CARE
can do a great deal for herself if she is allowed to take Restorative care is primarily carried out by the nursing
her time and go at her own pace. Mrs. Winesap, her staff. As a nurse assistant, you play a critical role in
roommate, fell and broke her hip just after her 95th providing restorative care. This is a very important and
birthday. Mrs. Winesap is not allowed to stand up and essential part of your job, because you are the member
bear weight on her hip for several more weeks; of the health care team who will spend the most time
as a result, she requires a great deal of assistance with with the person each day. As you carry out your daily
toileting and dressing. After greeting the roommates responsibilities, you will provide restorative care by
and helping Mrs. Steele into the bathroom so that she encouraging and helping the person to do as much for
can use the toilet and brush her teeth, you turn your herself as she is able, and by providing care according
attention to helping Mrs. Winesap use a fracture pan to the person’s care plan (Figure 11-1). Much of the
(a special type of bedpan often used for people with physical care you provide, such as repositioning people
broken hips). In this way, while you are helping and helping them to get out of bed and walk, is essential
Mrs. Winesap, you can still keep an eye on Mrs. Steele for helping the people in your care to maintain or regain
and be available to offer assistance if she needs it. their physical health, strength and abilities. In addition,
when you encourage a person to do something for himself
(instead of just doing it for him), you help to maintain
the person’s physical abilities as well as his sense of
independence, which is important for the person’s dignity
and emotional health.
GOALS OF RESTORATIVE CARE
Some of the people in your care will need to learn new
The people in your care require nursing care because
ways to do old things so that they can do as much for
they are ill, injured or very frail. Because of physical
themselves as possible. Another important aspect of
disability, mental disability or both, their ability to care for
providing restorative care is encouraging and helping
themselves is decreased. One of the primary goals of
those in your care to practice these new skills. Often,
the nursing staff is to help people maintain the abilities
the person will work with other members of the health
they still have, and to help them regain (to the greatest
care team (such as a physical therapist, occupational
extent possible) the abilities they have lost. This kind of
therapist or speech therapist) to learn these new skills,
caregiving is called restorative care or rehabilitation
but you will be responsible for helping the person to
nursing. Restorative care helps a person become as
practice the skills on an ongoing basis (Figure 11-2).
fully functional and independent as possible, which
For example, a physical therapist may teach a person
increases the person’s ability to enjoy life.
how to walk with a walker, but you will be responsible for
Practicing the principles of restorative care is important encouraging the person to use the walker, and making
with all of the people in your care, no matter where you sure that she is using the walker correctly.

Chapter 11 | Providing Restorative Care | 141

 Figure 11-2 Nurse assistants help the people in their care to practice
new skills that they are learning in therapy.

take note of how much effort it took for the person to

complete the task. Listen to the person’s comments,
and observe physical signs, such as sweating, difficulty
catching the breath, or the number of times the person
must stop and rest before continuing. Always remember
to report and record the restorative care that you
provide, and your observations about the person’s
progress or setbacks. This information helps the other
health care team members adjust the person’s care plan
as necessary. In facilities that receive Medicare funding,
accurate documentation is also essential for ensuring
Figure 11-1 Enabling the resident by ensuring that her cane is within that the person continues to be eligible for therapy and
reach gives her the power to be more independent.
other services as needed, and that the facility receives
Seeing positive results from restorative care can take proper reimbursement for the services provided.
a long time. A key part of your job is observing and
Guidelines for providing restorative care are given in
reporting even the smallest changes in a person’s
Box 11-1.
abilities. What you observe depends on the goals that
are written in the person’s care plan. You may have to
watch to see how far the person walks, how much she
eats or how far she can bend a joint. It is important to
PROMOTING INDEPENDENCE
note changes in the person’s abilities in measurable Helping a person to keep or achieve his best level
terms, such as distance, amount, or length of time. Also of independence is an important goal of restorative

Box 11-1 Nurse Assistant DO’s and DON’Ts

Providing Restorative Care
DO follow the person’s care plan. DO help the person set realistic goals. DO recognize and celebrate even the
smallest successes.
DO recognize what the person can do for DON’T offer false encouragement, or
herself, and encourage her to do it. compare the person to others. Each DO ask the therapist or nurse to show
person is an individual. you how to best help the person practice
DO emphasize the person’s abilities,
new skills or use new assistive devices
rather than her disabilities. DO be patient.
correctly.
DO focus on the whole person, not just DON’T rush the person through tasks.
DO report and record the restorative
the affected part of her body. Consider Give the person enough time to complete
care you provide and your observations
the person’s emotional needs as well as the task independently.
regarding the person’s abilities, using
her physical ones.
measurable terms.

142 | | Nurse Assistant Training

care. Remember that promoting independence is
one of the five principles of care. Think about how it
would make you feel to have to depend on another
person to help you with routine activities, like dressing,
eating or bathing. Would you feel like a burden? Would
you feel ashamed that you need help doing things
that other people are able to do easily on their own?
Would it frustrate you to have to arrange your schedule
around when someone else is available to help you?
Most people, even people who are ill, injured or elderly,
have an emotional need to do as much for themselves
as possible, for as long as possible. The ability to act
independently is important for a person’s self-esteem
and sense of dignity. Doing things for oneself is also
important for a person’s physical health. Activity
strengthens and inactivity weakens.
Figure 11-3 An important part of providing restorative care is helping
As a nurse assistant, you will help to promote the person to be as independent as possible. This man can shave
independence by allowing the people in your care to himself if someone brings him the necessary supplies.
provide for their own personal care as much as they are
able (Figure 11-3). By encouraging the person to do as
much for himself as possible, you help increase his self-
esteem and sense of purpose. Explain what you want the
person to do in a way that he can understand, and review
the steps if necessary. Make sure the person has the Eating Devices
supplies he needs to complete the task. Many people use
assistive devices to make it easier for them to complete
certain tasks independently (Figure 11-4). If the person
uses an assistive device for a certain task, make sure it is
within reach. Reassure the person that you are available
to help if necessary, but encourage him to do as much for
himself as possible. Remember to be patient. The person
will require more time to complete the task and may need
to try several times before successfully completing a step.
Resist the urge to complete the task for the person. It is
better to allow him the opportunity to succeed and feel Grooming and Dressing Devices Walking Devices
the sense of accomplishment that comes with success. Figure 11-4 Assistive devices can help people remain independent.
Of course, if the person is becoming very frustrated
or seems overly exhausted, it is appropriate to step in
used to remind a person what to do without actually
and help him to complete the task. Always notice and
telling her. If a person hesitates to do something that you
comment on small successes. If you say, “Mr. Lightfoot,
know she can do, it is better to prompt her than to do it
you were able to eat everything on your tray but dessert
for her. For example, suppose a person is about to stand
today, and last week you could only get halfway through
up by herself and use her walker. The walker should be
your meal before getting tired!” he will probably want to
in front of her when she stands up, but it is to the left
try to eat the entire meal without any help by next week.
of where she is going to stand. By asking the person if
Sharing your observations about the progress he has
her walker is where she wants it, you remind her that it
made encourages him to keep trying to improve.
is not in the right place and give her the chance to move
Many of the people in your care will be receiving therapy the walker into the correct position before proceeding. If
to learn new skills to help increase their independence. the person seems to get stuck while completing the task
For example, the occupational therapist may teach the and gives you a questioning look, do not assume that
person how to use an assistive device for eating, or the the person does not know what to do. She may just be
physical therapist may teach the person how to use an worried about doing the task incorrectly in front of you.
assistive device for walking. You continue that teaching Help by asking, “What do you think you should do next?”
by encouraging the person to use her new skills, and by The person may tell you and then go on with the task.
making sure that she is performing the skills correctly. If necessary, tell her what step should come next, but
Prompting is a communication technique that can be encourage her to complete the task independently.

Chapter 11 | Providing Restorative Care | 143

 Although Mrs. Steele tires very easily, she likes how much you were able to accomplish on your own
to choose her own clothes and dress herself as much today! I hardly had to help you at all!” Mrs. Steele looks
as possible. Today, Mrs. Steele has selected a pair of up at you and smiles weakly. She says, “I’ve done things
slacks, a sweater set and a necklace. She has put on for myself my whole life. I don’t want to stop now.”
her slacks and the short-sleeved sweater, but she is
Nurse assistants are taught to always put
having trouble with the cardigan. She is sitting on the
the client first. By allowing Mrs. Steele to
edge of the bed and is clearly very tired. It has taken a
complete most of her personal care by herself
lot of energy for her to use the toilet, brush her teeth,
while you helped Mrs. Winesap, did you
choose her outfit and begin dressing. You are almost
neglect your responsibilities toward
finished helping Mrs. Winesap when Mrs. Steele says,
Mrs. Steele? Why or why not?
“Honey, would you be a sweetheart and just help me
with these sleeves?” You are almost finished in Room You decided to help Mrs. Steele finish putting
120 and would like to finish helping your other four on her cardigan herself, instead of just
assigned residents get ready for breakfast. You know putting the cardigan on her. Was the extra
that the easiest and quickest thing to do would be time it took to help Mrs. Steele put on the
just to finish dressing Mrs. Steele in her cardigan, but cardigan herself worth it? Why or why not?
instead, you say, “Of course! Here, let me help you.”
You hold up the cardigan for her and ask her to put Mrs. Steele’s condition, heart failure, is
one arm in. Before continuing with the other arm, terminal (that is, it cannot be cured, and
Mrs. Steele needs to stop and rest, but after about a eventually, it will probably cause her
minute she is able to put her other arm in the sleeve. death). Do you think it is important to
Then you fasten her necklace for her and help her to provide restorative care for a person who
apply lipstick. You say, “Mrs. Steele, I’m so proud of has a terminal condition? Why or why not?

addition, the ability to move is important for our physical

PROMOTING MOBILITY and emotional health.
Another major goal of restorative care is helping the Have you ever heard the expression “Use it or lose
person to maintain or achieve her best level of mobility. it”? This condition really can happen. Immobility, or
If we cannot move, it becomes much more difficult to the state of not moving, can cause many physical and
do things for ourselves and to remain independent. In emotional problems (Figure 11-5). For example:
Continued on page 146

Figure 11-5 Immobility can cause physical and emotional problems.

144 | | Nurse Assistant Training

Table 11-1 Assistive Devices for Walking
Ensuring Guidelines for
Assistive Device Used By Proper Fit Proper Use
A person who can The top of the walker frame ■ Make sure the walker is directly in front
bear weight but should be even with the of the person.
needs support on person’s hip bones. ■ Make sure the person places his hands
both sides on the walker’s handgrips, stands erect
and slightly flexes his elbows.
{ Pick-up walker: Have the person
lift the walker and put it down about
6 inches forward and then step or hop
into it.
{ Four-wheeled or semi-wheeled
walker: Have the person roll the
walker forward about 6 inches and
then step into it.
■ Encourage the person to walk normally,
Walker looking ahead, while using the walker.

A person who The top of the cane should ■ Make sure the person holds the cane
needs assistance be even with the person’s handle with the hand opposite the weak
with balance but is hip bone. leg and stands erect, with his elbow
able to walk without slightly flexed.
much difficulty ■ Position yourself on the person’s
weaker side.
■ Have the person move the cane forward
about 6 to 11 inches. Make sure the tip
of the cane is firmly on the floor.
■ Have the person use the cane for
support while standing on the stronger
side and moving the weaker leg forward
until it is even with the cane. Next, the
person moves the stronger leg forward,
ahead of the cane and the weaker leg.
Cane ■ Encourage the person to look ahead
while using the cane.

A person who The top of the crutches ■ Make sure the person stands erect,
cannot use one leg should rest against the supporting his weight on the handgrips
or when both legs person’s sides (not in the and gripping the crutches between
are weak and need person’s armpits). the chest and the inside of the
support upper arms.
■ Have the person move both
crutches forward along with the
weaker leg, and then bring the
strong leg up to meet the
crutches.
■ Encourage the person to look ahead
while using the crutches.

Crutches

Chapter 11 | Providing Restorative Care | 145

■ Musculoskeletal problems. Bones lose does not pass after several minutes, help the person
calcium and become brittle. Muscle mass to lie back down and report the dizziness to the nurse.
decreases (a condition called atrophy), and The person may also become dizzy after she has been
strength is lost. Holding a joint in the same walking for awhile. If this occurs, or if the person
position for too long can cause the tendons to becomes sweaty, short of breath or complains of
shorten and become stiff, resulting in loss of pain, help her to sit down and rest. Some people
motion in the joint. This is called a contracture. may begin to fall quite suddenly while they are
Bend your wrist so that your palm moves toward walking, especially if they are weak, ill or unsteady
the inside of your arm. This position is similar to on their feet. Do not try to stop a fall; doing so
that of a contracture that affects the wrist. Imagine may injure you and the person. Instead, use
what it would be like to try to eat, dress and go to the technique shown in Box 11-2 to minimize
the bathroom with your hand bent in this position. injury to the person and to yourself if the person
■ Respiratory problems. Lying down for long begins to fall while you are assisting her
periods of time decreases the person’s ability to with walking.
fully inflate the lungs with each breath, which allows A transfer (gait) belt is a wide, webbed belt that
secretions to pool in the lungs and puts the person is placed around the person’s waist when you are
at risk for pneumonia. assisting the person to walk. The transfer belt allows
■ Cardiovascular problems. Inactivity slows you to support the person by giving you a safe
circulation. As a result, healing is delayed and place to put your hands (Figure 11-6). Many
dangerous blood clots can form. employers will require you to use a transfer
■ Skin problems. Pressure ulcers can develop. belt when helping a person to stand, walk or
Pressure ulcers are painful, difficult-to-heal sores transfer (for example, from the bed to a chair),
that can be fatal. You will learn more about pressure unless the person has a medical condition that
ulcers in Chapter 12. makes using a transfer belt unsafe. A transfer belt
■ Elimination problems. A lack of activity causes should not be used for people with certain medical
food to move more slowly through the intestines, conditions, including recent abdominal, chest or
putting the person at risk for constipation. Immobility back surgery; severe respiratory problems; or severe
can also lead to incontinence (an inability to control cardiac problems. When putting a transfer belt on a
the release of urine or feces). person, make sure that it is snug without being too
tight. You should be able to slip two fingers between
■ Emotional problems. Depression and
the person’s body and the belt.
feelings of helplessness, anger and loneliness
can occur. Guidelines for helping a person to walk safely are given
As a nurse assistant, you help a person stay active and in Box 11-3. Skill 11-1 describes step by step how to
mobile with ambulation (walking) and range-of-motion help a person to walk.
exercises (exercises that help to keep joints functional by
moving them in a systematic way).

Helping a Person to Walk

Encouraging the people in your care who can walk to
do so several times a day has many important health
benefits, even if the person only goes a short distance
at a time. Some people will only need your assistance
to remain safe and steady on their feet while they are
walking. Others will use an assistive device, such as a
cane, a walker or crutches, to walk (Table 11-1). For
many people, the use of an assistive device allows the
person to walk independently.
Dizziness is common when a person sits up after
being in bed for awhile. Before assisting a person
to walk, allow her to sit on the edge of the bed for Figure 11-6 A transfer belt gives you a safe place to grasp when
several minutes before standing up. If the dizziness helping a person to stand up and move from one place to another.

146 | | Nurse Assistant Training

▼ Box 11-2 Minimizing Injury When a Person Starts to Fall While Walking

Put your arms around the person’s waist or under his arms, Bend your knees and lower the person slowly to the floor by
and hug the person’s torso close to your body. sliding him down your leg.

Place one foot behind the other to widen your base of support. Lower yourself to the floor and sit beside the person. Call for
help. While waiting for help to arrive, stay with the person.
Provide reassurance and make the person comfortable.

Box 11-3 Nurse Assistant DO’s and DON’Ts

Helping a Person to Walk
DO make sure the person is wearing standing up to walk, if the person has DO make sure you know the proper way
footwear. The person’s shoes or been lying down in bed. to use the person’s assistive device
slippers should fit well and have for walking, if the person uses one.
DO handle medical equipment,
nonskid soles. Watch the person’s technique and
such as an IV bag and tubing or a
correct any errors.
DO use a transfer belt, unless the person urinary catheter drainage bag and
has a condition that makes the use of tubing, appropriately so that treatment DO make sure the assistive device is in
a transfer belt dangerous (for example, is not disrupted and the person is not good working order. Rubber tips on canes,
recent abdominal, chest or back surgery; harmed as you help her walk. An IV crutches or walkers that are missing, worn
severe respiratory problems; or severe bag should always be higher than or cracked should be replaced. Frames on
cardiac problems). the IV entry site. A urinary catheter walkers should be secure.
drainage bag and tubing should
DON’T hold onto the person’s arm. DO watch the person carefully for signs
always be lower than the bladder.
Instead, grasp the transfer belt. of fatigue, dizziness or pain.
Make sure tubing is properly
DO allow the person to sit on the edge secured so that it does not become DO gradually increase the distance the
of the bed for several minutes before a tripping hazard. person walks to help build confidence.

Chapter 11 | Providing Restorative Care | 147

Table 11-2 Common Medical Terms Used To Describe Movement
Term Defintion
Flexion Bending

Extension Straightening

Abduction Moving away from the body

Adduction Moving toward the body

Rotation Moving in a circular motion along a

fixed point or axis

Pronation Turning the palm downward

Supination Turning the palm upward

Radial Deviation Bending the wrist toward the thumb

(the side where the radius bone is
located)

Ulnar Deviation Bending the wrist toward the little

finger (the side where the ulna bone is
located)

Dorsiflexion Bending the ankle so that the toes

point up

Plantar Flexion Bending the ankle so that the toes

point down

Inversion Turning the ankle inward

Eversion Turning the ankle outward

148 | | Nurse Assistant Training

 Box 11-4 Nurse Assistant DO’s and DON’Ts
Assisting with Range-of-Motion Exercises
DO follow the person’s care plan, and DO move each joint slowly, gently DO pay attention to verbal and nonverbal
exercise only the joints specified on the and smoothly. expressions of pain. If the person has
care plan. pain, stop the movement and report your
DO support the joint during the movement.
observations to the nurse.
DO work in a systematic manner.
DON’T move the joint further than the
DO use good body mechanics. person can tolerate.

by the person with help from a caregiver), or passive

While you are helping Mrs. Winesap with her (done by a caregiver for the person). When you are
early morning care, she says to you, “I am so tired helping a person with range-of-motion exercises, you
of lying in this bed all day! I can’t wait until I’m able should only move the joint as far as is comfortable for
to be up and on my feet again!” You know that Mrs. the person. Be aware that range of motion differs from
Winesap is not allowed to bear weight on her healing person to person. It may even differ within the same
hip right now, but later on in her recovery she will person, depending on the time of day. For example, a
begin to walk again using an assistive device. person who has arthritis may not have much range of
motion in the early morning because of joint pain.
Once Mrs. Winesap’s doctor has approved
But in the late morning, after her bath and after she
a change to weight-bearing status, which
has taken her pain medication, she may have more
assistive device for walking would you expect
range of motion.
the physical therapist to recommend for
Mrs. Winesap? Range-of-motion exercises may be ordered for one
joint, several joints or all joints. Always check the
When Mrs. Winesap has progressed enough
person’s care plan. When assisting a person with
in therapy to walk without the physical
range-of-motion exercises, work in a systematic manner,
therapist present, what will you look for
beginning at the top of the person’s body and working
when you are helping her to use the assistive
your way down. Do all of the exercises on one side
device to ensure that she is safe and using the
of the body, and then repeat them on the other side.
device properly?
Box 11-4 contains general guidelines for assisting a
person with range-of-motion exercises, and Skill 11-2
provides step-by-step instructions for assisting with
Helping a Person with passive range-of-motion exercises.

Range-of-Motion Exercises
To remain functional, joints must be used and put through
their normal range of motion. Normally, the activities we CHECK YOUR UNDERSTANDING
do every day are enough to keep our joints healthy and
functioning well. However, when a person has an injury or
condition that prevents normal activity, range-of-motion Questions for Review
exercises may be used to keep the joints flexible and
mobile. Range-of-motion exercises put the joint through 1. The nursing staff provides what kind of care
its maximal extent of movement (that is, the joint’s range to help people maintain or achieve their best
of motion) and are important for preventing contractures possible level of functioning?
from developing. Common medical terms used to a. Physical therapy
describe movement are defined in Table 11-2. b. Occupational therapy
Range-of-motion exercises may be active (done c. Restorative care
independently by the person), active-assisted (done d. Personal care

Chapter 11 | Providing Restorative Care | 149

2. A stroke has made it difficult, but not c. A transfer belt
impossible, for Mrs. Klein to feed herself. To best d. A wheeled walker
assist Mrs. Klein, you would:
a. Feed Mrs. Klein yourself so that her food does 7. As part of providing restorative care, nurse
not get cold. assistants are responsible for which of the
b. Place Mrs. Klein’s meal tray on her over-bed following?
table, and then leave the room. a. Helping the person practice what he or she has
c. Let Mrs. Klein feed herself for 5 minutes, and been taught in therapy
then finish feeding her the rest of the meal. b. Providing support and encouragement
d. Encourage Mrs. Klein to use the assistive c. Reporting and recording the restorative care
device the occupational therapist gave to her that was provided and what the person was able
for eating. to achieve, using measurable terms
d. All of the above
3. Inactivity can cause:
a. Atrophied muscles. 8. Which of the following people is a candidate for
b. Blindness. receiving restorative care?
c. Arthritis. a. Mrs. O’Leary, who is 98 years old
d. All of the above. and blind
b. Mr. Dunlap, who has had several toes amputated
4. Mrs. Clymer has arthritis and needs to do (surgically removed) due to complications of
range-of-motion exercises. When you go to her diabetes
room to help her, she says that she cannot do c. Mrs. Singer, who has multiple sclerosis, a
them today because she hurts too much. The progressive neurologic disease with no cure
best way to respond is to say:
d. All of the above
a. “You need to do them because the doctor ordered
them. Let’s just do them and get them over with.” 9. Mrs. Garcia, who is recovering from a broken hip,
b. “If we do them quickly, we’ll finish up faster.” is upset because she couldn’t reach the end of
c. “Okay, we’ll do them tomorrow.” the hallway today. “Yesterday I walked twice as
far with this stupid thing!” she says, and angrily
d. “It’s so important for you to do these exercises
pushes her walker away. What can you say to
to keep your joints flexible. Let’s try to do them
help her feel better?
very slowly, and you can let me know when you
need to rest or stop.” a. “I’m sure you’ll be back on your feet and have no
need for the walker soon!”
5. You are helping Mr. Grey to walk to the bathroom b. “I know you can do it! Why, just last week
when he suddenly starts to fall. What should Mrs. Reynolds made it all the way down the hall
you do? and back.”
a. Grab Mr. Grey’s arm to keep him from falling. c. “Yes, you made it all the way to the end of the
hall yesterday, and you made it almost that far
b. Assist Mr. Grey to sit in a chair or on the floor.
today. You’re doing great! Healing from a broken
c. Hug Mr. Grey’s body close to yours and use good hip takes a long time, and I’m really pleased with
body mechanics to lower him gently to the floor. how much you’ve been able to do already.”
d. Call for the nurse so that she can check d. “I’ll talk to the physical therapist. Maybe he can
Mr. Grey for injuries. help you with the walker.”

6. Mrs. Ward has emphysema, a lung disease that

makes it difficult for her to breathe. As a result, she
Questions to Ask Yourself
becomes winded and tired very easily. To make 1. Mr. Rivera had a stroke, which resulted in left-side
it easier for her to walk and to help her maintain paralysis. What suggestions do you have for
her current level of independence, the physical Mr. Rivera to help him increase his activity?
therapist has recommended that she use an
2. Mr. Roberts, one of your home care clients, has
assistive device for walking. Which type of assistive
severe Parkinson’s disease. Because his hands
device would be most appropriate for Mrs. Ward?
shake so much, he struggles to eat. You are
a. Crutches responsible for making sure Mr. Roberts eats lunch.
b. A cane You know that with time and encouragement, he

150 | | Nurse Assistant Training

 can eat independently using adaptive devices for 6. Name some of the body parts that are exercised
eating. One day, Mr. Roberts’ wife says to you, “You when you help someone with passive range-
are so patient! I just don’t have that kind of patience. of-motion exercises. Why are these exercises
For me, it’s just easier to feed him his dinner every important for providing restorative care?
night.” How would you respond? 7. Ever since he developed severe arthritis in his
3. Ms. Jones is unsteady on her feet and very afraid of hands, Mr. Hudson has lost weight. “I’m just not
falling. She wants you to take her to the bathroom as hungry as I used to be,” he tells you at lunch.
in her wheelchair. What do you think would be the One day you overhear Mr. Hudson telling his
best thing for you to do? roommate that he doesn’t want to be a burden
to anyone. What can you do to make sure Mr.
4. How can you help maintain independence for a Hudson receives adequate nutrition and maintains
person who needs to use a walker? his independence?
5. How can you help maintain good body mechanics
for someone who uses a cane to walk?

Chapter 11 | Providing Restorative Care | 151

SKILLS

Skill 11-1
Helping a Person to Walk

PREPARATION back side of the person’s waist, with your palms

up (Figure 1).
1. Wash your hands.
2. Gather your supplies:
■
Transfer belt, if you are using one
■ The person’s walker, cane or crutches (if the
person uses an assistive device)
■ The person’s robe, and slippers or shoes
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Lower the bed to the level specified in the person’s
care plan. Make sure the wheels on the bed
are locked.

PROCEDURE
6. If the person has been lying down in bed, allow her
to sit on the edge of the bed with her feet flat on the
floor for at least 2 minutes before continuing. Some
dizziness is common when a person sits up after
being in bed for a while. See if the dizziness passes
in 2 minutes. If it does not pass, if it gets worse, if
she becomes sweaty or short of breath, or if she is
in any pain, help the person to lie back down and
report your observations to the nurse.
7. Help the person put on the robe and footwear.
Put the transfer belt on the person.
8. If necessary, help the person to stand up: Stand
Figure 1
facing the person, and either grasp the transfer belt
on the back side of her waist with your palms up or,
if you are not using a transfer belt, put your arms 11. Starting on the same foot as the person, walk on her
underneath the person’s arms and place your hands weaker side and a little behind.
on her shoulder blades. Place your toes against
the person’s toes and bend your knees so that they COMPLETION
rest against, or near, her knees. Have the person
lean forward, toward you. Tell the person that on the 12. Ensure the person’s comfort and good body
count of 3 she can push down on the bed or chair alignment.
with her hands while you assist her to a standing
13. Adjust equipment for safety: Lower the bed to
position. On the count of 3, straighten your legs,
the level specified in the person’s care plan. Make
helping to lift the person to a standing position.
sure the wheels on the bed are locked. Place the
9. If the person is using an assistive device for walking, person’s method of calling for help within reach.
make sure it is positioned properly. If the person is Lower or raise the side rails according to the
using a walker, it should be positioned directly in person’s care plan.
front of her. If the person uses a cane, make sure
14. Clean up your work area.
she is holding it in the hand opposite her weak leg.
15. Wash your hands.
10. Stand slightly behind the person on the person’s
weaker side. Grasp the transfer belt on the 16. Report and record.

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 SKILLS

Skill 11-2
Helping a Person with Passive Range-of-Motion Exercises
PREPARATION 9. Abduction and adduction. With the person’s arm
by his side and the palm up, move the person’s arm
1. Wash your hands. out away from the body (Figure 1B). Then return the
2. Gather your supplies. arm to the person’s side. Repeat 5 times.
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. Make
sure the wheels on the bed are locked.

PROCEDURE
6. Lower the head of the bed as low as the person
can tolerate. Make sure the person is in the supine
position (lying on the back) and in good body
alignment.

Task 1: Exercise the Shoulder

7. With one hand, hold the person’s wrist and put your Figure 1B
other hand under the elbow. Provide this support
throughout the following motions.
10. Horizontal abduction and adduction. Hold the
8. Flexion and extension. With the person’s arm by person’s arm out away from the body with the palm
his side and the palm down, raise the person’s arm up. Bend the elbow, touching the person’s hand to
straight up and then move it alongside the ear the opposite shoulder (Figure 1C). Then straighten
(Figure 1A). Then lower the arm to the person’s side. the person’s elbow, returning the hand to its original
Repeat 5 times. position. Repeat 5 times.

Figure 1C

11. Rotation. Bend the person’s arm and position the

elbow so that it is at the same height as the shoulder.
Move the hand up toward the person’s head and then
Figure 1A down (Figure 1D). Repeat 5 times.
Continued on next page

Chapter 11 | Providing Restorative Care | 153

SKILLS

Skill 11-2
Helping a Person with Passive Range-of-Motion Exercises Continued
14. Pronation and supination. Bend the person’s
elbow so that the forearm is at a right angle to the
bed. Gently turn the person’s hand so that the palm
is facing the foot of the bed. Then turn the hand so
that the palm is facing the head of the bed
(Figure 2B). Repeat 5 times.

Figure 1D

Task 2: Exercise the Elbow

12. With one hand, hold the person’s wrist and put your
other hand under the elbow. Provide this support
throughout the following motions.
13. Flexion and extension. With the person’s arm by
his side with the palm up, bend the person’s arm at
the elbow so that the hand moves toward the shoulder
on the same side (Figure 2A). Then straighten the arm Figure 2B
back down to the hip. Repeat 5 times.
Task 3: Exercise the Wrist
15. Hold the person’s wrist with the palm down with one
hand and the person’s fingers with your other hand.
Provide this support throughout the following motions.
16. Flexion and extension. Bend the person’s elbow
so that the forearm is at a right angle to the bed.
Bend the wrist to move the person’s hand forward,
and then straighten the wrist to move the hand
backward (Figure 3A). Repeat 5 times.

Figure 2A Figure 3A

154 | | Nurse Assistant Training

 SKILLS

17. Radial and ulnar deviation. With the person’s 20. Abduction and adduction. Hold the person’s
hand still raised off the mattress, gently tilt the thumb and index finger together in one of your
person’s hand toward the thumb. Then tilt the hand hands. With the other hand, spread the middle finger
the other way, toward the person’s little finger away from the index finger. Move the middle finger
(Figure 3B). Repeat 5 times. to the index finger and hold the middle finger, index
finger and thumb together. Move the ring finger
away from the other three fingers (thumb, index and
middle), then back to them (Figure 4B). Hold all four
fingers. Move the little finger away from the other
four fingers (thumb, index, middle and ring), then
back to them. Now work in the other direction. Hold
the little finger and ring finger together and move
the middle finger away and back. Complete with the
index finger and thumb. Repeat 5 times.

Figure 3B

Task 4: Exercise the Fingers and

Thumb
18. Raise the person’s hand off the mattress. Hold the
person’s wrist with one hand and the fingers with
your other hand. Provide this support throughout the Figure 4B
following motions.
19. Flexion and extension. Bend each of the fingers 21. Thumb flexion and extension. Bend the person’s
(one at a time) and the thumb to touch the palm thumb in toward the palm, and then return it to its
(Figure 4A). Then extend each of the fingers (one at natural position (Figure 4C). Repeat 5 times.
a time) and the thumb. Repeat 5 times.

Figure 4C

Figure 4A

Continued on next page

Chapter 11 | Providing Restorative Care | 155

SKILLS

Skill 11-2
Helping a Person with Passive Range-of-Motion Exercises Continued
22. Thumb opposition. Touch the tip of the thumb to 25. Abduction and adduction. Move the person’s leg
each finger (Figure 4D). Repeat 5 times. out away from his body (Figure 5B). Then return the
leg to the person’s side. Repeat 5 times.

Figure 4D

Task 5: Exercise the Hip and Knee Figure 5B

23. Put one hand under the person’s knee and your
other hand under the ankle. Provide this support 26. Hip rotation. Keeping the person’s leg straight, turn
throughout the following motions. the leg inward and then outward to rotate the hip
(Figure 5C). Repeat 5 times.
24. Flexion and extension. Bend the person’s knee
and move it up toward the head to flex the knee and
hip (Figure 5A), then straighten the person’s knee,
extending the knee and hip. Lower the person’s leg
to the bed. Repeat 5 times.

Figure 5C

Task 6: Exercise the Ankle

Figure 5A 27. Put one hand under the person’s ankle and grasp
the foot with your other hand. Provide this support
throughout the following motions.

156 | | Nurse Assistant Training

 SKILLS

28. Dorsiflexion and plantar flexion. Gently push

the person’s foot backward toward his head and
then forward toward the mattress (Figure 6A).
Repeat 5 times.

Figure 7A

Figure 6A 32. Abduction and adduction. Starting with the big

toe and the one next to it, hold the two toes together
29. Inversion and eversion. Turn the person’s and move the middle toe away from them (Figure 7B).
foot inward and then outward (Figure 6B). Continue spreading the toes in the same way you
Repeat 5 times. spread the fingers in Task 4, Step 20. Repeat 5 times.

Figure 6B

Figure 7B
Task 7: Exercise the Toes
30. Put one hand under the person’s foot. Provide this COMPLETION
support throughout the following motions.
33. Ensure the person’s comfort and good body alignment.
31. Flexion and extension. Place your other hand
on the top of the foot, over the toes. Curl the toes 34. Adjust equipment for safety: Lower the bed to the
downward and then straighten them (Figure 7A). level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or raise
the side rails according to the person’s care plan.
35. Clean up your work area.
36. Wash your hands.
37. Report and record.

Chapter 11 | Providing Restorative Care | 157

C HA P T E R
Assisting with Positioning
12 and Transferring
After reading this chapter, you will have the information needed to:
■ Explain factors that put people at risk for developing pressure ulcers.
■ Describe the role frequent repositioning plays in helping to prevent pressure ulcers.
■ Describe basic positions that are often used in the health care setting.
■ Explain the importance of good body alignment for the people in your care.
Goals ■ Protect your safety and the safety of those in your care when you position or
transfer them.
After practicing the corresponding skills, you will have the information needed to:
■ Reposition a person in bed or a chair.
■ Transfer a person from a bed to a chair, and from a chair to a bed.
■ Use a mechanical lift to transfer a person from a bed to a chair.

158 | | Nurse Assistant Training

 Key Terms:
pressure ulcer shearing high Fowler’s position Sims’ position

bony prominences supine position side-lying (lateral) position prone position

skin breakdown Fowler’s position modified side-lying logrolling

position
friction low Fowler’s position

a chair) for a long period of time. Pressure ulcers usually

You have been providing care for 78-year-old develop over bony prominences (parts of the body
Victor Rivera since he was transferred from the where there is only a thin layer of fat and muscle between
hospital to Morningside Nursing Home several weeks the skin and the bone or cartilage underneath). Examples
ago. An earlier stroke left him paralyzed on his left of these areas include the back of the head, shoulder
side and incontinent of urine and stool. The stroke blades, elbows, hips, coccyx (tailbone), knees, ankles and
also affected Mr. Rivera’s ability to speak, chew heels (Figure 12-1). When a person stays in one position
and swallow. too long, the weight of his body squeezes the tissue
between the bone and the surface he is resting on, which
Because of his paralysis, Mr. Rivera is unable to move
slows down blood flow to the area. Because the tissue is
much by himself. So every day, according to his care
not getting enough oxygen and nutrients, it starts to die.
plan, you help him change position at least every 2
This loss of healthy, intact skin, called skin breakdown,
hours. By changing his position and relieving pressure
can lead to a pressure ulcer.
on certain parts of his body, you help provide comfort
and help prevent pressure ulcers from developing on Friction and shearing injuries can also lead to skin
his dry, fragile skin. When Mr. Rivera’s wife comes to breakdown, putting a person at risk for developing a
visit every day, she helps by gently rubbing lotion into pressure ulcer. Friction occurs when two surfaces rub
his skin. against each other. Friction injuries can occur when
the skin rubs against another surface, such as the bed
This morning, when you first check on Mr. Rivera,
linens, or when skin rubs against skin (for example,
you notice that he has been positioned on his side for
under folds of skin in very overweight people, under the
sleeping. But he has moved his unaffected leg, which
breasts, or where the buttocks meet the thighs). Medical
has caused the pillow that was between his knees
devices, such as catheter tubing or a nasal cannula
to shift out of position, so his knees have been lying
(the device used to deliver oxygen through the nose),
against each other. As you reposition him, you check
can also cause friction injuries when they rub against
the inner surfaces of his knees and notice a red spot
the skin. Shearing occurs when a surface moves one
on each knee. You report the condition of Mr. Rivera’s
way against another surface that offers resistance,
skin to the nurse.
causing a dragging effect. Shearing injuries can occur
when a person is pulled across the bed instead of
lifted. Because the bed offers resistance, the person’s
Like Mr. Rivera, many of the people in your care will
body does not move easily across the sheets, and the
have difficulty changing positions, moving from one
place to another, or both. As you learned in Chapter 11,
immobility puts a person at risk for many serious
complications. In addition, remaining in one position for
too long is very uncomfortable. As a nurse assistant,
you will help to prevent complications of immobility
and promote comfort by assisting those in your care to
reposition themselves and to transfer (that is, move from
one place to another).

PRESSURE ULCERS
Pressure ulcers are one of the most serious
complications of immobility. A pressure ulcer is a sore
that develops when part of a person’s body presses Figure 12-1 A pressure ulcer can form on any part of the body.
against a hard surface (such as a mattress or the seat of Common sites of pressure ulcer formation are shown here.

Chapter 12 | Assisting with Positioning and Transferring | 159

top layer of skin is pulled in a direction opposite the and prevent pressure ulcers (Table 12-1, Figure 12-2).
underlying layers, leading to injury. Closely observing the person’s skin for signs of excessive
pressure and skin breakdown while you are providing
Pressure ulcers develop in stages (Box 12-1) and can
care and reporting your observations to the nurse can
be very difficult to treat, especially in the later stages.
help prevent a pressure ulcer in the early stages from
Pressure ulcers are extremely painful for the person, and
getting worse. You also help to prevent pressure ulcers
they can lead to the person’s death. For these reasons,
by regularly helping the people in your care to reposition
every effort must be made to prevent a pressure ulcer
themselves, if they cannot do this independently.
from forming in the first place.

When you report the reddened areas on

Observations Into Action! Mr. Rivera’s knees to the nurse, she thanks you and
The following may be early signs of a pressure ulcer says that she will go check on Mr. Rivera right away.
and should be reported to the nurse right away. Your She says, “Mr. Rivera has so many risk factors for
ability to identify a pressure ulcer in the early stages developing pressure ulcers—it’s great that you are
can make all the difference! paying such close attention to the condition of his
skin. We’ll keep a close eye on those areas, and I’ll take
{ A reddened or darkened area that does not
another look at Mr. Rivera’s care plan to make sure
return to normal within a few minutes when
we are doing everything we can to protect his skin and
the pressure is relieved
lower his risk for developing a pressure ulcer.”
{ A white, pale or shiny area
{ An area that feels hot or cool to the touch, Why could Mr. Rivera easily develop pressure
or is painful ulcers? Give three reasons.

In addition to immobility, many of the people in your care What are some of the actions to help prevent
will have other risk factors for developing pressure ulcers pressure ulcers that you would expect to see
(Box 12-2). As a nurse assistant, you will play a very listed on Mr. Rivera’s care plan?
important role in helping to keep the person’s skin healthy

▼ Box 12-1 Stages of Pressure Ulcer Development

Stage 1. An area is red, pale or dark, and the normal color
does not return within a few minutes of relieving the pressure. The
area may be firmer, softer, warmer, cooler or more painful than the
surrounding tissue. Detection may be more difficult in people with
darker skin.

Stage 2. The area may look like a shallow, open ulcer with pink or
red exposed tissue at the bottom. Sometimes, instead of looking
like an ulcer, the area looks like a blister.

Stage 3. More tissue is lost. The fat that lies beneath the skin may
be visible.

Stage 4. A deep crater forms. Muscle or bone may be visible.

Stage 4 pressure ulcer. Image © B. Slaven/Custom Medical
Stock Photo, Inc., 2012.

▼ Box 12-2 Risk Factors for Pressure Ulcer Development

■ Immobility ■ Poor nutrition
■ Advanced age ■ Poor hydration (not enough fluid intake)
■ Fragile, dry skin ■ Poor circulation (for example, as a result of
■ Moisture (for example, where one skin surface touches cardiovascular disease)
another, or where skin is in contact with soiled linens ■ Poor oxygenation (for example, as a result of respiratory
or clothes) disease)

160 | | Nurse Assistant Training

Table 12-1 Protecting the Person’s Skin
To Prevent This… Do This…
Direct Pressure ■ Change the person’s position according to the person’s care plan and at least every
2 hours.
■ Observe and report immediately any reddened, pale or darkened areas of the skin.
■ Make sure the person is in good body alignment. Use appropriate positioning aids when
needed.
■ Use pressure-reducing devices (for example, pressure-reducing mattress pads,
heel and elbow protectors) as ordered to relieve pressure and protect skin.
■ If the person uses hair pins or barrettes to style the hair, make sure these items are removed
when the person’s head is resting on a pillow.

Friction and ■ Get help when moving the person—be sure to lift the person’s body all the way off
Shearing Injuries the mattress.
■ Elevate the head of the bed no more than 30 degrees (except when a person is eating or has
difficulty breathing). This will keep the person from sliding down in bed. Avoid leaving the person
in Fowler’s position for any length of time.
■ Make a tight, neat, wrinkle-free bed.
■ Prevent medical equipment from rubbing against the person’s body.
■ Pad supportive devices (such as splints).
■ Ensure that shoes and socks fit correctly.

Skin-to-Skin ■ Check for skin changes under skin folds, especially under breasts, and under the folds of skin on
Contact people who are overweight.
■ Position the person so that air circulates around the person’s arms and legs to keep skin from
touching skin.

Moisture ■ Wash, rinse and dry the person’s skin thoroughly, especially in areas where skin meets skin.
■ Check people with incontinence at least every 2 hours and keep their skin, clothing and linens
clean and dry.
■ Cover a vinyl chair with a pad or sheet.
■ Have the person wear moisture-absorbing clothes made from natural fabrics such
as cotton.

Poor Circulation ■ Elevate the person’s arms and legs.

■ Provide gentle massage.
■ Observe the person’s skin frequently and report any changes to the nurse.

To Improve This… Do This…

Nutrition and ■ Encourage the person to eat a well-balanced diet.
Hydration ■ Encourage the person to drink an adequate amount of fluids.

Mobility ■ Reposition the person often.

■ If the person is able, assist the person with transferring out of bed and walking.

Chapter 12 | Assisting with Positioning and Transferring | 161

 Figure 12-2 Nurse assistants do many things to lower a person’s risk for developing pressure ulcers.

your care, too. It is essential for comfort, and it helps

ASSISTING WITH POSITIONING to prevent complications such as contractures and
Many of the people in your care will need your help to pressure ulcers.
change positions and maintain good body alignment. Helping people to reposition themselves and ensuring
In Chapter 7, you learned how maintaining good body good body alignment are major responsibilities of the
alignment can help to reduce strain on your joints and nurse assistant. Some people will only need to be
muscles and prevent you from injuring yourself on the encouraged to change their position, and checked
job. Good body alignment is important for those in to make sure they are in good body alignment. Other

162 | | Nurse Assistant Training

people, such as those who are confused, weak, frail,
in pain, paralyzed or unconscious, will need more help
from you. To check the alignment of a person who is
lying in bed, imagine a line starting at the person's nose,
continuing through the person's belly button, and ending
between the person's feet. The line should be straight
(Figure 12-3, A). When a person is sitting in a chair, his
back and buttocks should rest against the back of the
chair. His feet should rest flat on the floor (or the footrests
of a wheelchair), and his knees should be level with
his hips (see Figure 12-3, B). Many people will have a
tendency to lean to the side or slump when they are in
bed or sitting in a chair. To help the person maintain
good body alignment, you may need to support parts
of the body with rolled towels or pillows (Figure 12-4).
Special positioning aids, such as foam wedges, may
also be ordered for the person to help keep the body in Figure 12-4 You may need to use positioning aids such as pillows,
proper alignment. rolled towels or blankets, or devices made specifically for the purpose of
providing support, to help the person maintain good body alignment.

Basic Positions
In the health care setting, several basic positions are
used. A person may be positioned a certain way during
a procedure, or to make an activity, such as eating,
easier and safer. People who are unable to change
positions easily on their own will have an individualized
schedule for repositioning. This schedule will be part of
the person’s care plan. The schedule uses a sequence
of positions to ensure that no single area is under
pressure for too long. This is essential for reducing
the person’s risk for developing pressure ulcers. Basic
positions that are commonly used in the health care
setting are shown in Figure 12-5 and described in the
sections that follow.

Supine position
In the supine position, the bed is flat. The person is on
her back, with her head supported by a pillow. A small
pillow or rolled towel is used to support the small of the
back. The person’s arms are extended at her sides, with
her palms down. If the person’s arms are paralyzed or
weak, they should be supported with small pillows.
The person’s thighs extend in a straight line from her hips.
If the person’s feet tend to roll outward, rolled towels or
pillows can be placed against the outer thighs to keep the
legs in alignment. A foot board may be used to prevent
foot drop and keep the toes pointing upward. To keep
pressure off the heels, a small pad may be placed under
the person’s calves and ankles.

Fowler’s position
Figure 12-3 Proper body alignment is as important for those in your In Fowler’s position, the person is in the supine
care as it is for you. (A) When a person is lying in bed, the spine position, but the head of the bed is raised 45 degrees
should be straight. (B) When a person is seated in a chair, the back
and buttocks should be positioned against the chair, the feet should
so that the person is sitting up in bed. There are two
be resting flat on the floor (or on the footrests of a wheelchair) and the variations of Fowler’s position: low Fowler’s position
knees should be level with the hips. (also called semi-Fowler’s position), where the head of

Chapter 12 | Assisting with Positioning and Transferring | 163

 Figure 12-5 Basic positions used in the health care setting.

the bed is raised only 30 degrees, and high Fowler’s person will tend to slide down in the bed. Fowler’s
position, where the head of the bed is raised position also places a great deal of pressure on
90 degrees. If the person is in an adjustable bed, the the person’s tailbone, which can lead to pressure
bed may be raised under the person’s knees to prevent ulcer formation.
him from sliding down in the bed. Alternatively, a small
pillow or folded blanket can be placed under the Side-lying (lateral) position
person’s knees. As in the supine position, positioning
In the side-lying (lateral) position, the person is
aids should be used as necessary to support the arms,
lying on her side, with her head supported by a pillow.
legs and feet.
The lower arm is positioned so that the person is not
Fowler’s position should only be used for short periods lying on it, and the top arm is supported on a pillow.
of time (for example, when the person is eating in bed). A rolled blanket or towel is placed along the back to
Leaving a person in Fowler’s position for too long puts keep the person in the proper position. The bottom leg
the person at risk for shearing injuries, because the is straight, and the top knee is bent. A pillow is placed

164 | | Nurse Assistant Training

lengthwise between the lower legs to support the (Figure 12-6) or a raised side rail that the person can
knee and ankle and prevent the legs from resting on grasp may increase the person’s ability to assist with the
each other. move. Also consider whether or not you will need help
from a co-worker to move the person safely. Two people
The modified side-lying position is a variation of the
can lift or move someone more easily than one person
side-lying position. In the modified side-lying position,
can. Generally, if a person is much heavier or larger than
a pillow is placed along the person’s back, and the
you are, or very ill or injured, it is best to ask a co-worker
person is tilted slightly backward to lean onto the pillow.
to help you with repositioning the person. Just remember
This helps to relieve pressure on the hip. The modified
to return the favor! Guidelines for repositioning people
side-lying position is frequently part of the sequence
safely are given in Box 12-3.
of positions used in a repositioning schedule. For
example, the person may move from the left modified
ELDER CARE NOTE. Elderly skin is very fragile
side-lying position (left side down) to the supine or low
and thin, and it can rip or tear very easily.
Fowler’s position, and then to the right modified
Whenever you are repositioning an elderly
side-lying position (right side down).
person (or providing any other type of hands-on
care), handle the person carefully to avoid
Sims’ position damaging the person’s skin.
Sims’ position is an exaggerated side-lying
position that is used for procedures such as taking
a rectal temperature or giving an enema. In Sims’ Many different skills are used for repositioning a person
position, the person is almost lying on his stomach. in bed or a chair:
His head is turned to the side. The top leg is bent at ■ Lifting a person’s head and shoulders. To adjust
the knee and supported by a pillow, and the top arm a pillow or help a person sit up in bed (for example,
is bent at the elbow, with the hand near the face and to readjust her clothing), you will have to lift the
supported by a pillow. The bottom leg is straight person’s head and shoulders off the bed. This is
and the bottom arm is positioned so that the hand is described in Skill 12-1.
near the person’s hips. Make sure the person is not
■ Moving a person up in bed. A person who is
lying on the arm.
sitting up in bed may slide down toward the end
of the bed. To ensure good body alignment and to
Prone position keep the person comfortable, you will need to move
In the prone position, the person lies on his the person up in bed. Skills 12-2, 12-3 and 12-4
stomach, with his head turned toward the side. The describe different ways of moving a person up in bed,
head is supported with a small pillow. The arm the depending on the situation, the person’s ability to help,
person is facing is bent at a 90-degree angle, with the and whether or not you have help from a co-worker.
hand placed palm-down near the person’s head. The
■ Moving a person to the side of the bed. The first
other arm is extended straight along his side.
step of many procedures is to move the person to
A folded blanket or small pillow is tucked underneath
the side of the bed. For example, if you want to turn
the person’s lower abdomen or pelvis to give the
person’s chest room to expand when the person
breathes. A pillow is placed under the person’s shins
to raise the person’s toes off the bed. The prone
position is not used often because many people find it
uncomfortable. If the prone position has been ordered
for a person (or the person prefers the prone position),
ask the nurse to help you assist the person into the
prone position.

Helping a Person to Change

Position in a Bed or a Chair
Before repositioning a person in bed, it is important
to know the person’s capabilities and plan the move
accordingly. Always encourage the person to help you
as much as possible with the move. This is important for
the person’s self-esteem and sense of independence. Figure 12-6 A trapeze enables people to change positions by
Equipment such as a trapeze that hangs over the bed themselves or with some assistance.

Chapter 12 | Assisting with Positioning and Transferring | 165

 Box 12-3 Nurse Assistant DO’s and DON’Ts
Repositioning People
DO be familiar with the person’s care DO give clear directions to the people that may be in place, such as catheter
plan. Not all positions are allowed for who are helping you (that is, the person tubing or an IV line.
every person. receiving care, your co-worker or both).
DO protect the person’s dignity by not
DO plan how you will reposition the DO use good body mechanics to protect exposing her body unnecessarily while
person and what you need to accomplish your back. Raise the bed to a comfortable you are moving her.
the move safely (for example, help from a working height.
DO smooth the bed linens and the
co-worker, special equipment).
DO make sure the brakes on the bed person’s clothes after repositioning the
DO tell the person how you are going are locked. person. Lying on wrinkles can cause skin
to reposition him, even if the person is breakdown, putting the person at risk for
DO use a draw (lift) sheet to lift, rather than
unconscious. As you move through the pressure ulcers.
pull, the person into position. This helps to
steps, explain each step as you come to it.
prevent friction and shearing injuries. DO make sure the person is comfortable,
DO tell the person what he can do to help that his body is in proper alignment and
DO be careful while you are repositioning
make the move easier, and encourage the that he is supported as needed by pillows
the person not to pull out medical devices
person to help as much as possible. or other positioning aids.

a person onto his side in bed, first you will need to

move him to the side of the bed so that he is in the tells you that he wants to rest. Although you had
center of the bed when you are finished repositioning planned to start your day by providing personal care
him. Skill 12-5 describes how to move a person to for Mr. Rivera, you observe that he seems tired, and
the side of the bed if you are working alone. Skill 12-6 you adjust your schedule to meet his needs. Because
describes how to move a person to the side of the he has just eaten, you lower the head of the bed to low
bed when you have help. Fowler’s position and make him comfortable.
■ Turning a person onto her side in bed. Skill In about 15 minutes, you return to Mr. Rivera’s room
12-7 describes how to turn a person onto her side to help him with his bath. To perform this personal
in bed. Logrolling is the method used to turn a care procedure, you lower the head of the bed and put
person onto her side in bed when her spine must be him in a supine position. During the bath you need to
kept in alignment throughout the move. Skill 12-8 turn him onto his side to wash his back and give him
explains how to logroll a person. a backrub. Because of his paralysis, he finds it difficult
■ Repositioning a person in a chair. A person who to position himself but is able to help turn with his
is seated in a chair may slide down in the chair over unaffected side.
time. Skill 12-9 explains how to move the person
back up in the chair for proper body alignment. As you reposition Mr. Rivera in his bed to
make it easier to accomplish various tasks
throughout the day, what will you do to ensure
You return to Mr. Rivera’s room to prepare Mr. Rivera’s safety, as well as your own?
him for breakfast. He is lying on his right side in a What skills will you use?
modified side-lying position, with a rolled blanket
supporting his back. He has a pillow between his
knees to reduce strain on his upper hip and to prevent
pressure on his knees and ankles. His paralyzed arm
rests on a pillow. You ask a co-worker to help you ASSISTING WITH TRANSFERRING
position Mr. Rivera in high Fowler’s position for To transfer means to move from one place to another
eating. You roll him onto his back, move him up in (for example, from the bed to a chair). As when
bed, and elevate the head of his bed so that he can sit repositioning a person in bed or a chair, you will need
up and eat. After breakfast, you collect Mr. Rivera’s to plan the safest way to transfer the person and make
meal tray and tell him it will soon be time for his arrangements for help or special equipment (such as
personal care. He shakes his head and, with effort, a mechanical lift or standing-assist device) as needed.
When planning a transfer, knowledge about the

166 | | Nurse Assistant Training

person’s mobility and level of independence can help
you determine how much the person will be able to
help with the transfer. Questions to consider include:
■ Can the person support all of his weight on one leg
or both legs?
■ Is one side stronger than the other?
■ Can the person maintain his sense of balance?
■ Does the person have vision problems?
■ Is the person able to hear and respond to
verbal instructions?
■ Does the person have pain when he moves?
■ Is the person afraid of being moved?
■ Has the person ever suddenly refused to cooperate?
■ Does the person behave in a predictable way?
Figure 12-7 A mechanical lift is the safest way to assist a person who
When assisting a person who can bear weight, a transfer is heavy or unable to bear weight with transferring.
belt is used unless the person has a medical condition
that makes it dangerous to use a transfer belt (see
Chapter 11). During the transfer, you grasp the transfer General guidelines for completing transfers safely are
belt to support the person, rather than the person’s given in Box 12-4. Skill 12-10 describes how to assist a
clothing or arms. Remember that the transfer belt is a person with transferring from a bed to a chair, and Skill
support device, not a lifting device! A person who cannot 12-11 describes how to assist a person with transferring
bear any weight at all or who is very heavy will need to from a chair to a bed. If the person is usually predictable
be transferred using a mechanical lift (Figure 12-7). but may not be consistent about helping to bear his
There are many different types of mechanical lifts. own weight, you will want to ask a co-worker to help
Although they all work in generally the same way, make you with the transfer. Skill 12-12 describes how to use
sure you have been trained specifically in how to use the a mechanical lift to transfer a person. Use a mechanical
lift at your facility before using it. lift according to your employer’s policy and the person’s

Box 12-4 Nurse Assistant DO’s and DON’Ts

Transferring People
DO plan the transfer and identify DO use good body mechanics to protect DO allow the person to sit on the edge
what you need to accomplish the your back. Get as close as possible to theof the bed for several minutes before
transfer safely (for example, help from person. Use a good base of support, keep continuing with the transfer. Dizziness
a co-worker, special equipment). Move the person close, keep your back straight is common when a person sits up after
furniture out of the way, if necessary, and and lift smoothly, without jerking or twisting.
being in bed for awhile. If the person is
plan the transfer so that the person is dizzy and the dizziness does not pass,
DO lower the bed to its lowest height and
leading with her strongest side. do not continue with the transfer.
make sure the brakes on the bed and the
DO tell the person how you are going to wheelchair are locked. DON’T rush the person. Ask the person
transfer him, even if he is unconscious. As if she is ready to stand up before
DO make sure the person is wearing
you move through the steps, explain each continuing with the transfer.
footwear. The person’s shoes or slippers
step as you come to it.
should fit well and have nonskid soles. DON’T allow the person to put her arms
DO tell the person what he can do to help around your neck during the transfer.
DO use a transfer belt, unless the person
make the transfer easier, and encourage Instead, have the person place her hands
has a condition that makes the use of
the person to help as much as possible. on your arms for support.
a transfer belt dangerous (for example,
DO give clear directions to the people recent abdominal, chest or back surgery; DON’T use a mechanical lift until you
who are helping you (that is, the person severe respiratory problems; or severe have been properly trained in its use.
receiving care, your co-worker or both). cardiac problems).

Chapter 12 | Assisting with Positioning and Transferring | 167

care plan. For many people, being moved in a lift is 5. Mr. Klein is in the side-lying (lateral) position.
very frightening, so be sure to reassure the person Where will you place positioning aids to ensure
throughout the procedure. good body alignment?
a. Under Mr. Klein’s knees
b. Between Mr. Klein’s lower legs and against
After his bath, Mr. Rivera agrees that he his back
would like to get out of bed and sit in the chair by his c. Against his outer thighs
bed. His mobility is limited because of his left-sided
d. Against his feet
paralysis, but he can balance himself with assistance
and can support his own weight. 6. Miss Singleton is at risk for developing
pressure ulcers. Which piece of equipment
What do you consider before getting
will you use when repositioning her to help
Mr. Rivera out of bed and into the chair?
prevent friction and shearing that can lead to
Which type of transfer method should
skin breakdown and put her at further risk for
you use?
pressure ulcers?
a. A foot board
b. A bed cradle
c. A draw sheet
CHECK YOUR UNDERSTANDING d. A wheelchair

7. You are helping Mr. Lipkin transfer from his bed

Questions for Review to a wheelchair. What should you do to ensure
Mr. Lipkin’s safety during the transfer?
1. What is the first sign of a pressure ulcer?
a. Allow him to place his arms around your neck.
a. A reddened area on the skin
b. Use a draw (lift) sheet.
b. A fever
c. Allow him to rest on the edge of the bed before
c. An open sore
continuing with the procedure.
d. Bleeding
d. Raise the bed to a comfortable working height
2. To avoid damaging the skin of a person who and unlock the wheels on the bed and wheelchair.
is unable to move without help, you should
reposition him: Questions to Ask Yourself
a. Whenever you can fit him into your schedule. 1. Mrs. Karmody has been sitting in a chair watching
b. At least every 4 hours. television for the past 2 hours. When you come to
c. According to the schedule in the person’s help her change position, she wants to lie on her
care plan. back and sleep. What should you do?
d. When you come to work and before you go home. 2. Mr. Eller, who is paralyzed on his right side, is sitting
in a chair next to his bed. Every time you look into
3. When planning to move a person, some of the his room, he has slumped over to his weaker side.
things you must know are: What could you do to position him properly and
a. Whether the person is permitted to move (per maintain his alignment?
the person’s care plan).
3. Mrs. Hillman, who weighs 200 pounds, begins
b. Whether the person has risk factors for to stand up from the chair where she is sitting.
pressure ulcers. Knowing that she often gets dizzy without warning,
c. How recently the person ate. you offer to help her, but she insists that she is able
d. The person’s mobility, level of independence and to stand up by herself. What safety precautions
ability to help. should you take to prevent potential injury? How
many people are needed to help Mrs. Hillman
4. In which position is the head of the bed raised transfer safely?
30 degrees?
4. Mrs. Romano is sitting in the chair in her room while
a. Supine her niece is visiting. When Mrs. Romano says she
b. Modified side-lying wants to get back into her bed, her niece says that
c. Prone she will help her. You offer to help, but the niece
d. Low Fowler’s says she can do it by herself. What should you do?

168 | | Nurse Assistant Training

 SKILLS

Skill 12-1
Lifting a Person’s Head and Shoulders off the Bed

PREPARATION 9. Raise the person’s head and shoulders off the bed
by shifting your weight toward the foot of the bed
1. Wash your hands. (Figure 2). Remember not to twist when you lift.
2. Gather your supplies. Ask the person to assist you as much as he can by
helping to support himself with his free hand.
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. Make
sure the wheels on the bed are locked.

PROCEDURE
6. Face the head of the bed and position your feet
so that one foot is about 12 inches in front of your
other foot.
7. If the person can help, ask him to place his arm
that is nearer to you under your arm and to hold on
behind your shoulder.
8. Place your arm that is nearer to the person under his Figure 2
closest arm and behind his shoulder. Place your arm
that is farthest from the person under his upper back 10. Use your hand that is under the person's shoulders
and shoulders (Figure 1). to readjust the pillow, and then help the person lie
back down.

COMPLETION
11. Ensure the person’s comfort and good
body alignment.
12. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or
raise the side rails according to the person’s
care plan.
13. Clean up your work area.
14. Wash your hands.
Figure 1 15. Report and record.

Chapter 12 | Assisting with Positioning and Transferring | 169

SKILLS

Skill 12-2
Moving a Person Up in Bed (One Nurse Assistant)

PREPARATION 8. Prepare the person to help with the move.

■ Option A: Ask the person to bend his knees
1. Wash your hands.
and place his feet firmly on the bed. Then ask
2. Gather your supplies.
him to place his hands palm side down on the
3. Knock, greet the person and ensure privacy. bed. Place one arm under his shoulders and
4. Explain the procedure. one hand under his thighs (Figure 2A). Ask the
person to help by pushing against the bed with
5. Adjust equipment for body mechanics and safety:
his hands and feet on your count of 3.
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Lower the head of the bed as low as the person
can tolerate. Ask the person to lift his head, or if he
is unable, gently lift his head and remove the pillow.
Place the pillow against the headboard.
7. Face the head of the bed and position your feet so
that one foot is about 12 inches in front of your other
foot (Figure 1). Bend your hips and knees so that
your upper back remains straight.

Figure 2A

■ Option B: If the person is able, ask him to grasp

a trapeze (Figure 2B). Ask the person to assist
you by pulling himself up on your count of 3.

Figure 2B

9. Tell the person to get ready to move on your count of 3.

10. On your count of 3, shift your weight onto the foot
nearest the headboard, moving the person up
toward the head of the bed.
11. Help the person lift his head and replace the pillow.
Figure 1

170 | | Nurse Assistant Training

 SKILLS

COMPLETION method of calling for help within reach. Lower or raise

the side rails according to the person’s care plan.
12. Ensure the person’s comfort and good body alignment.
14. Clean up your work area.
13. Adjust equipment for safety. Lower the bed to the
level specified in the person’s care plan. Make sure 15. Wash your hands.
the wheels on the bed are locked. Place the person’s 16. Report and record.

Chapter 12 | Assisting with Positioning and Transferring | 171

SKILLS

Skill 12-3
Moving a Person Up in Bed Using a Draw Sheet
(Two Nurse Assistants)

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■
Draw sheet, if one is not already on the bed
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. Make
sure the wheels on the bed are locked.

PROCEDURE Figure 1
6. Ask your co-worker to stand as close to the bed
as possible on one side of the bed while you stand 12. Tell the person that if he is able to help, he should
on the other side. Review the procedure with bend his knees and push up with his feet at your
your co-worker. count of 3. Tell your co-worker that on your count of
3, together you will move the person to the top of the
7. Lower the head of the bed as low as the person can
bed by lifting up and moving the draw sheet toward
tolerate. If a draw sheet is not already on the bed,
the head of the bed.
position one under the person now. Make sure the
person is in the center of the bed. 13. On your count of 3, both you and your co-
worker shift your weight onto the foot nearest the
8. Ask the person to lift his head, or if he is unable,
headboard, moving the person up toward the head
gently lift his head and remove the pillow. Place the
of the bed by lifting and moving the draw sheet. Lift
pillow against the headboard.
smoothly, without jerking, and lift the person high
9. Face the head of the bed and position your feet so enough off the bed so that he does not slide along
that one foot is about 12 inches in front of your other the bottom sheet. Keep your elbows as close to your
foot. Bend your hips and knees so that your upper body as you can to avoid straining your back.
back remains straight. Your co-worker does
14. Help the person lift his head and replace the pillow.
the same.
15. Retuck or remove the draw sheet.
10. Loosen the draw sheet on each side of the bed and
roll it toward the side of the person. Your co-worker
does the same. COMPLETION
11. With your palms up and your hands close to the 16. Ensure the person’s comfort and good
person’s body, grasp the rolled draw sheet with both body alignment.
hands, placing one hand at the person’s shoulders 17. Adjust equipment for safety: Lower the bed to the
and the other at the person’s hips (Figure 1). Your level specified in the person’s care plan. Make sure
co-worker does the same. the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or raise
the side rails according to the person’s care plan.
18. Clean up your work area.
19. Wash your hands.
20. Report and record.

172 | | Nurse Assistant Training

 SKILLS

Skill 12-4
Moving a Person Up in Bed Using a Draw Sheet
(One Nurse Assistant)
NOTE: This procedure can only be performed with a bed 11. Bend your hips and knees so that your upper back
that does not have a headboard. remains straight.
12. Tell the person to get ready to move on your count
PREPARATION of 3. On your count of 3, rock backward, moving the
1. Wash your hands. person up toward the head of the bed by lifting and
moving the draw sheet.
2. Gather your supplies:
13. Help the person lift his head and replace the pillow.
■ Draw sheet, if one is not already on the bed
14. Retuck or remove the draw sheet.
3. Knock, greet the person and ensure privacy.
4. Explain the procedure. COMPLETION
5. Adjust equipment for body mechanics and safety: 15. Ensure the person’s comfort and good body
Raise the bed to a comfortable working height. alignment.
Make sure the wheels on the bed are locked.
16. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
PROCEDURE the wheels on the bed are locked. Place the person’s
6. Loosen the draw sheet on both sides of the bed. method of calling for help within reach. Lower or
raise the side rails according to the person’s
7. Lower the head of the bed as low as the person can care plan.
tolerate. If a draw sheet is not already on the bed,
position one under the person now. Make sure the 17. Clean up your work area.
person is in the center of the bed. 18. Wash your hands.
8. Ask the person to lift his head, or if he is unable, 19. Report and record.
gently lift his head and remove the pillow. Place it
alongside the person or on a chair.
9. Stand at the center of the head of the bed (facing
the foot of the bed) and position your feet so that one
foot is about 12 inches in front of your other foot.
10. Roll the draw sheet close to the person’s head and
shoulders. With your palms up, grasp the rolled draw
sheet with both hands, on either side of the person’s
head (Figure 1). Ask the person to bend his knees if
he is able and place his feet flat against the bed so
that he can help push up.

Figure 1

Chapter 12 | Assisting with Positioning and Transferring | 173

SKILLS

Skill 12-5
Moving a Person to the Side of the Bed
(One Nurse Assistant)

PREPARATION
1. Wash your hands.
2. Gather your supplies.
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Lower the head of the bed as low as the person can
tolerate. Ask the person to lift her head, or if she is Figure 2
unable, gently lift her head and remove the pillow.
Place the pillow against the headboard. person’s lower legs toward you so that the person is
in proper body alignment (Figure 3).
7. Face the bed and position your feet so that one
foot is about 12 inches in front of your other foot.
Bend your hips and knees so that your upper back
remains straight.
8. Ask the person to cross her arms over her chest.
9. Place one of your arms under the person’s neck and
shoulders and the other arm under the person’s upper
back. On your count of 3, rock backward and lift the
person’s upper body toward you (Figure 1).

Figure 3

12. Moving the person to the side of the bed is usually

the first step in another procedure. Continue with
the other procedure as planned.

COMPLETION
13. Ensure the person’s comfort and good body alignment.
14. Adjust equipment for safety: Lower the bed to the
Figure 1
level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
10. Reposition your hands, placing one hand under the method of calling for help within reach. Lower or raise
person’s waist and the other under her thighs (Figure 2). the side rails according to the person’s care plan.
Using the same motion, count to 3 and rock backward,
15. Clean up your work area.
lifting the person’s lower body toward you.
16. Wash your hands.
11. Finally, reposition your hands under the person’s
calves and feet and, on your count of 3, move the 17. Report and record.

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 SKILLS

Skill 12-6
Moving a Person to the Side of the Bed
(Two Nurse Assistants)

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Draw sheet, if one is not already on the bed
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Ask your co-worker to stand on one side of the Figure 1
bed while you stand on the other side. Review the
procedure with your co-worker. 12. Tell your co-worker that on your count of 3, together
you will move the person by lifting up and moving the
7. Lower the head of the bed as low as the person can draw sheet toward your co-worker’s side of the bed.
tolerate. If a draw sheet is not already on the bed,
position one under the person now. 13. On your count of 3, shift your weight from your
back foot to your front foot, while your co-worker
8. Ask the person to lift her head, or if she is unable, shifts her weight from her front foot to her back
gently lift her head and remove the pillow. Place the foot. Move the person toward your co-worker’s
pillow against the headboard. side of the bed by lifting and moving the draw
9. Face the side of the bed and position your feet so sheet. Lift smoothly, without jerking, and lift the
that one foot is about 12 inches in front of your other person high enough off the bed so that she does
foot. Bend your hips and knees so that your upper not slide along the bottom sheet. Keep your
back remains straight. Your co-worker does the elbows as close to your body as you can to avoid
same. straining your back.

10. Loosen the draw sheet on each side of the bed and 14. Moving the person to the side of the bed is usually
roll it toward the side of the person. Your co-worker the first step in another procedure. Continue with
does the same. the other procedure as planned.

11. With your palms up and your hands close to the

person’s body, grasp the rolled draw sheet with both COMPLETION
hands, placing one hand at the person’s shoulders
15. Ensure the person’s comfort and good
and the other at the person’s hips (Figure 1). Your
body alignment.
co-worker does the same.
16. Adjust equipment for safety: Lower the bed to
the level specified in the person’s care plan. Make
sure the wheels on the bed are locked. Place the
person’s method of calling for help within reach.
Lower or raise the side rails according to the
person’s care plan.
17. Clean up your work area.
18. Wash your hands.
19. Report and record.

Chapter 12 | Assisting with Positioning and Transferring | 175

SKILLS

Skill 12-7
Turning a Person onto Her Side
(One or Two Nurse Assistants)

PREPARATION 11. Turn the person onto her side.

■ Option A: If you are working alone, stand on
1. Wash your hands.
the side of the bed toward which the person is
2. Gather your supplies:
turning. Face the side of the bed and position
■
Draw sheet, if one is not already on the bed your feet so that one foot is about 12 inches
■
Blanket or towel in front of your other foot. Bend your hips and
■ Two or three extra pillows knees so that your upper back remains straight.
Place one hand on the person’s far shoulder and
3. Knock, greet the person and ensure privacy.
the other hand on her upper thigh (Figure 2A).
4. Explain the procedure. Roll the person toward you by transferring your
5. Adjust equipment for body mechanics and safety: weight from your front foot to your back foot.
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. If a co-worker is assisting you, ask your co-worker to
stand on one side of the bed while you stand on the
other side. Review the procedure with your co-worker.
7. Lower the head of the bed as low as the person can
tolerate. If a draw sheet is not already on the bed,
position one under the person now.
8. Ask the person to lift her head, or if she is unable,
gently lift her head and remove the pillow. Place the
pillow against the headboard.
9. Move the person to the side of the bed nearest you Figure 2A
(see Skills 12-5 or 12-6).
10. Tell the person that she can help you by crossing her ■ Option B: If you are working with a co-worker,
arms over her chest and crossing her ankles toward
the direction that you are turning her. For example, your co-worker grasps the draw sheet and rolls it
if the person is turning onto her left side, cross her close to the side of the person’s body. Grasping
right ankle over her left (Figure 1). the rolled-up draw sheet with palms up and using
a broad base of support, your co-worker counts
to 3, lifts the draw sheet, and rolls the person
toward you onto her side (Figure 2B). You help
to roll the person toward you by transferring your
weight from your front foot to your back foot.

Figure 1

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 SKILLS

a third pillow lengthwise between the person’s lower

legs. (The bottom leg should be straight and the top
leg slightly bent.) Place a rolled towel or blanket, or
another pillow, along the person’s back.
13. Retuck or remove the draw sheet.

COMPLETION
14. Ensure the person’s comfort and good body
alignment.
15. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or raise
Figure 2B the side rails according to the person’s care plan.
12. Make sure the person is not lying on her lower arm. 16. Clean up your work area.
Help the person lift her head and replace the pillow. If
17. Wash your hands.
the person will be remaining in the side-lying position,
place a second pillow under the person’s top arm and 18. Report and record.

Chapter 12 | Assisting with Positioning and Transferring | 177

SKILLS

Skill 12-8
Turning a Person Using a Logrolling Technique

PREPARATION 10. On your count of 3, both of you rock backwards,

transferring your weight to the back foot
1. Wash your hands. to move the person toward the side of the
2. Gather your supplies: bed (Figure 2).
■
Blanket or towel
■ Two or three extra pillows
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Stand with your co-worker on the same side of
the bed.
7. Lower the head of the bed as low as the person
can tolerate.
8. Place your hands under the person’s head and
shoulders, and have your co-worker place his hands
under the person’s hip and legs (Figure 1).

Figure 2

11. Raise the side rail and move to the opposite side of
the bed.
12. Place a pillow lengthwise between the person’s
lower legs. Cross the person’s arms over his chest.
Figure 1
If the person is turning onto his right side, place his
right arm on top. If the person is turning onto his left
9. Face the side of the bed and position your feet so side, place his left arm on top.
that one foot is about 12 inches in front of your
other foot. Bend your hips and knees so that your
upper back remains straight. Your co-worker does
the same.

178 | | Nurse Assistant Training

 SKILLS

13. Place your hands on the person’s far shoulder and 15. Make sure the person is not lying on his lower arm.
hip, and have your co-worker place his hands on the Place a small pillow or folded blanket under the
person’s far hip and calf (Figure 3). person’s head, if allowed. Leave the pillow between
the person’s legs in place. Place another pillow
under the person’s top arm and a third along the
person’s back.

COMPLETION
16. Ensure the person’s comfort and good body alignment.
17. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or raise
the side rails according to the person’s care plan.
18. Clean up your work area.
19. Wash your hands.
Figure 3 20. Report and record.

14. On your count of 3, roll the person toward you,

keeping his head, back and legs in a straight
line (Figure 4).

Figure 4

Chapter 12 | Assisting with Positioning and Transferring | 179

SKILLS

Skill 12-9
Repositioning a Person in a Chair
(Two Nurse Assistants)

PREPARATION 9. Support the person’s head against your chest or one

shoulder, and grip the transfer belt firmly with your
1. Wash your hands. palms up.
2. Gather your supplies: 10. Tell the person and your co-worker that on your
■
Transfer belt count of 3 you are going to move the person back.
3. Knock, greet the person and ensure privacy. 11. On your count of 3, your co-worker slightly lifts the
person’s legs and guides them toward the back of
4. Explain the procedure. the chair, while you lift the person’s upper body by
5. Adjust equipment for body mechanics and safety: slowly straightening your legs (Figure 2). Make sure
If the person is in a wheelchair, remove or fold back the person’s back and buttocks are resting against
the footrests and lock the brakes. the back of the chair. Place his feet on the footrests,
if used.
PROCEDURE
6. Put the transfer belt on the person.
7. Stand as close as possible to the back of the chair,
facing the person’s back.
To give yourself a broad base of support, place one
leg against the back of the chair, and place your
other leg about 12 inches behind the first. Bend
your knees.
8. Ask your co-worker to kneel on one knee close
to the person’s legs and place an arm under the
person’s knees (Figure 1).

Figure 2

COMPLETION
12. Ensure the person’s comfort and good body
alignment.
13. Adjust equipment for safety: If the person is in a
wheelchair, make sure the wheels on the wheelchair
are locked. Place the person’s method of calling for
help within reach.
14. Clean up your work area.
15. Wash your hands.
Figure 1 16. Report and record.

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 SKILLS

Skill 12-10
Transferring a Person from the Bed to a Chair
(One or Two Nurse Assistants)
PREPARATION person sits up after being in bed for a while. See
if the dizziness passes in 2 minutes. If it does not
1. Wash your hands. pass, if it gets worse, if he becomes sweaty or
2. Gather your supplies: short of breath, or if he is in any pain, help
the person to lie back down and report your
■ Transfer belt observations to the nurse.
■ Wheelchair or chair 10. Help the person put on the robe and footwear.
■ The person’s robe and slippers or shoes Put the transfer belt on the person.
3. Knock, greet the person and ensure privacy. 11. Prepare the person to stand up.
4. Explain the procedure. ■ Option A: Grasp the transfer belt on the back
5. Adjust equipment for body mechanics and safety. side of the person’s waist (Figure 2A).
Lower the bed to its lowest position. Make sure the
wheels on the bed are locked.

PROCEDURE
6. Place the chair against the bed on the person’s
stronger side so that it faces the foot of the bed. If
you are using a wheelchair, remove or fold back the
footrests and lock the brakes.
7. Raise the head of the bed so that the person is
almost in a sitting position.
8. Face the side of the bed, and position your feet so
that one foot is about 12 inches in front of your other
foot. With your knees bent and back straight, put
one of your arms across the person’s upper back Figure 2A
and the other arm under his thighs. On your count of
3, pivot your feet to turn the person toward you so
that he is sitting on the edge of the bed (Figure 1). ■ Option B: If you are not using a transfer belt, put
your arms underneath the person’s arms, and place
your hands on his shoulder blades (Figure 2B).

Figure 1

9. Allow the person to sit on the edge of the bed with Figure 2B
his feet flat on the floor for at least 2 minutes before Continued on next page
continuing. Some dizziness is common when a

Chapter 12 | Assisting with Positioning and Transferring | 181

SKILLS

Skill 12-10
Transferring a Person from the Bed to a Chair
(One or Two Nurse Assistants) Continued
■ Option C: If you have help from a co-worker, 13. Tell the person that on your count of 3, he can push
have your co-worker grasp one side of the down on the bed with his hands while you assist him
transfer belt on the back side of the person’s to a standing position. On your count of 3, straighten
waist, while you grasp the other. Alternatively, your legs, helping to lift the person to a standing
position (Figure 4).
each of you can place one arm underneath
the person’s arm, resting your hand on the
person’s shoulder blade.
12. Block the person’s lower extremities to prevent him
from slipping. To do this, face the person, placing
your feet “toe-to-toe.” Turn your toes slightly outward
to create a supportive base, and position your foot
closest to the chair farther back than the other foot.
Bend your knees deeply so that they rest against or
near the person’s knees (Figure 3). Have the person
lean forward toward you. If you are working with a
co-worker, each of you blocks one of the person’s feet.

Figure 4

14. Tell the person to place his arms on your upper arms
or shoulders to steady himself during the move.
Taking small steps, together, pivot around until the
person is right in front of the chair. Ask the person to
tell you when he can feel the chair against the back
of his legs (Figure 5).

Figure 3

182 | | Nurse Assistant Training

 SKILLS

Figure 6

16. Assist the person to position himself in the chair so

Figure 5 that his back is against the back of the chair. Place
his feet on the footrests, if used.
15. Help the person to feel for the arms of the chair, one 17. Remove the transfer belt.
arm at a time, while keeping your other arm around
his waist for support. Put your head to the person’s COMPLETION
side closest to the chair so that you can keep the
18. Ensure the person’s comfort and good body
chair in sight during the move. Lower the person into
alignment.
the chair by bending your knees and keeping your
back straight (Figure 6). 19. Adjust equipment for safety: If the person is in a
wheelchair, make sure the wheels on the wheelchair
are locked. Place the person’s method of calling for
help within reach.
20. Clean up your work area.
21. Wash your hands.
22. Report and record.

Chapter 12 | Assisting with Positioning and Transferring | 183

SKILLS

Skill 12-11
Transferring a Person from the Chair to a Bed
(One or Two Nurse Assistants)

PREPARATION your foot closest to the chair farther back than the
other foot. Bend your knees deeply so that they
1. Wash your hands. rest against or near the person’s knees. Have the
2. Gather your supplies: person lean forward toward you. If you are working
with a co-worker, each of you blocks one of the
■
Transfer belt person’s feet.
3. Knock, greet the person and ensure privacy. 12. Tell the person that on your count of 3, she can push
4. Explain the procedure. down on the arms of the chair with her hands while
you assist her to a standing position. On your count
5. Adjust equipment for body mechanics and safety: of 3, straighten your legs, helping to lift the person to
Lower the bed to its lowest position. Make sure the a standing position.
wheels on the bed are locked.
13. Tell the person to place her arms on your upper
PROCEDURE arms or shoulders to steady herself during the move.
Taking small steps, together, pivot around until the
6. Place the chair against the bed on the person’s person is in front of the bed. Ask the person to tell
stronger side so that it faces the foot of the bed. you when she can feel the bed against the back of
If the person is in a wheelchair, remove or fold back her legs.
the footrests and lock the brakes.
14. Help the person to sit on the edge of the bed.
7. Raise the head of the bed. Put your head to the person’s side closest to
the bed so that you can keep the bed in sight
8. Put the transfer belt on the person. during the move. Lower the person onto the
9. Face the person and position your feet so that one bed by bending your knees and keeping your
foot is about 12 inches in front of your other foot. back straight.
Help the person move to the front of the seat so that 15. Remove the transfer belt, the person’s robe and the
she is able to place her feet flat on the floor. person’s footwear.
10. Prepare the person to stand up. 16. Move the wheelchair out of the way.
■ Option A: Grasp the transfer belt on the back 17. With your knees bent and back straight, put one of your
side of the person’s waist. arms across the person’s upper back and the other arm
■ Option B: If you are not using a transfer belt, under her thighs. On your count of 3, pivot your feet to
put your arms underneath the person’s arms and turn the person so that she is lying on the bed.
place your hands on her shoulder blades.
■ Option C: If you have help from a co-worker, COMPLETION
have your co-worker grasp one side of the 18. Ensure the person’s comfort and good body
transfer belt on the back side of the person’s alignment.
waist, while you grasp the other. Alternatively, 19. Adjust equipment for safety: Make sure the wheels
each of you can place one arm underneath the on the bed are locked. Place the person’s method of
person’s arm, resting your hand on the person’s calling for help within reach. Lower or raise the side
shoulder blade. rails according to the person’s care plan.
11. Block the person’s lower extremities to prevent her 20. Clean up your work area.
from slipping. To do this, face the person, placing
21. Wash your hands.
your feet “toe-to-toe.” Turn your toes slightly
outward to create a supportive base, and position 22. Report and record.

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 SKILLS

Skill 12-12
Using a Mechanical Lift to Transfer a Person
(Two Nurse Assistants)

PREPARATION part of the sling. Pull the fanfolded sling toward you
until it is completely unfolded (Figure 1B). Help the
1. Wash your hands. person lie flat.
2. Gather your supplies:
■ Mechanical lift
■ Sling in the correct size for the person
■ Wheelchair or chair
■ The person’s robe, and her slippers or shoes
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Place the chair against the bed on the person’s
stronger side so that it faces the foot of the bed. If Figure 1B
you are using a wheelchair, remove or fold back the
footrests and lock the brakes.
Note: You can help the person put on his bathrobe
7. Ask your co-worker to stand on one side of the while he is turning from side to side. Make sure the
bed while you stand on the other side. Review the person's clothing is wrinkle-free. Put the person's
procedure with your co-worker. footwear on at this time too.
8. Detach the sling from the lift and fanfold half of it. 10. Wheel the lift into place over the person. Spread the
9. Roll the person toward you and place the fanfolded legs of the lift so that they are in their widest position
part of the sling along his back, making sure it is to provide a wide base of support during the move.
smooth for comfort (Figure 1A). Make sure the top Lock the brakes on the lift.
of the sling is under the person's shoulders and the 11. Attach the sling to the mechanical lift according to
bottom is at the person's knees. Roll the person over the manufacturer’s instructions (Figure 2).
the fanfolds, toward your co-worker and onto the flat

Figure 1A Figure 2

Continued on next page

Chapter 12 | Assisting with Positioning and Transferring | 185

SKILLS

Skill 12-12
Using a Mechanical Lift to Transfer a Person
(Two Nurse Assistants) Continued
12. Tell the person he may place his arms across his 14. Lock the brakes on the lift. While you slowly lower
chest or grasp the straps or chains. Use the crank, the person into the chair, your co-worker guides and
handle or electronic control on the lift to slowly lift steadies the person so that he is properly seated in
the person from the bed (Figure 3). the chair (Figure 5). Make sure the person’s back
and buttocks are resting against the back of the
chair. Place his feet on the footrests, if used.

Figure 3

Figure 5
13. Release the brakes on the lift and move the lift
away from the bed to the chair. Your co-worker
makes sure that the person’s body does not come 15. Remove the sling from the lift. You may keep the
in contact with the lift as you move him into position sling under the person, in preparation for using the
over the chair (Figure 4). lift to move the person back to the bed later. Make
sure the fabric of the sling is wrinkle-free.

COMPLETION
16. Ensure the person’s comfort and good body
alignment.
17. Adjust equipment for safety: If the person is in a
wheelchair, make sure the wheels on the wheelchair
are locked. Place the person’s method of calling for
help within reach.
18. Clean up your work area.
19. Wash your hands.
20. Report and record.
Figure 4

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Assisting with Personal C H A PT E R

Cleanliness and
Grooming 13
After reading this chapter, you will have the information needed to:
■ Understand how personal care can affect a person’s physical and emotional health.
■ Incorporate the five principles of care when assisting a person with personal care.
■ List observations that should be reported when assisting a person with personal care.
■ Explain why mouth care is important, and describe when mouth care should be
Goals provided.
■ Explain how to maintain the hair.
■ Explain how to assist a person with shaving, and describe safety measures that should
be observed.

Continued on next page

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 187

 Continued from previous page

■ Explain general principles to follow when assisting a person with dressing or

undressing.
■ Explain how to assist a person with maintaining vision and hearing aids.
■ Explain why hand care and foot care are important.
■ Explain general principles to follow when assisting a person with perineal care.
■ Explain the benefits of bathing.
■ Explain the benefits of a back rub.
After practicing the corresponding skills, you will have the information needed to:
■ Assist a person with natural teeth, a person with dentures and an unconscious person
Goals with mouth care.
■ Brush and comb a person’s hair.
■ Wash a person’s hair in bed.
■ Assist a person with shaving using a safety razor and an electric razor.
■ Assist a person to dress and undress.
■ Assist a person to insert and remove an in-the-ear hearing aid.
■ Assist a person with hand and foot care.
■ Assist a person with perineal care.
■ Give a person a complete bed bath.
■ Assist a person with a shower or tub bath.
■ Give a person a back rub.

Key Terms:
aspiration cuticles ingrown toenail perineal care

depilatory hangnail podiatrist circumcision

appearance. Personal cleanliness (hygiene), which is

Whenever you see Mrs. Winnie Steele, one achieved through regularly washing the body and hair
of your residents at Morningside Nursing Home, you and brushing the teeth, is important for both physical
are always impressed by how nice she looks and the and emotional health. These activities help to keep the
care she takes with her appearance. Even though skin, hair and mouth healthy by removing infection-
heart failure has slowed her down considerably and causing microbes. In addition, keeping the body and
made even the most routine tasks challenging for mouth clean prevents odors, which is important for
her, she still makes the effort needed to maintain her self-esteem. Grooming activities, such as dressing,
appearance. Mrs. Steele has olive skin and black hair, shaving, and styling the hair, help to maintain a neat
which she has professionally washed and styled every appearance and are also important for maintaining a
Wednesday at Morningside’s hair salon. She favors person’s emotional health. When you help a person
sweater sets in bright jewel tones, such as emerald with personal hygiene and grooming activities, you help
green, turquoise blue and ruby red, paired with white the person feel confident and attractive. A person who
or black dress slacks. Every day, she chooses jewelry feels confident and attractive is more likely to socialize
or a scarf to accessorize her outfit perfectly, and she with others, and feel better about himself or herself in
never leaves her room without first applying her general. Think about how you felt on a day when you
signature shade of lipstick. knew you looked your best, versus how you felt on a
day when you had to rush through your normal personal
care activities!
As a nurse assistant, you will help the people in your The way we appear to others says a lot about who we
care with the activities necessary for maintaining are and how we view ourselves. The decisions we make
personal cleanliness and a neat, well-cared-for that affect our outward appearance, such as how we

188 | | Nurse Assistant Training

choose to style our hair or what clothes we choose to scheduling these activities. For example, some
wear, are deeply personal because they are so closely people may prefer to bathe in the evening instead
tied to our self-image and self-esteem. Cultural and of in the morning. It is important to try and
religious beliefs can influence the decisions a person accommodate the person’s preferences as much as
makes about his or her outward appearance. So can possible when scheduling care. Also, be aware that
the person’s feelings about his or her own sexuality. often, care related to personal hygiene and grooming
Many of the people in your care will need your help to is provided outside of the regularly scheduled time.
maintain personal cleanliness and a neat appearance. For example, if a person spills food on her blouse
However, this does not mean that they have given up while eating, you will help her to change her blouse
the desire to make their own decisions concerning after the meal.
hygiene and grooming. When you are assisting with
Illness or disability can make it difficult for a person to
personal care, always try to find out the person’s
maintain her normal personal care routines. For many
preferences and honor them.
people, it can be difficult or embarrassing to accept
In health care facilities, activities related to personal help with activities of such a private, personal nature.
hygiene and grooming usually take place at Imagine what it would feel like to have a stranger
predictable times (Table 13-1). Scheduling of brush your teeth, bathe you, comb your hair and
these activities is necessary because they must be dress you. Be sensitive to the person’s feelings, and
accomplished in addition to other routine events remember to provide restorative care by encouraging
throughout the day, such as meals, therapy sessions the person to do as much for himself as he is able. This
and social events. It is still possible, however, to is important for the person’s self-esteem and sense of
take an individual’s preferences into account when independence.

Table 13-1 Scheduling of Routine Personal Care and Grooming Activities

Type of Care When It Is Provided What It Includes
Early Morning Care After the person wakes up, in preparation for Toileting
breakfast Mouth care
Washing the face and hands
Brushing the hair
Dressing

Morning Care After breakfast, in preparation for the Toileting

rest of the day Mouth care
Bathing
Washing and styling the hair
Shaving
Dressing
Bedmaking

Afternoon Care Before and after lunch and dinner, in Toileting

preparation for these meals and other activities, Mouth care
such as visiting hours or social events
Washing the face and hands
Brushing the hair

Evening Care Before bed Toileting

Mouth care
Washing the face and hands
Changing into sleepwear
Back rub

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 189

 harmful bacteria, regular mouth care also helps to
Today, Mrs. Steele’s daughter is coming to keep the tissues of the oral cavity moist. A dry mouth
take her mother to afternoon tea at a local hotel. is uncomfortable and can alter the taste of food and
Mrs. Steele is excited about seeing her daughter. She beverages, making them less appealing.
tells you that she has decided to wear a purple dress,
because it looks nice with a scarf her daughter gave
ELDER CARE NOTE. Good mouth care is
her for her birthday. While you are helping Mrs. Steele
important for people of all ages, but it is
with her early morning care, she reminds you that her
especially important for older people. Saliva
daughter is coming today and asks if you can help her
helps to keep bacteria from sticking to the
get ready before her daughter arrives at 2:00. She says
surfaces of the teeth. However, as we age,
she is going to need help changing clothes, tying the
saliva production decreases, leading to a
scarf and styling her hair. You have a busy day ahead,
dry mouth. Medications that older people
but you tell Mrs. Steele that you will come by around
commonly take, such as those used to treat
1:15 to help her get ready for her daughter’s visit.
high blood pressure, can also decrease saliva
If you were a visitor to Morningside Nursing production. In addition to allowing plaque to
Home and saw Mrs. Steele in the common build up faster, a dry mouth is uncomfortable
area, what opinions would you form about and can make food less appealing. For these
her well-being and the care she is receiving? reasons, regular mouth care is particularly
important for the older people in your care.
You agree to spend a little extra time to help
Mrs. Steele get ready for the outing with her
daughter. Why is this important? Do you At minimum, assist those in your care with mouth care:
think Mrs. Steele would enjoy the visit with ■ Every morning
her daughter as much if her hair weren’t ■ Every evening
styled the way she likes it, or if she was
■ After each meal
wearing an outfit she didn’t pick out herself?
Why or why not? ■ Every 2 hours, if the person is unconscious, on
“nothing by mouth” (NPO) status, on oxygen
therapy or breathes through the mouth (all of these
conditions can cause the mouth to become dry and
uncomfortable)
MOUTH CARE ■ After the person vomits
Assistive devices, such as toothbrushes with built-up
When you get up in the morning, how does your
handles or electric toothbrushes, may enable some
mouth feel? What do your teeth feel like after you eat
people to provide for their own mouth care independently
a meal? Part of your responsibility in assisting with
(Figure 13-1). Others will need varying amounts of
personal care is to help provide mouth care, also
assistance from you to ensure that they receive the proper
called oral hygiene. Mouth care includes care of the
mouth care. When assisting with mouth care, follow
teeth, gums, tongue, lips and soft parts of the inside
standard precautions, and take the opportunity to observe
of the mouth, such as the cheeks and the roof of
for changes that could indicate a health problem.
the mouth.
Good oral hygiene is necessary to keep the mouth
and the body healthy. Regular brushing and flossing Observations Into Action!
helps to remove plaque, a sticky, colorless layer of
bacteria that forms on the teeth. Sugars and starches Whenever you assist a person with mouth care,
in the food we eat cause the bacteria in plaque to observe for changes in the person’s mouth that
grow. These bacteria can cause bad breath odors. In could be a sign of a problem. Report any of the
addition, they produce acids, which destroy the outer following to the nurse:
surface of the tooth, leading to tooth decay. If plaque { Swollen, red or tender gums
is not removed by brushing the teeth, it hardens into { Bleeding gums
tartar. Tartar can cause gum irritation and infection, as { White patches
well as tooth decay and loss. The same bacteria that
{ Sores
cause gum inflammation and infection can also cause
inflammation and infection in other parts of the body, { Painful or sensitive areas
putting the person at risk for heart disease, stroke { Ill-fitting or broken dentures
and other serious conditions. In addition to removing { Bad breath that does not go away

190 | | Nurse Assistant Training

 dentures in place, it is easier for the person to chew food
properly and speak clearly.
Keeping the soft tissues of the person’s mouth healthy
and the dentures clean is important for health and also
makes it more likely that the person will want to wear the
dentures. Dentures are cleaned by brushing them with a
special toothpaste made for dentures. Some people may
also soak their dentures in a denture-cleansing solution as
part of their denture-cleaning routine. Dentures that have
been soaking in a denture-cleansing solution should be
brushed and thoroughly rinsed before placing them in the
person’s mouth. A soft mouth sponge is used to clean the
soft tissues of the mouth after the dentures are removed
for cleaning. Caring for the soft tissues of the person’s
mouth keeps the tissue healthy and helps to ensure that
the dentures continue to fit properly.
Figure 13-1 Some people may be able to manage their own mouth
care, if you set them up with the necessary supplies. Dentures are removed for cleaning and, ideally, for at least
8 hours every day (usually overnight) to rest the gums.
However, some people may prefer to wear their dentures
Mouth Care for a Person with at all times and only remove them for cleaning. When the
person is not wearing the dentures, they should be stored
Natural Teeth in a labeled denture cup in water or denture-cleansing
Natural teeth are cared for using a soft-bristled solution to prevent warping. Always handle a person’s
toothbrush, toothpaste and dental floss. The soft bristles dentures carefully, so that they do not chip or break. Also,
of the toothbrush remove plaque and food particles from take care not to lose the person’s dentures. Dentures are
the teeth and tongue and stimulate circulation in the expensive and time-consuming to replace, because they
gums, which helps keep them healthy. The toothbrush are custom-made for the person. To make it easier to
should be replaced every 3 to 4 months, or when it return dentures to their owner should they be misplaced
begins to show wear. A toothbrush with worn or frayed in a health care setting, many dentists label the dentures
bristles does not properly clean the teeth and may with the person’s initials or some other identification
injure the gums. Unless instructed otherwise, use a code when they are made. Denture-labeling kits are also
toothpaste that contains fluoride (a chemical that helps available and can be used if the dentures were not labeled
to strengthen the tooth enamel and prevent tooth decay). at the time of manufacture.
In some regions of the United States where the water
Skill 13-2 describes step-by-step how to provide mouth
contains high levels of fluoride, dentists may recommend
care for a person with dentures.
using toothpaste that does not contain fluoride. After
brushing, dental floss is used to remove plaque and
food particles from between the teeth. Waxed dental Mouth Care for a Person Who Is
floss slides between the teeth more easily than unwaxed Unconscious
dental floss does. Before flossing a person’s teeth, check
with the nurse or review the person’s care plan to see An unconscious person is not able to respond to her
whether there are any restrictions or special precautions environment and will be totally reliant on you for mouth
to be considered. For example, some people taking care. People who are unconscious breathe through their
certain medications may bleed excessively if their teeth mouths, which causes drying of the soft tissues of the
are flossed. Skill 13-1 describes step by step how to mouth and leads to the build-up of mucus and other
provide mouth care for a person with natural teeth. secretions on the teeth and tongue. You must provide
mouth care for an unconscious person every 2 hours
throughout the day and night to remove these secretions
Mouth Care for a Person with and prevent the mouth from becoming excessively dry.
Dentures When providing mouth care for a person who is
Many people have dentures (false teeth). Complete (full) unconscious, elevate the head of the bed (if allowed)
dentures replace all of the top teeth or all of the bottom and turn the person’s head to the side to allow fluids
teeth. Partial dentures replace only a few teeth. Wearing to run out of the mouth instead of down the person’s
dentures decreases gum shrinkage after teeth have been throat. This is important to prevent aspiration
removed and maintains the shape of the mouth. With (inhalation of fluids or other foreign materials into the

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 191

lungs). Aspiration can lead to pneumonia. Use a mouth When styling a person’s hair, be sure to ask about
sponge to clean the soft tissues of the person’s mouth the person’s preferences and follow them as
and a soft-bristled toothbrush moistened with water or closely as you can. For example, most people have
a mixture of mouthwash and water to clean the person’s a preferred side for parting their hair. Provide the
teeth. Remember to tell the person what you are doing person with a mirror, so that she can see what you
as you are doing it. Even though the person cannot are doing. If you must make decisions about how to
respond to you, he may be aware that something style a person’s hair for the person, choose an age-
is being done to him. Skill 13-3 describes step-by- appropriate, attractive style. Some people with very
step how to provide mouth care for a person who is curly hair may find it easier to keep their hair tangle-
unconscious. free if it is braided. Check with the person to make
sure that she wants her hair braided. If she does, be
careful not to braid the hair too tightly, because hair
HAIR CARE tends to draw tighter as it dries and may pull too
tightly on the scalp.
Hair care, which includes washing, brushing, combing
and styling the hair, is necessary to keep the hair and Skill 13-4 explains the procedure for brushing and
scalp healthy, and to maintain a neat appearance. combing a person’s hair.
Washing the hair (shampooing) removes dirt, oil and
bacteria from the hair and scalp. Brushing, combing Shampooing the Hair
and styling the hair helps to prevent painful tangles
from forming and provides for a neat appearance. Shampooing cleans the scalp and hair and stimulates
Many long-term care facilities have salons where blood flow to the scalp. Many people find it very relaxing
residents can go to have their hair professionally cut, to have the head and scalp gently massaged as part of
washed and styled. Many residents will choose to take the shampoo, and having clean hair can help a person to
advantage of this service, but you will be responsible feel better in general.
for helping the person with hair care in between visits How often the hair is washed varies from person to
to the salon. person. Older people tend to have drier skin and hair
People often have strong preferences regarding what and are usually less active than younger people, so they
products are used to care for their hair. For example, may only need to wash their hair once or twice a week.
some people may prefer a certain type of shampoo, or People with oily skin and hair or people who are very
like to use a conditioning rinse in addition to shampoo. active may need to wash their hair every day. Take into
People of African descent, who often have very curly account the person’s preferences and your employer’s
hair and dry scalps, may use oils, creams or lotions policies when working out a schedule for shampooing
to make the hair easier to comb and to moisturize the the person’s hair. Also, be aware that sometimes an
scalp. These products are usually applied to the scalp unscheduled shampoo can help a person to feel better
after shampooing and then massaged into the scalp and (for example, if the person is feverish and the hair has
hair. When assisting a person with hair care, find out become sweaty).
what products the person likes to use, and honor those Shampooing is often accomplished in the shower or
preferences as much as possible. tub while bathing. If the person is unable to get out
of bed, his hair can be washed while he is in the bed
Brushing, Combing and Styling using a shampoo tray (a device that funnels the water
into a wash basin placed on a chair or the floor beside
the Hair the bed) (Figure 13-2, A). If a shampoo tray is not
A comb with widely spaced, blunt teeth is used to available (for example, in the home setting), one can
remove tangles from wet or dry hair. A brush is used on be improvised using a large plastic trash bag. Place
dry hair to neaten the appearance of the hair. To prevent a rolled towel inside the bag. Twist it into a C shape.
hair from breaking and to detangle the ends, start Place the person’s head in the center of the C. Drape
brushing or combing from the ends of the hair, working the sheet or bag toward the side of the bed so that
toward the scalp, and work in small sections. If the water drains into a washbasin placed on a chair. Skill
hair is very tangled, wet the hair and apply conditioner 13-5 describes step-by-step how to wash a person’s
before combing, and then wash and rinse the hair after hair in bed using a shampoo tray. A shampoo cap
you have removed all the tangles. Remember to comb can also be used to wash a person’s hair in bed (see
and brush hair gently so that you do not pull it out. With Figure 13-2, B). The cap, which contains a rinse-free
age, hair becomes drier and more fragile. In addition, cleanser, is placed over the person’s hair, and the hair
some medications and medical treatments cause hair to and scalp are massaged through the cap to remove
become brittle or fall out. dirt and oils.

192 | | Nurse Assistant Training

A B
Figure 13-2 A person’s hair can be washed in bed using (A) a shampoo tray or (B) a shampoo cap.

Observations Into Action! bleed excessively if they are cut, check the person’s care
plan or ask the nurse before assisting a person to shave
Whenever you assist a person with hair care, with a safety razor. For people with conditions that can
observe for unusual conditions. Report any of the cause them to bleed excessively, an electric razor is
following to the nurse: usually preferred.
{ Sores on the person’s scalp Before helping a person to shave using a safety razor,
{ Unusual flaking or dandruff inspect the skin for moles or other raised areas. Shave
{ Excessive hair loss carefully around these areas to avoid scraping or cutting
{ Tangles that cannot be removed them, which could cause bleeding. Apply shaving cream,
gel or soap to soften the hair and help the razor glide
over the skin. Many men will prefer to finish the shave by
applying aftershave lotion, which has a nice scent and
helps to soothe the skin. The alcohol in most aftershave
SHAVING lotions also acts as an antiseptic and can help to stop
Shaving is done to remove unwanted hair from the body. bleeding from small nicks or cuts. If a nick or cut does
Many men shave their faces daily, either in the morning occur while shaving, report this to the nurse.
or at bedtime, to remove facial hair. Skill 13-6 describes
Always take standard precautions when helping a
how to help a man to shave his face. Women may shave
person to shave with a safety razor. Because blood
leg and underarm hair. This type of shaving is most easily
particles may be left on the razor blade and can
done at bath time.
spread infection, make sure each person has his
Removal of unwanted hair can be accomplished in own safety razor. When the blade on a safety razor
a variety of ways. A safety razor is used with warm becomes dull, it is more likely to nick the person’s skin.
water and shaving cream, gel or soap. An electric razor Depending on the type of safety razor, the entire unit
is used after applying a pre-shave lotion. Men who may be disposable, or you may just need to replace
have very curly beards may prefer not to shave, but the blade. Always handle razors and blades carefully
to use a depilatory cream or powder to chemically to avoid nicking yourself, and dispose of them properly
dissolve and remove facial hair. Many women also use in a sharps container. To store a safety razor between
a depilatory product to remove unwanted leg, underarm uses, place it blade-end down in a container without
or facial hair. recapping it. You may accidentally cut yourself if you
attempt to recap the razor.
Shaving with a Safety Razor
When using a safety razor, it is easy to nick the skin,
Shaving with an Electric Razor
causing bleeding. Because people with certain medical An electric razor lifts the hair away from the skin before
disorders or who are taking certain medications can slicing it off with the blade. Thus, an electric razor carries

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 193

a lower risk of cutting or nicking the skin and is preferred
for people with blood-clotting disorders and those who
are taking medications that affect the blood’s ability to
clot. Applying a pre-shave lotion can help to soften the
hairs and may result in a smoother shave when using an
electric razor.
Electric razors are small appliances, so remember
to take the same precautions when using them that
you would with any electrical appliance. Inspect the
razor before using it to make sure that the cord is not
frayed and that it is operating normally. If the razor is
malfunctioning (for example, it stops and starts, or
is making a strange sound), do not use it. Check with
the nurse before using an electric razor in a room where
a person is receiving oxygen therapy, because an
electrical spark could ignite a fire. (It may be safe to use
Figure 13-3 Allow the people in your care to choose what clothing they
a battery-operated or rechargeable electrical razor in will wear whenever possible.
these circumstances, but check with the nurse first.)
To keep the razor in good working order, take it apart
and clean it after each use.
Clothing should fit properly and be in good condition. If
you notice that an article of clothing is stained, ripped,
torn, missing buttons or in need of alterations to make it
DRESSING AND UNDRESSING fit properly, talk to the nurse so that arrangements can
Clothing changes occur several times throughout be made to have the clothing cleaned, altered, repaired
the day. At minimum, people usually change clothing or replaced.
in preparation for the day ahead and in preparation Skill 13-7 describes how to help a person to put on
for sleep. In addition, whenever an article of clothing and take off clothing. Sometimes there will be special
becomes soiled or wet, it must be changed. circumstances that you must take into account when
Many people will be able to dress and undress with helping a person to dress. When helping a person
minimal assistance from you. Assistive devices such as with a weak, paralyzed or injured arm or leg to dress,
shoehorns, buttoning aids and zipper pulls can help a put the garment on the affected arm or leg first. Then,
person function more independently with dressing and do the opposite when you are helping the person to
undressing. So can choosing clothing that is easier for undress: Remove the garment from the affected arm or
the person to put on and take off. For example, pants leg last.
with elastic waistbands may be easier for a person to Some people will be required to wear compression
manage than pants with zippers, buttons or ties. stockings. These stockings, which are made of tight-
For some people who are receiving health care, it can be fitting elastic, compress (squeeze) the veins in the legs.
very difficult to make the effort required to get dressed Compressing the veins in the legs helps to return blood
each day. However, it is important to encourage them to the heart, preventing complications such as blood
to do so, unless they are very ill. Getting dressed every clots. Because they are so tight, these stockings can be
day helps people to maintain their sense of identity and very difficult for a person to put on independently. Skill
purpose. Encourage the person to do as much as he 13-8 describes how to assist a person with putting on
can, and provide help as needed. compression stockings. These stockings must be put
on before the person gets out of bed in the morning.
It is also important to allow people to make their own If the person has been standing, have her sit in a chair
decisions about what they want to wear (Figure 13-3). with the legs elevated for 15 minutes before putting on
If the person has trouble making decisions, limit the the stockings. Compression stockings usually have an
number of choices, but still allow the person to choose. opening across the top of the toes. This opening is so
When helping a person select clothing, consider: that you can check the person’s toes for changes that
■ The person’s preferences. might suggest poor circulation to the toes, such as a
bluish color or coldness. Check the person’s circulation
■ The person’s physical capabilities.
hourly. If you note that the toes are pale, blue or cold, or
■ What the person will be doing that day. the person complains of numbness or tingling in the feet,
■ The weather and the season. report these signs and symptoms to the nurse.

194 | | Nurse Assistant Training

 wear them, especially when they are out of bed. This is
At 1:15, you go to Mrs. Steele’s room as important for safety.
promised. She has gotten the dress and scarf she
Eyeglasses are expensive and it can be inconvenient to
wants to wear out of the closet and laid them on the
replace them if they become broken or lost, so always
bed. You pull the privacy curtain, and help Mrs. Steele
handle them carefully. When the person is not wearing
sit on the edge of the bed and get out of the clothes
them, they should be stored in their case. The person
she is wearing. While you are helping Mrs. Steele get
may need help keeping the glasses clean. Clean the
ready, you chat with her about her daughter and about
glasses with soap and water or eyeglass-cleaning wipes,
how excited she is for this visit. Mrs. Steele is able
which are moistened with a cleansing agent meant
to put her slip on by herself, but she needs your help
specifically for cleaning eyeglasses. If soap and water
pulling her stockings up. After you help her with her
are used to clean the glasses, dry them with a soft, clean
stockings, Mrs. Steele pulls the dress over her head,
cloth to avoid scratching the lenses.
and you help her zip it up the back. Next, you arrange
the scarf around her neck and tie it the way you know
she likes it tied. You smile and say, “Here’s a hand
mirror, Mrs. Steele. Did I get it right?” Mrs. Steele Observations Into Action!
checks the mirror, smiles back and says, “It’s perfect,
When a person in your care wears eyeglasses, report
dear.” You hand Mrs. Steele her hair brush and say,
any of the following observations to the nurse:
“Let me hold the mirror for you while you brush your
hair. We messed it up a bit when we pulled that dress { The person does not seem to be seeing
over your head.” Mrs. Steele brushes her hair, and well with the eyeglasses.
then you help her to put her shoes on. Just then, Mrs. { The person states that the eyeglasses are
Steele’s daughter knocks and calls out, “Mom? OK if I “not working as well as they used to.”
come in?” You pull back the privacy curtain and open { The eyeglasses pinch or rub the person’s
the door. “Mom, you look beautiful as always,” says nose or ears, or slip down the person’s
Mrs. Steele’s daughter as she enters the room. “Are nose.
you all ready to go?” { The eyeglasses are in need of repair.
Why do you think it is important for
Mrs. Steele’s daughter to see her mother
looking “beautiful as always”? Do you
Contact Lenses
think she would be concerned if there were Contact lenses are placed directly on the eye to
a change in Mrs. Steele’s usual neat, well- correct vision. Some contact lenses are worn once
cared-for appearance? Why or why not? and discarded, while others need to be cleaned daily.
The solutions used to clean and store contact lenses
What are some of the advantages of talking
vary, depending on the type of lens. If you need to
with the people in your care while you assist
help a person maintain his contact lenses, be sure you
them with personal care?
know what products to use. Because contact lenses
are placed directly on the eye, it is very important to
maintain them properly. A damaged or dirty contact
lens can scratch the eye or cause an infection. Always
VISION AND HEARING AIDS wash your hands before handling a person’s contact
lenses.
Many of the people in your care will use vision aids
(such as eyeglasses or contact lenses), hearing aids
or both. These devices help the person interact with Prosthetic (False) Eyes
others and are therefore important to the person’s A person who has had an eye removed due to illness
overall quality of life. Although prosthetic (false) eyes or disease may choose to wear a prosthetic (false) eye.
do not help the person to see, they are important for Prosthetic eyes are custom-made for the person and can
helping the person maintain his or her appearance, and be very expensive to replace. If a person in your care has
in that respect are important to the person’s self-esteem a prosthetic eye and needs help caring for it, the nurse
and quality of life. will show you how to assist the person with removing,
cleaning and re-inserting the prosthesis. As with contact
lenses, it is important to care for the prosthetic eye
Eyeglasses properly to prevent injury to the eye socket and eyelid.
Eyeglasses are worn to correct vision problems. Always handle a prosthetic eye carefully, and with
Encourage the people in your care who have glasses to clean hands.

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 195

Hearing Aids Trimming the person’s fingernails may not be within
your scope of practice. Even if trimming the fingernails
A person with impaired hearing may use a hearing aid. is within your scope of practice, it may not be
Hearing aids are battery-operated devices worn in or permitted with certain people (such as those who
behind the ear to make sounds louder. Some of the have diabetes or other conditions that can impair
people in your care may need help inserting or removing circulation and sensation). Check with the nurse or
their hearing aids, and keeping them clean. Skill 13-9 consult the person’s care plan to make sure that you
describes how to insert and remove an in-the-ear are allowed to trim the person’s fingernails before
hearing aid. You may also need to help the person to doing so. If you are allowed to trim the nails, cut them
keep the hearing aid clean. Follow the manufacturer’s straight across so that the edge of the nail extends
instructions for cleaning. Make sure the person keeps slightly beyond the tip of the finger (Figure 13-4).
an extra battery on hand, so that the battery can be Then, smooth the edges of the nails using the
replaced promptly when necessary. emery board.
Like other assistive devices, hearing aids are expensive to
replace if they are lost or damaged. Moisture and hair care
products (such as hair spray) can damage a hearing aid, Observations Into Action!
so help the person to insert the hearing aid after providing
Assisting with hand care gives you a good
hair care. Store the hearing aid in its case, and out of
opportunity to observe for changes that could be
reach of children, pets and confused adults who might
a sign of a medical problem. Report any of the
mistake the battery for something that can be swallowed.
following observations to the nurse:
{ Reddened or discolored areas
{ Sores
HAND AND FOOT CARE { Hangnails
Hand and foot care involves cleaning and caring for the { Badly torn nails
skin of the hands and feet, and keeping the nails trimmed { Nails that have an odd shape or are
and smooth. Many people who are receiving health care unusually thick
need help caring for their hands and feet. Skill 13-10 { Nail beds that are blue or pale, instead of pink
describes how to provide hand and foot care.

Caring for the Hands Caring for the Feet

You will help the people in your care to wash their hands The feet have a large number of sweat glands. Washing
before meals, after using the bathroom and whenever and drying the feet and changing the socks regularly
else it may seem necessary. Assisting with care for the are important for comfort and to control odor. Keeping
fingernails is done as needed. Keeping the fingernails the nails trimmed and the edges smooth makes wearing
trimmed and smooth helps to prevent the person from footwear more comfortable.
accidentally scratching herself. Keeping the skin of the Many of the people in your care will not be mobile
hands moisturized promotes comfort and helps to keep enough to care for their own feet. In addition, many will
the cuticles (the skin along the edges of the nails) from have conditions such as diabetes that affect circulation
becoming ragged and torn. Hangnails (ragged and and sensation in the feet. In a person with poor
torn cuticles) are painful and unsightly, and can become circulation and sensation in the feet, a small injury such
infected.
Soaking the nails in warm water softens them and
makes them easier to trim. For this reason, nail care is
often done following a bath or shower. However, you
can assist a person with nail care any time by bringing a
small basin of warm water to the bedside.
Equipment used when providing nail care includes:
■ Nail clippers (used to trim the nails).
■ An emery board (used to smooth rough edges).
■ An orange stick (a wooden stick with an angled Figure 13-4 If trimming the person’s fingernails is within your scope
edge that is used to push the cuticles back and of practice, trim the nail straight across so that the nail extends slightly
clean underneath the nails). beyond the fingertip.

196 | | Nurse Assistant Training

as a blister or an ingrown toenail can lead to a serious
infection. (An ingrown toenail occurs when the toenail
is trimmed too short and the edge curls down and
grows into the neighboring skin.) Because sensation is
impaired in the foot, the person may not even be aware
of the injury.
With age, the toenails become thicker and more
difficult to cut. In addition, many people have
conditions such as diabetes that can make even a
small injury to the foot very dangerous. Because it
is easy to injure the person by trimming the toenails
too short or nicking the skin around the toenail, and
because such injuries can have serious consequences,
trimming a person’s toenails is usually outside of the
scope of practice for a nursing assistant. Instead,
a doctor who specializes in care of the feet (called
a podiatrist) or a nurse is usually responsible for
trimming the person’s toenails.
Your responsibilities with regard to foot care include
caring for the skin of the feet by washing the feet, drying
them well, and applying lotion to avoid dryness and
cracking. Foot care is often carried out during bath time,
but it may also be done independent of a bath. While Figure 13-5 During perineal care, the genitals, perineum and anal
region are cleansed. (A) Female anatomy. (B) Male anatomy.
you are providing foot care, you will have an opportunity
to inspect the feet for injuries or other problems. Report
any unusual conditions to the nurse. When providing perineal care, it is especially important
to take steps to protect the person’s dignity and
privacy. Always ask the person’s permission first, and
explain what you are going to do using words the
Observations Into Action! person can understand. For example, you can say,
Assisting with foot care gives you a good “I’m going to clean the area between your legs now.”
opportunity to observe for changes that could be Use a bath blanket to cover the person so that only
a sign of a medical problem. Report any of the the perineal area is exposed. Allow the person to
following: provide for his or her own perineal care to the greatest
extent possible.
{ Reddened or discolored areas
{ Sores or blisters Assisting a person with perineal care may also be
embarrassing for you. Although these feelings are
{ Breaks in the skin between the toes
normal, if the person senses that you are embarrassed or
{ Toenails that need trimming
uncomfortable, he or she will likely become embarrassed
{ Ill-fitting socks or shoes or uncomfortable, too. A straightforward, professional
approach can help to put the person at ease. Think
about how you would feel if you were unable to provide
for your own perineal care. Would you feel better
PERINEAL CARE about the situation if the person helping you was kind,
competent and professional?
Perineal care is the cleansing of the area between the
legs, including the genitals and the anus (Figure 13-5). Practice proper infection-control measures when
Perineal care is provided during a bath or shower, but it providing perineal care. Wear gloves, because contact
may also be provided any time it is needed. For example, with body fluids is likely. Also, use proper technique
a person who is incontinent of urine or feces will need for washing, rinsing and drying to avoid contaminating
perineal care after each episode of incontinence. Urine clean areas of the person’s body with microbes from
and feces are very irritating to the skin and if not removed, dirtier areas. The digestive tract contains microbes
they can lead to skin breakdown. Also, removing urine that are passed from the body with feces, through the
and feces from the skin is necessary to prevent odor and anus. It is important not to contaminate other parts
protect the person’s dignity and self-esteem. of the body, such as the urethra or vagina, with these

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 197

 body. Good blood flow to the skin helps to keep the skin
healthy. A back rub, which is often provided as part of
the bath, stimulates blood flow to the skin as well.
When and how a person chooses to bathe can be
influenced by factors such as the person’s culture,
religious beliefs or long-standing habits. Always make
an effort to accommodate a person’s preferences
for bathing.

Bathing
Figure 13-6 A man may be (A) uncircumcised or (B) circumcised. Have you ever had to be bathed by another person?
If so, how did you feel? Was the person who bathed
you sensitive to your feelings? When you are assisting
microbes, because they can cause an infection if a person to bathe, be aware that the person may be
they are introduced into parts of the body where embarrassed about needing help. Encourage the person
they do not normally live. When assisting a to complete as much of the bath as he or she can
person with perineal care, wipe from front to back independently, and take measures to keep the person
(that is, from the genitals to the anus; see warm and protect his or her modesty.
Figure 13-5). Cleaning in this direction avoids
contaminating the urethral opening (and the When you are scheduling bath times, take into account
vaginal opening in women) with bacteria from the the person’s preferences as well as your employer’s
anal area. policies. Be aware that the people in your care do have
the right to refuse a bath. However, if this happens too
Men may be uncircumcised or circumcised frequently, you will need to talk to the nurse because
(Figure 13-6). Circumcision is the surgical removal regular bathing is necessary for good hygiene.
of the foreskin (the fold of skin that covers the head
of the penis). When providing perineal care for an Close attention is needed to prevent accidents when
uncircumcised man, you must pull the foreskin back bathing. Water on hard bathroom surfaces can be very
to wash, rinse and dry the head of the penis. Always slippery. Make sure that showers and tubs have nonskid
return the foreskin to its natural position after you are mats and surfaces and that grab bars are tightly fastened
finished washing, rinsing and drying the head of to the wall. To prevent burns, check the temperature
the penis. of shower or bath water by using a bath thermometer
(Figure 13-7). The temperature should be between
Skill 13-11 describes how to provide perineal care. 105° F and 115° F. If a thermometer is not available,
use the inside of your wrist to check the temperature
of the water.
Observations Into Action!
Providing perineal care gives you a good opportunity Observations Into Action!
to observe for changes that could be a sign of a
medical problem. Report any of the following: Assisting with bathing gives you a good opportunity to
observe the person for changes that could be a sign
{ Redness or swelling
of a medical problem. Report any of the following:
{ Discharge
{ Foul odor
{ The person refuses the bath
{ Person seems to be experiencing pain
{ Reddened areas of skin
or discomfort during the procedure, or { Sores or bruises
states that the procedure is painful or { Signs of physical abuse (such as burn
uncomfortable marks or bruises in unusual places)
{ Changes in mental status (such as confusion
in a person who is not normally confused)

SKIN CARE Assisting a person with a bed bath

Bathing does a lot for a person: It refreshes and relaxes; A complete bed bath involves bathing all parts of a person’s
eliminates body odor; removes dirt, oils and dead skin body while she is in bed. A partial bed bath involves bathing
cells; and stimulates blood flow (circulation) through the only the face, hands, axillae (armpits), perineal area, back

198 | | Nurse Assistant Training

 Figure 13-7 Always check the temperature of the water before allowing
the person to get in the bathtub or shower.

and buttocks. A partial bath may be given on days when a

complete bath is not scheduled. A partial bath can also be
a useful compromise when the person refuses a complete Figure 13-8 A shower chair should be used for a person who is weak or
unsteady on her feet.
bath. When assisting with a bed bath, help the person
maintain her independence by discussing with her how she
can help. A person may be able to help only by washing her
face, but any amount of self-care is good. If the person has
more ability, you may suggest that she do her own perineal
care. In this case, hand her the washcloth and provide
privacy for her, after making sure she is safe. Skill 13-12
describes how to assist a person with a complete bed bath.

Assisting a person with a shower or

tub bath
People who are able to get out of bed will take a shower
or a tub bath.
Shower stalls in health care facilities are usually large enough
to accommodate a shower chair, so that the person can sit
down while showering (Figure 13-8). A shower chair should
be used if the person is not reliably steady on his feet.
You may see several different types of bathtubs in use in a Figure 13-9 Bathtubs in health care facilities are often modified to allow
easier access for the person.
health care facility. Walk-in tubs have a door that swings
open so that the person can easily enter the tub without
stepping over a high edge (Figure 13-9). Some tubs may For some people, a whirlpool bath may be ordered. A
be equipped with a lift device that the person sits on to whirlpool bath is given in a special type of bathtub called
be lowered into the tub. If using a standard bathtub (for a hydrotherapy tub. The hydrotherapy tub circulates
example, in a person’s home), make sure that the person the water, massaging and improving blood flow to the
can get in and out of the tub safely. The person should be: skin during the bath. Often the water temperature is a
bit warmer than it would be for a regular bath. If you are
■ Predictable.
required to assist a person with a whirlpool bath, the nurse
■ Able to bear all or most of his own weight. or physical therapist will show you how to operate the tub
■ Able to stand on one foot and lift the other foot over and tell you how hot the water should be and how long the
the edge of the tub with minimal assistance. person should remain in the tub. A person may become
■ Able to lower his body into the tub. faint or dizzy while taking a whirlpool bath because the

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 199

bath increases blood flow to the skin and away from the 4. What should you do when you finish using a
brain. Never leave a person alone during a whirlpool bath, disposable safety razor to shave someone?
and observe carefully for signs of dizziness or fainting. a. Recap the razor. Put it in the person’s drawer.
Skill 13-13 describes how to help a person with a b. Do not recap the razor. Put it in the person’s
shower or tub bath. drawer.
c. Do not recap the razor. Put it in the sharps
container.
Back Rub
d. Do not recap the razor. Put it in a plastic bag
Back rubs promote blood flow to the skin and can be and put the bag in a waste container.
very relaxing for the person. Often a back rub is provided
as part of the bed bath. Alternatively, you may give a 5. Mr. Upchurch is paralyzed on his right side. How
person a back rub before bed to help the person relax will you help him put on a button-down shirt?
and sleep better. During a back rub, you can also check a. Button the shirt and pull it over Mr. Upchurch’s
the person’s skin for reddened areas or other changes head, then help him to put his arms through the
that could signal the beginning of a pressure ulcer. sleeves.
Before giving a back rub, consult with the nurse or check b. Help Mr. Upchurch put on the right sleeve first,
the person’s care plan. Back rubs are not allowed for then the left.
people with certain conditions, such as those who are c. Help Mr. Upchurch put on the left sleeve first,
recovering from back surgery. Skill 13-14 describes how then the right.
to give a back rub. d. Mr. Upchurch cannot wear a button-down shirt.

6. Mr. Boyer is a new resident at Morningside

CHECK YOUR UNDERSTANDING Nursing Home. When you tell him that usually
residents are assisted with bathing three times
a week in the morning, Mr. Boyer tells you that
Questions for Review he prefers to bathe before bed. How should you
respond?
1. When you help a person with mouth care: a. Tell Mr. Boyer that he must follow the facility’s
a. Use a stiff toothbrush to clean the teeth policies now.
thoroughly. b. Tell Mr. Boyer that he can choose which
b. First rinse the person’s mouth with plain water. mornings he would like to have his bath.
c. Rinse the person’s mouth with full-strength c. Explain to Mr. Boyer that it is very difficult to
mouthwash after brushing. make exceptions to the rules, but you will try to
d. Rinse the person’s mouth with diluted accommodate him.
mouthwash before and after mouth care. d. Tell Mr. Boyer that you will be glad to make
bathing part of his evening care routine.
2. When providing mouth care for an unconscious
person, you should:
7. Which of the following observations should be
a. Position the person in a supine position. reported when assisting a person with foot care?
b. Use a lot of water to clean the person’s mouth a. The person’s toenails need to be cut.
thoroughly.
b. A blister is forming on the person’s heel.
c. Turn the person’s head to the side.
c. The person complains that his shoes hurt his feet.
d. Remain silent, because the person cannot hear
d. All of the above
you talk.

3. When giving a person a complete bed bath and 8. Which of the following responsibilities is usually
shampoo, do all of the following except: outside of the nurse assistant’s scope of
a. Inspect the person’s skin for injuries or changes practice?
in condition. a. Providing perineal care
b. Ensure that the water temperature is 140° F. b. Trimming a person’s toenails
c. Keep the person well covered. c. Helping a woman to shave her legs
d. Cover the person’s eyes with a washcloth while d. Helping a person with a paralyzed, weak or
shampooing. injured arm or leg to change clothes

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9. Which of the following statements about assisting Questions to Ask Yourself
a person to dress and undress is true?
1. Mrs. Jaskowitz is right-handed, but because of her
a. There is no need to provide privacy, because stroke, she is not able to use her right hand to grip
the person’s body is exposed frequently for care the toothbrush. How should you help Mrs. Jaskowitz
procedures, and the person must get used to it. brush her teeth?
b. Most people do not care what they wear, so it is
best to just choose an outfit for the person. 2. Mr. Randal is unconscious. What should you talk
about while you provide mouth care for him?
c. Assistive devices and smart clothing choices
can help a person be more independent with 3. You are bathing Mrs. Feld when Mr. Lloyd, a
dressing and undressing. confused resident from down the hall, walks into
d. A person who does not want to get dressed the room. He tries to enter the privacy curtain, but
should be allowed to remain in pajamas all day. cannot seem to find the opening immediately. What
should you do?
10. Which of the following is a benefit of hair care?
4. You walk by Mrs. Kitzmiller’s room while a new
a. It helps to massage the scalp. nurse assistant is styling her hair. You have
b. It helps to keep hair tangle-free. assisted Mrs. Kitzmiller before and you know she
c. It is important for the person’s self-esteem and likes to wear her hair in a bun. The new nurse
dignity. assistant is putting it in pigtails. What should
d. All of the above you do?
5. Because of a problem with his leg, Mr. Wingard
11. When assisting a person with a shower, has been having bed baths without a shampoo
you should: for 11 days. He likes to wash his hair only in
a. Encourage the person to do as much for himself the shower. Today the nurse has asked you to
as he is able. make sure his hair is washed. How should you
b. Use a shower chair if the person is unsteady on do this?
his feet. 6. Mrs. Lanver wants to help dress herself, but she
c. Take measures to provide privacy and warmth. is very slow. What can you do to increase her
d. All of the above independence and maintain her dignity?

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 201

SKILLS

Skill 13-1
Brushing and Flossing a Person’s Teeth

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■
Towel
■ Gloves
■ Protective eyewear and a gown (optional; use if
blood may splash or spray)
■ Paper towels
■ Toothbrush
■ Toothpaste
■ Emesis basin
■ Cup Figure 1
■ Floss pick or dental floss
■ Mouthwash 11. Wet the toothbrush by pouring mouthwash solution
■
over it.
Lip balm or petroleum jelly and cotton-tipped
applicator 12. Put toothpaste on the wet brush.
3. Knock, greet the person and ensure privacy. 13. Brush the upper teeth and gums:
4. Explain the procedure. ■ Starting at the back of the mouth, place the
5. Adjust equipment for body mechanics and safety: toothbrush on the outer surface of the upper
Raise the bed to a comfortable working height. teeth at a 45-degree angle (Figure 2). Gently
Make sure the wheels on the bed are locked. brush the outer surface of each tooth, using
short back-and-forth (tooth-wide) strokes.
PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. In the cup, prepare a solution
of half water and half mouthwash.
7. Position the person in high Fowler's position.
8. Unfold the towel. Place it across the person’s chest.
9. Put on the gloves and any other personal
protective equipment.
10. Give the person a mouthful of the mouthwash mixture
to rinse his mouth. Hold the emesis basin under the
person’s chin to catch the liquid (Figure 1). Dry the
person’s mouth and chin using the towel. Figure 2

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 SKILLS

■ Next, clean the chewing surfaces of the upper ■ Dental floss. Break off about 18 inches of
teeth, moving from one side of the mouth to the floss from the dispenser. Wrap most of the floss
other and using the same short, back-and-forth around the middle fingers of both hands, leaving
strokes. (Figure 3). 1 inch of floss between your hands. Stretch the
floss tightly between your thumbs and index
fingers (Figure 5). Starting between the two
front teeth, slide the floss carefully between
the teeth. Hold the floss against the tooth and
scrape the side of the tooth, moving the floss
away from the gum. After you floss each tooth,
unwrap a clean 1-inch section of floss from
your finger and wrap the soiled floss around the
other finger. Floss from the front of the mouth to
the back of the mouth on one side and then the
other side. Then repeat for the lower teeth.

Figure 3

■ Finally, put the brush vertically against the inside

surfaces of the front upper teeth and brush with
a gentle up-and-down motion (Figure 4).

Figure 5

18. Give the person a mouthful of the mouthwash

mixture to rinse his mouth. Hold the emesis basin
under the person’s chin to catch the liquid.
19. Dry the person’s mouth and chin with the towel, and
Figure 4 place the towel in the linen hamper.

14. Brush the lower teeth and gums in the same way. 20. Encourage the person to apply lip balm or petroleum
jelly to the lips. Assist the person as needed.
15. Brush the tongue.
21. Remove and dispose of your gloves.
16. Give the person a mouthful of the mouthwash
mixture to rinse his mouth. Hold the emesis basin
under the person’s chin to catch the liquid. Dry the COMPLETION
person’s mouth and chin using the towel.
22. Ensure the person’s comfort and good body alignment.
17. Floss the person’s teeth.
■
23. Adjust equipment for safety: Lower the bed to the
Floss pick. Starting between the two front teeth, level specified in the person’s care plan. Make sure
hold the handle of the floss pick and slide the the wheels on the bed are locked. Place the person’s
floss carefully between the teeth. Hold the floss method of calling for help within reach. Lower or raise
against the tooth and scrape the side of the tooth, the side rails according to the person’s care plan.
moving the floss away from the gum. Repeat with 24. Clean up your work area.
the next tooth, moving from the front of the mouth
to the back of the mouth on one side and then the 25. Wash your hands.
other side. Then repeat for the lower teeth. 26. Report and record.

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 203

SKILLS

Skill 13-2
Providing Denture Care

PREPARATION Task 2: Clean the Denture

1. Wash your hands. 11. Take the emesis basin, the denture cup, the
washcloth, the denture brush or toothbrush, the
2. Gather your supplies: denture toothpaste and the denture-cleansing tablet
■
Washcloth (if used) to the sink.
■
Towel 12. Line the sink with the washcloth or several
■
paper towels.
Gloves
■ Paper towels 13. Using a paper towel, turn on the faucet and adjust
the water temperature so that it is cool.
■ Cup
14. Wet the toothbrush and apply denture
■ Emesis basin toothpaste.
■ Denture cup
15. Allow the sink to fill halfway with cool water.
■ Disposable mouth sponges
16. If the person has more than one denture, clean
■ Regular toothpaste, toothbrush and dental floss one denture at a time. Remove one denture from
if the person has some natural teeth the emesis basin and hold it in the palm of your
■ Denture brush or toothbrush hand over the sink. Use the toothbrush to clean all
surfaces of the denture, using circular movements
■ Denture toothpaste (Figure 1).
■ Mouthwash
■ Lip balm or petroleum jelly and cotton-tipped
applicator
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. In the cup, prepare a solution
of half water and half mouthwash.
7. Position the person in high Fowler's position. Figure 1

Task 1: Remove the Denture

8. Unfold the towel. Place it across the person’s 17. Rinse the denture thoroughly under cool, running
chest. water and place it in the denture cup.
9. Put on the gloves. 18. Repeat steps 16 and 17 with the other denture.
10. Have the person remove her denture and put it in 19. If the person will not be putting the denture
the emesis basin. If the person needs assistance back in the mouth right away, add enough cool
removing the denture, grasp the denture firmly with water to the denture cup to cover the denture.
your thumb and index finger and use a rocking Add a denture-cleansing tablet, if used, and
motion to gently remove the denture and put it in replace the lid.
the emesis basin. A person may wear more than one 20. Turn off the faucet with a paper towel.
denture (for example, one to replace the upper teeth
and one to replace the lower teeth). If necessary,
repeat to remove the other denture.

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 SKILLS

Task 3: Provide Care for the 24. Give the person a mouthful of the mouthwash
mixture to rinse her mouth. Hold the emesis basin
Person’s Mouth under the person’s chin to catch the liquid. Dry the
21. Take the denture cup and the emesis basin back to person’s mouth and chin with the towel.
the person’s bedside.
25. Have the person put the denture back in the
22. Give the person a mouthful of the mouthwash mouth. If the person needs assistance, grasp
mixture to rinse her mouth. Hold the emesis the denture with your gloved thumb and index
basin under the person’s chin to catch the finger and guide it into place. If the person is not
liquid. Dry the person’s mouth and chin with returning the denture to the mouth right away,
the towel. make sure the denture cup is within the person’s
23. Help the person clean the roof of the mouth, easy reach.
the inside of the cheeks, the gums, under the 26. Dry the person’s mouth and chin with the towel, and
tongue, and the lips with mouth sponges dipped place the towel in the linen hamper.
in the mouthwash mixture (Figure 2). If the person
has any natural teeth, help her brush and 27. Encourage the person to apply lip balm or petroleum
floss them. jelly to the lips. Assist the person as needed.
28. Remove and dispose of your gloves.

COMPLETION
29. Ensure the person’s comfort and good body
alignment.
30. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or
raise the side rails according to the person’s
care plan.
31. Clean up your work area.
32. Wash your hands.
Figure 2 33. Report and record.

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SKILLS

Skill 13-3
Providing Mouth Care for an Unconscious Person
PREPARATION
1. Wash your hands.
2. Gather your supplies:
■
Two towels
■ Gloves
■ Gauze squares
■ Tongue depressor
■ Tape
■ Paper towels
■ Cup
■ Disposable mouth sponges Figure 1
■ Toothbrush
■ Mouthwash 13. Insert the padded tongue depressor between the
■ Lip balm or petroleum jelly and cotton-tipped upper and lower teeth at the back of the mouth to
applicator hold the person’s mouth open (Figure 2).
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. In the cup, prepare a solution
of half water and half mouthwash.
7. Position the person in high Fowler's position. Turn
the person’s head toward you.
8. Unfold one towel. Place it across the person’s chest. Figure 2
Place the other towel under the person’s head.
9. Put on the gloves.
14. Clean the roof of the mouth, the inside of the
10. Place the emesis basin on the towel near the cheeks, the gums, under the tongue, and the lips
person’s cheek. with mouth sponges dipped in the mouthwash
mixture. Wrap a gauze square around your finger
11. Pad the tongue depressor by wrapping the end in or use a mouth sponge to remove thick mucus
gauze and securing the gauze with tape. or secretions.
12. Without using force, gently separate the person’s 15. Use a toothbrush moistened with diluted mouthwash
upper and lower teeth. To do this, cross the middle to clean the person’s teeth.
finger and thumb of one hand. Put the thumb against
the person’s top teeth and the middle finger against 16. Apply lip balm or petroleum jelly to the person’s lips.
her lower teeth and gently push the finger and thumb
17. Remove and dispose of your gloves.
apart to open the jaw (Figure 1).
18. Lower the head of the bed.

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 SKILLS

COMPLETION method of calling for help within reach. Lower or

raise the side rails according to the person’s
19. Ensure the person’s comfort and good body care plan.
alignment.
21. Clean up your work area.
20. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure 22. Wash your hands.
the wheels on the bed are locked. Place the person’s 23. Report and record.

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SKILLS

Skill 13-4
Brushing and Combing a Person’s Hair

PREPARATION 10. Comb or brush the hair gently, beginning at the ends,
1. Wash your hands. and work up in sections to the scalp (Figure 1).

2. Gather your supplies:

■
Comb and brush
■ Towel
■ Mirror
■ Paper towels
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
Figure 1
6. Cover the over-bed table with the paper towels and
arrange your supplies. 11. Style the person’s hair the way she likes it.
7. Position the person in high Fowler's position. If the 12. Give the person the hand mirror so that she can see
person cannot tolerate having the head of the bed the way her hair is styled.
raised, you can comb her hair while she is lying in
the supine position by turning her head to one side, COMPLETION
and then to the other.
13. Ensure the person’s comfort and good body
8. Place the towel over the person’s shoulders (or alignment.
under the shoulders if the person is in bed).
14. Adjust equipment for safety: Lower the bed to the
9. If the person wears glasses, remove them. Remove level specified in the person’s care plan. Make sure
any hairpins or other styling aids from the hair. the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or
raise the side rails according to the person’s
care plan.
15. Clean up your work area.
16. Wash your hands.
17. Report and record.

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 SKILLS

Skill 13-5
Shampooing a Person’s Hair in Bed

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■ Towels
■ Washcloth
■ Gloves (optional)
■ Paper towels
■ Bed protector
■ Shampoo tray
■ Two wash basins
■ Paper cup
Figure 1
■ Bath thermometer
■ Shampoo and other desired hair care products 11. Wet the hair with cups of water from the wash basin
■ Comb and brush until it is fully wet.
3. Knock, greet the person and ensure privacy. 12. Apply a small amount of shampoo to the hair and
4. Explain the procedure. massage the scalp with your fingertips, starting at
the hairline and working toward the back of head,
5. Adjust equipment for body mechanics and safety: until the scalp is completely lathered.
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked. 13. Rinse the person’s hair with cups of water from the
wash basin until all shampoo is removed (Figure 2).
PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. Fill one of the wash basins
with warm water. Use the bath thermometer to verify
that the water temperature is between 105° F and
115° F. Place the wash basin on the over-bed table.
Place a chair close to the head of the bed, and place
the empty wash basin on the chair.
7. Position the person in high Fowler's position.
Remove any pins or clips from the hair. Brush or
comb the hair to remove any tangles.
8. Lower the head of the bed as low as the person
can tolerate.
9. Assist the person to raise her head and shoulders off Figure 2
the pillow. Reposition the pillow under the person’s
shoulders. Cover the head of the bed and the pillow
with a bed protector, and place the shampoo tray on
the bed protector. Gently lower the person’s head and
shoulders so that the person’s head is resting on the
shampoo tray. Make sure the runoff from the shampoo
tray is directed into the wash basin on the chair.
10. Place a towel across the person’s chest. Ask the
person to hold the washcloth over her eyes
(Figure 1). Put on the gloves, if you are using them.
Continued on next page
Chapter 13 | Assisting with Personal Cleanliness and Grooming | 209
SKILLS

Skill 13-5
Shampooing a Person’s Hair in Bed Continued
14. Apply conditioner if the person likes to use it. Work COMPLETION
the conditioner through the hair with your fingertips.
Rinse the hair until the conditioner is removed. 20. Ensure the person’s comfort and good body
alignment.
15. Unfold a clean, dry towel and dry the hair. Wrap the
person’s head in the towel. 21. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
16. Assist the person to raise her head and the wheels on the bed are locked. Place the person’s
shoulders. Remove the shampoo tray and bed method of calling for help within reach. Lower or
protector. Reposition the pillow under the raise the side rails according to the person’s
person’s head. Gently lower the person’s head care plan.
and shoulders so that the person’s head is
resting on the pillow. 22. Clean up your work area.
17. Remove and dispose of your gloves, if used. 23. Wash your hands.
18. Raise the head of bed so that the person is almost 24. Report and record.
in a sitting position. Comb the person’s hair to
remove tangles. Dry and style the hair as the
person prefers.
19. Replace any wet linens.

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Skill 13-6
Helping a Man to Shave

PREPARATION 13. Assist the person with shaving, if needed. Shave one
1. Wash your hands. side of the face first and then the other.
■ Safety razor: With the fingers of one hand, hold
2. Gather your supplies:
the person’s skin on the cheek tight as you use the
■ Towel razor to shave downward, in the direction that the
■ Washcloths hair grows (Figure 1A). Shave both cheeks, rinsing
■ Gloves the razor often in the washbasin. Use shorter
■ Paper towels strokes around the person’s chin and lips. To shave
the neck, have the person tip his head back. Pull
■ Wash basin
the skin tight and shave the neck, moving the razor
■ Bath thermometer up toward the chin.
■ Soap (optional)
■ Aftershave lotion (optional)
Safety razor:
■ Safety razor
■ Shaving cream, gel or soap
Electric razor:
■ Electric razor
■ Pre-shave lotion
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. Figure 1A
Make sure the wheels on the bed are locked.
■ Electric razor: With the fingers of one hand,
PROCEDURE hold the person’s skin tight as you use the razor to
6. Cover the over-bed table with the paper towels and shave as the manufacturer suggests, usually in a
arrange your supplies. Fill the wash basin with warm circular motion (Figure 1B).
water. Use the bath thermometer to verify that the
water temperature is between 105° F and 115° F.
Place the wash basin on the over-bed table.
7. Position the person in high Fowler's position.
8. Unfold the towel. Place it across the person’s chest.
9. Put on the gloves.
10. Inspect the area to be shaved for moles, birthmarks
or sores.
11. Assist the person in washing his face with soap
(optional) and warm water. Remove soap, if used,
with a wet washcloth.
12. If the person is using a safety razor, assist him in
applying shaving cream, gel or soap to his face. If
the person is using an electric razor, assist him to
apply pre-shave lotion. Figure 1B

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SKILLS

Skill 13-6
Helping a Man to Shave Continued

14. Use the wet washcloth to rinse the person’s face. 20. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
15. Dry the person’s face with the towel, and place the
the wheels on the bed are locked. Place the person’s
towel in the linen hamper.
method of calling for help within reach. Lower or
16. Give the person a hand mirror so that he can inspect raise the side rails according to the person’s
the shaved area. care plan.
17. Assist the person to apply aftershave 21. Clean up your work area.
lotion (optional).
22. Wash your hands.
18. Remove and dispose of your gloves.
23. Report and record.
COMPLETION
19. Ensure the person’s comfort and good body
alignment.

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Skill 13-7
Helping a Person to Change Clothes

PREPARATION head. (If the person cannot lift her head and
1. Wash your hands. shoulders from the pillow, turn the person onto
her side and remove her arm from the sleeve on
2. Gather your supplies:
that side. Repeat the process on the other side,
■ Bath blanket and then turn the person back into the supine
■ Clean clothes position.)
3. Knock, greet the person and ensure privacy. ■ Tops that fasten in the front: Undo any
fasteners, such as buttons or zippers. Assist the
4. Explain the procedure.
person to raise her head and shoulders off the
5. Adjust equipment for body mechanics and safety: pillow. Help the person to remove her strong arm
Raise the bed to a comfortable working height. from the top first, then her weak arm, by sliding the
Make sure the wheels on the bed are locked.
sleeves down the arms.
■ Bottoms: Undo any fasteners, such as
PROCEDURE
buttons or zippers. Ask the person to bend her
Task 1: Assist the Person with knees and place her feet firmly on the bed, so
that she can raise her hips off the bed. Reach
Undressing
under the bath blanket and slide the pants
6. Lower the head of the bed as low as the person
can tolerate. down over the hips (Figure 2). (If the person
cannot raise her hips off the bed, turn the
7. Cover the person and the top sheet with the bath person onto her side and pull the pants over
blanket (to provide privacy and warmth). Ask the
the buttocks and hip on that side. Repeat the
person to hold the edge of the bath blanket (or tuck
the edges under the person’s shoulders) while you process on the other side, and then turn the
fold the top linens down to the bottom of the bed. person back into the supine position).
8. Help the person remove her clothing.
■ Tops that pull over the head: Undo any
fasteners, such as buttons or zippers. Help the
person remove her strong arm from the top
first, then her weak arm, by sliding the sleeves
down the arms. Gather the top around the
person's neck. Assist the person to raise her
head and shoulders off the pillow (Figure 1).
Remove the top by lifting it over the person’s

Figure 2

Task 2: Assist the Person with

Dressing
9. Help the person put on undergarments.
■ Underpants: Gather the leg opening to the
waistband. Help the person place her weak foot
Figure 1 through the leg opening first, then her strong

Continued on next page

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SKILLS

Skill 13-7
Helping a Person to Change Clothes Continued
foot, and slide the underpants up the person’s
legs as far as they will go. Ask the person to
bend her knees and place her feet firmly on
the bed, so that she can raise her hips off the
bed. Reach under the bath blanket and pull the
underpants over her hips. (If the person cannot
raise her hips off the bed, turn the person onto
her side and pull the underpants over the hips
and buttocks on that side. Repeat the process
on the other side, and then turn the person back
into the supine position.)
■ Bra: Help the person place her weak arm Figure 4
through the strap of the bra, then her strong arm.
Slide the straps onto the person’s shoulders, 10. Help the person to put on outerwear.
and adjust the cups of the bra so that they cover ■ Pants: Use the same technique used for putting
the person’s breasts. Assist the person to raise
on underpants. Fasten any fasteners, such as
her head and shoulders off the pillow and fasten
zippers or hooks.
the bra in the back (Figure 3).
■ Tops that fasten in the front: Face the person
and put your hand through the wrist opening
of the top. Hold the person’s hand and slip the
sleeve off your hand and onto the person’s arm
(Figure 5). Adjust the sleeve so it sits properly
on the person’s shoulder. Assist the person to
raise her head and shoulders off the pillow and
bring the top around the person’s back. Assist
the person to place her other arm in the sleeve.
Fasten any fasteners, such as zippers or buttons.

Figure 3

■ Undershirt: Gather the hem of the undershirt

to the neck opening. Slip the undershirt over
the person’s head. Assist the person to put her
weak arm through the arm opening, then her
strong arm (Figure 4). Assist the person to raise
her head and shoulders off the pillow and pull
the undershirt down.

Figure 5

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 SKILLS

■ Tops that fasten in the back: Face the ■ Shoes or slippers: Loosen any laces. Guide
person and put your hand through the wrist the person’s foot into the shoe or slipper, and tie
opening of the top. Hold the person’s hand the laces or secure other fasteners.
and slip the sleeve off your hand and onto
the person’s arm. Adjust the sleeve so it sits COMPLETION
properly on the person’s shoulder. Repeat on the
other side. Assist the person to raise her head 12. Ensure the person’s comfort and good body
and shoulders off the pillow so that you can alignment.
fasten the top in the back. 13. Adjust equipment for safety: Lower the bed to the
11. Help the person put on footwear. level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
■ Socks or stockings: Gather the opening method of calling for help within reach. Lower or raise
of the sock or stocking to the toe. Guide the the side rails according to the person’s care plan.
person’s foot into the sock or stocking, adjusting 14. Clean up your work area.
the sock or stocking so that it fits properly on
the foot. Pull the sock or stocking up the leg, 15. Wash your hands.
smoothing any wrinkles. 16. Report and record.

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SKILLS

Skill 13-8
Helping a Person to Put On Compression Stockings

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■
Compression stockings in the correct size
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
Figure 2
6. Lower the head of the bed as low as the person
can tolerate.
10. Slide the rest of the stocking up the person’s leg,
7. Adjust the top covers and the person’s clothing as smoothing out any wrinkles (Figure 3).
necessary to expose one leg at a time.
8. Turn one stocking inside out down to the heel (Figure 1).

Figure 3

11. Cover the person’s leg, and apply the second

Figure 1 stocking to the other leg.

9. Hold the stocking so that when you place it COMPLETION

on the person’s foot, the toe opening is facing
up or down, according to the manufacturer’s 12. Ensure the person’s comfort and good body alignment.
instructions. Slide the foot of the stocking over
13. Adjust equipment for safety: Lower the bed to the
the person’s toes, foot and heel (Figure 2). Make
level specified in the person’s care plan. Make sure
sure the opening is positioned properly across the
the wheels on the bed are locked. Place the person’s
person’s toes and that the stocking fits smoothly
method of calling for help within reach. Lower or raise
over the heel.
the side rails according to the person’s care plan.
14. Clean up your work area.
15. Wash your hands.
16. Report and record.

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Skill 13-9
Inserting and Removing an In-The-Ear Hearing Aid

PREPARATION earlobe, use the other hand to gently push up and in

1. Wash your hands. to seat the hearing aid properly in place.

2. Gather your supplies. 10. Turn the hearing aid on and adjust the volume until
the person can hear you.
3. Knock, greet the person and ensure privacy.
4. Explain the procedure. Task 2: Remove the Hearing Aid
11. Turn the hearing aid off.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height. 12. While using one hand to gently pull the top of the
Make sure the wheels on the bed are locked. person’s ear up, use the other hand to gently lift the
hearing aid up and out of the ear canal.
PROCEDURE 13. Place the hearing aid in its case.
6. Help the person into a comfortable position that
allows you to easily access the person’s ear. COMPLETION
14. Ensure the person’s comfort and good body
Task 1: Insert the Hearing Aid alignment.
7. Make sure the hearing aid is turned off and the
volume is turned down. 15. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
8. Inspect the person’s ear canal for excessive ear wax. the wheels on the bed are locked. Place the person’s
If necessary, gently wipe the ear canal with a warm, method of calling for help within reach. Lower or raise
wet washcloth, and then dry. the side rails according to the person’s care plan.
9. Gently place the narrow end of the hearing aid in 16. Clean up your work area.
the person’s ear canal, and then rotate the hearing
aid so that it follows the curve of the ear. While 17. Wash your hands.
using one hand to gently pull down on the person’s 18. Report and record.

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SKILLS

Skill 13-10
Providing Hand and Foot Care

PREPARATION
1. Wash your hands.
2. Gather your supplies:
■
Washcloth
■ Towel
■ Bed protector
■ Emesis basin (hand care) or wash basin
(foot care)
■ Bath thermometer
■ Nail clippers
■ Orange stick
Figure 1
■ Emery board (nail file)
■ Soap ■ Foot care: Place the bed protector on the floor
■ Lotion or the mattress near the person’s feet. Place the
■ Paper towels wash basin on the bed protector, and help the
■
person put her feet in the basin. Soak the feet in
Gloves (optional)
the water for 5 minutes.
3. Knock, greet the person and ensure privacy.
10. Wet the washcloth and apply soap. Lift the person’s
4. Explain the procedure. hand or foot from the water, one at a time. Wash the
5. Adjust equipment for body mechanics and safety: hand or foot, pushing the cuticles back gently with
If the person will be staying in the bed, raise the the washcloth (Figure 2). Use the orange stick to
bed to a comfortable working height. If the person gently clean underneath the person’s nails. Wipe the
will be getting out of bed, lower the bed to the level orange stick on the towel after cleaning under
specified in the person’s care plan. Make sure the each nail.
wheels on the bed are locked.

PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. Fill the emesis basin or wash
basin with warm water. Use the bath thermometer to
verify that the water temperature is between 105° F
and 115° F. Place the wash basin or emesis basin
on the over-bed table.
7. Help the person to transfer from the bed to a
chair, or to sit on the edge of the bed. Alternatively,
position the person in high Fowler's position.
8. Put on the gloves, if you are using them.
9. Help the person to soak her hands or feet. Figure 2

■ Hand care: Position the emesis basin within

the person’s reach. Help the person put her 11. Rinse the person’s hands or feet.
fingertips in the basin. Soak the fingertips in the 12. Dry the person’s hands or feet thoroughly, including
water for 5 minutes (Figure 1). between the fingers and toes.

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13. Care for the nails. COMPLETION

■ Hand care: If you are permitted to do so, use nail 16. Ensure the person’s comfort and good body
clippers to trim the person’s fingernails so that the alignment.
nail extends slightly beyond the tip of the finger.
17. Adjust equipment for safety: Lower the bed to the
Trim the nails straight across, and then shape and level specified in the person’s care plan. Make sure
smooth the edges with the emery board. the wheels on the bed are locked. Place the person’s
■ Foot care: Note whether or not the nails need to method of calling for help within reach. Lower or raise
be trimmed. Also inspect the condition of the skin the side rails according to the person’s care plan.
on the person’s feet, including in between the toes. 18. Clean up your work area.
14. Massage the person’s hands or feet with lotion. 19. Wash your hands.
Begin with the fingers or toes and move upward
toward the wrists or ankles. Do not massage the 20. Report and record.
person’s legs.
15. Remove and dispose of your gloves, if used.

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SKILLS

Skill 13-11
Providing Perineal Care

PREPARATION 13. Adjust the bath blanket as needed so that only the
1. Wash your hands. perineal area is exposed.

2. Gather your supplies: 14. Wet the washcloth and make a mitt with it by:
■ Holding a corner of the washcloth between your
■
Washcloths
thumb and fingers.
■ Towels
■ Wrapping the rest of the washcloth around your
■ Bath blanket
hand and holding it with your thumb.
■ Bed protector ■ Folding the cloth over your fingers and tucking it
■ Wash basin under the fold in your palm.
■ Bath thermometer 15. Put soap on the washcloth mitt.
■ Soap 16. Wash the perineal area.
■ Paper towels ■ Female: Separate the labia with one hand.
■ Gloves Place the washcloth mitt at the top of the vulva
■ Clean clothing and stroke downward, toward the anus. Clean
■ Clean linens (if needed) the middle, then one side, then the other side,
using a clean part of the mitt for each stroke
3. Knock, greet the person and ensure privacy.
(Figure 1A). Using a clean wet washcloth,
4. Explain the procedure. form another mitt and rinse the perineal area
5. Adjust equipment for body mechanics and safety: in the same manner as you washed it. Dry the
Raise the bed to a comfortable working height. perineal area with a clean towel, using the
Make sure the wheels on the bed are locked. same steps as you did when washing and
rinsing. Remove the bedpan or the folded towel
PROCEDURE or bath blanket.
6. Cover the over-bed table with the paper towels and
arrange your supplies. Fill the wash basin with warm
water. Use the bath thermometer to verify that the
water temperature is between 105° F and 115° F.
Place the wash basin on the over-bed table.
7. Lower the head of the bed as low as the person
can tolerate.
8. Cover the person and the top sheet with the bath
blanket (to provide privacy and warmth). Ask the
person to hold the edge of the bath blanket (or tuck
the edges under the person’s shoulders) while you
fold the top linens down to the bottom of the bed.
9. Put on the gloves.
10. Help the person to remove soiled clothing.
Figure 1A
11. Have the person bend her knees and spread her
legs as much as possible.
■ Male: Hold the man’s penis in one hand.
12. Have the person raise her buttocks off the bed,
and place a bed protector under the person’s hips. If the man is uncircumcised, retract the
If providing perineal care for a woman, elevate the foreskin. Moving from the urethral opening
woman’s pelvis by placing a bedpan or a folded outward, wash the penis using a circular
towel or bath blanket under her buttocks. motion, starting with the tip and moving down

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 SKILLS

to the base (Figure 1B). Using a clean wet

washcloth, form another mitt and rinse the
penis in the same manner as you washed it.
Dry the penis with a clean towel, using the
same steps as you did when washing and
rinsing. If the man is uncircumcised, return the
foreskin to its natural position. Wash, rinse and
pat dry the scrotum and perineum.

Figure 2

19. Remove the bed protector.

20. Remove and dispose of your gloves.
21. Help the person back into the supine position.
22. Help the person to put on clean clothing.
23. If the linens are soiled or wet, change the linens.
24. Pull up the top linens and remove the bath blanket.

Figure 1B
COMPLETION
25. Ensure the person’s comfort and good body
alignment.
17. Help the person turn onto one side so that his or her
26. Adjust equipment for safety: Lower the bed to the
back is facing you.
level specified in the person’s care plan. Make sure
18. Wet another washcloth, form a mitt and apply soap. the wheels on the bed are locked. Place the person’s
Using your other hand, separate the buttocks. method of calling for help within reach. Lower or
Moving from the genitals toward the anus (front to raise the side rails according to the person’s
back), wash one side, then the other side, and then care plan.
the middle, using a different part of the washcloth for
27. Clean up your work area.
each stroke (Figure 2). Using a clean wet washcloth,
form another mitt and rinse the anal area in the same 28. Wash your hands.
manner as you washed it. Dry the anal area with a
clean towel, using the same steps as you did when 29. Report and record.
washing and rinsing.

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SKILLS

Skill 13-12
Helping a Person with a Complete Bed Bath

PREPARATION Task 1: Wash the Person’s Face,

1. Wash your hands. Neck and Ears
2. Gather your supplies: 12. Place a towel on top of the bath blanket, across the
person’s chest. This helps to keep the bath blanket
■
Washcloths dry while you wash the person’s face, neck and ears.
■
Towels 13. Wet the washcloth and make a mitt with it by:
■ Bath blanket ■ Holding a corner of the washcloth between your
■ Bed protector thumb and fingers.
■ Wash basin ■ Wrapping the rest of the cloth around your hand
■ Bath thermometer and holding it with your thumb.
■ Soap ■ Folding the cloth over your fingers and tucking it
■ Paper towels under the fold in your palm.
■ Gloves 14. Without using soap, use the washcloth to bathe the
■
eye farther from you. Begin at the inner corner of the
Clean clothing eye, near the nose. Then move the washcloth across
■ Lotion (optional) the eye to the outer corner. Use the towel to dry the
■ Deodorant or antiperspirant (optional) eye. Use the opposite end of the mitt and towel to
bathe and dry the other eye (Figure 1).
■ Clean linens (if needed)
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. Fill the wash basin with warm
water. Use the bath thermometer to verify that the
water temperature is between 105° F and 115° F.
Place the wash basin on the over-bed table.
7. Lower the head of the bed as low as the person Figure 1
can tolerate.
8. Help the person move closer to the side of the bed
15. Using soap sparingly, wash, rinse and dry the
where you are working.
person’s face, neck and ears.
9. Remove and fold the bedspread and blanket for
reuse. Cover the person and the top sheet with the Task 2: Wash the Person’s Arms
bath blanket (to provide privacy and warmth). Ask and Hands
the person to hold the edge of the bath blanket (or
16. Fold back the bath blanket to expose the person’s
tuck the edges under the person’s shoulders) while
arm that is farther from you. Place the towel
you fold the top linens down to the bottom of
lengthwise under the arm.
the bed.
17. Wash, rinse and dry the shoulder, arm and underarm
10. Put on the gloves.
(axilla). Use the towel that was under the arm to dry
11. Help the person to remove soiled clothing. the shoulder, arm and underarm.

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 SKILLS

18. Place a bed protector on the mattress near the 27. Fold back the towel to expose the side of the
person’s hand, and place the wash basin on the person’s chest that is nearer to you.
bed protector. Place the person’s hand in the wash
28. Wash, rinse and dry the chest as in steps 25 and
basin. Wash, rinse and dry the person’s hand.
26 (Figure 3).
19. Recover the person’s arm with the bath blanket.
20. Fold back the bath blanket on the person’s arm that
is nearer to you. Place the towel lengthwise under
the arm.
21. Wash, rinse and dry the shoulder, arm, axilla and
hand as in steps 17 and 18 (Figure 2).

Figure 3

29. Wash, rinse and dry the person’s abdomen in the

same manner as the chest, doing the farther side
first, and then the nearer side.
30. Pull the bath blanket back up to cover the chest and
abdomen, and remove the towel from underneath.
Figure 2
31. Change the water if it becomes too soapy or cool.

22. Remove the towel from under the arm, and cover the Task 4: Wash the Person’s Legs
arm with the bath blanket.
and Feet
32. Fold the bath blanket away from the person’s leg that
Task 3: Wash the Person’s Chest is farther from you. Place the towel lengthwise under
and Abdomen the leg.
23. Place the towel on top of the bath blanket, over the
33. Wash, rinse and dry the leg. Use the towel that was
person’s chest and abdomen (stomach).
under the leg to dry it.
24. Reach under the towel that is over the bath blanket
34. Place a bed protector on the mattress near the
and fold the bath blanket down to the person’s pubic
person’s foot, and place the wash basin on the bed
area without exposing it. Leave the towel in place so
protector. Place the person’s foot in the wash basin.
that the person is not completely exposed.
Wash, rinse and dry the person’s foot.
25. Fold back the towel to expose the side of the
35. Re-cover the person’s leg with the bath blanket.
person’s chest that is farther from you. Wash, rinse
and dry the person’s chest. Inspect under the 36. Fold back the bath blanket on the person’s leg that is
person’s breast and skin folds as you work. nearer to you. Place the towel lengthwise under the leg.
26. Dry the person’s skin completely. Re-cover the chest 37. Wash, rinse and dry the leg and foot as in steps 33
with the towel. and 34 (Figure 4).
Continued on next page

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SKILLS

Skill 13-12
Helping a Person with a Complete Bed Bath Continued
43. If the person would like a back rub, provide a back
rub as in Skill 13-14.

Task 6: Wash the Perineal Area

44. Place the towel so that it will be under the person’s
hips when you help the person back into the supine
position. If the person is able to do his own perinal
care, provide a fresh washcloth, soap and clean
water. Give the person a few minutes alone to
complete perineal care. If the person is not able to
do his own perineal care, provide perineal care as in
Skill 13-11.
45. Remove and dispose of your gloves.
Figure 4
Task 7: Help the Person Dress
38. Re-cover the leg with the bath blanket. Remove the 46. Help the person back into the supine position.
towel from under the leg. 47. Help the person to apply deodorant or
39. Change the water. antiperspirant (optional).
48. Help the person to put on clean clothing.
Task 5: Wash the Person’s Back 49. If the linens are soiled or wet, change the linens.
and Buttocks
40. Help the person turn onto one side so that his back 50. Pull up the top linens and remove the bath blanket.
is facing you.
41. Place the towel on the sheet behind the person’s COMPLETION
neck, back and buttocks. Adjust the bath blanket
so that it covers the person’s chest, shoulders, 51. Ensure the person’s comfort and good body
abdomen and legs. alignment.
42. Wash, rinse and dry the person’s neck, back and 52. Adjust equipment for safety: Lower the bed to the
buttocks (Figure 5). Inspect the skin as you work. level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or
raise the side rails according to the person’s
care plan.
53. Clean up your work area.
54. Wash your hands.
55. Report and record.

Figure 5

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 SKILLS

Skill 13-13
Helping a Person with a Shower or Tub Bath

PREPARATION prevent hot water from dripping from the faucet

1. Prepare the shower or tub room. Obtain a shower and onto the person. Use the bath thermometer
chair, if one is needed. Cover the seat of the shower to verify that the water temperature is between
chair (or the tub, if the tub has a seat) with a folded 105° F and 115° F.
towel for comfort. Also place a folded towel on the 9. Ask the person if the water feels too warm before
seat where the person will sit to dry off. the person gets into the tub (sometimes even water
2. Wash your hands. at 105° F will feel too warm to the person).
3. Gather your supplies: 10. Put on the plastic apron, if you are using one.
■ Washcloths 11. If the person’s hair is not going to be washed, offer a
■
shower cap.
Towels
■ Bath blanket 12. Help the person undress. If the person seems chilled
or concerned about being exposed, offer the person
■ Bath thermometer a bath blanket or towel to place over the shoulders.
■ Soap The person can leave the bath blanket or towel in
■
place while he bathes.
Gloves
■ Clean clothing 13. Using good body mechanics, help the person into
the shower or tub. If a shower chair is used, lock the
■ Plastic apron (optional) brakes or place the chair against the shower wall.
■ Shower cap (optional) 14. Give the person the soap and a washcloth and
■ Shampoo and conditioner (optional) encourage the person to complete as much of
■ Lotion (optional) the bathing as possible independently. Stay in the
shower or tub room with the person. If safety allows,
4. Knock, greet the person and ensure privacy. you can provide the person with some privacy by
5. Explain the procedure. staying on the other side of the curtain.
6. Adjust equipment for body mechanics and safety: 15. Put on the gloves.
Lower the bed to the level specified in the person’s 16. Ask the person what parts of the body he needs help
care plan. Make sure the wheels on the bed are locked. washing. Wash from the cleanest areas of the body to
the dirtiest areas of the body: eyes; face, neck and ears;
PROCEDURE arms, armpits and hands; chest and abdomen; legs and
feet; back and buttocks; perineal area.
7. Help the person put on a robe and footwear, and assist
the person to the shower or tub room. If you are taking 17. Assist the person to rinse all of the soap off the skin.
the person to the shower or tub room in a wheelchair,
18. Assist the person to wash the hair, if necessary. If
have the person hold the supplies in his lap.
washing the hair in the tub, give the person a clean
8. Run the water: washcloth to hold over his eyes while you rinse the
■
hair with clean water from a pitcher.
Shower: Turn the faucet on, and adjust the
temperature of the water so that it is warm to the 19. Help the person to get out of the shower or tub and
touch. Use the bath thermometer to verify that the transfer to the towel-covered chair. Wrap the person
water temperature is between 105° F and 115° F. in a towel or bath blanket. If the person’s hair is wet,
wrap the person’s hair in another towel.
■ Tub: Turn the faucet on, and allow the tub to
fill halfway. Turn the hot water faucet off first to 20. If the person was taking a shower, shut off the water.
Continued on next page

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 225

SKILLS

Skill 13-13
Helping a Person with a Shower or Tub Bath Continued
21. Help the person to dry off completely. Make sure 22. Help the person to apply lotion, deodorant or
areas where “skin meets skin” are dry (Figure 1). antiperspirant, or other products as the
person requests.
23. Help the person to dress.
24. Assist the person back to his room.

COMPLETION
25. Ensure the person’s comfort and good body
alignment.
26. Adjust equipment for safety: Lower the bed to the
level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
method of calling for help within reach. Lower or
raise the side rails according to the person’s
care plan.
27. Clean up your work area.
28. Wash your hands.
29. Report and record.

Figure 1

226 | | Nurse Assistant Training

 SKILLS

Skill 13-14
Giving a Back Rub

PREPARATION the back (Figure 1). Use big circular motions. Start
1. Wash your hands. at the base of the back and move upward toward the
shoulders. Continue rubbing the back in this way for
2. Gather your supplies: 3 to 5 minutes.
■ Bath blanket
■ Wash basin
■ Lotion
■ Gloves (optional)
3. Knock, greet the person and ensure privacy.
4. Explain the procedure.
5. Adjust equipment for body mechanics and safety:
Raise the bed to a comfortable working height.
Make sure the wheels on the bed are locked.

PROCEDURE
6. Cover the over-bed table with the paper towels and
arrange your supplies. Fill the wash basin with warm Figure 1
water. Warm the lotion by placing the bottle in the
wash basin full of warm water.
14. Remove and dispose of your gloves, if using.
7. Lower the head of the bed as low as the person
can tolerate. 15. Help the person back into the supine position.
8. Cover the person and the top sheet with the bath 16. Help the person to put his top back on.
blanket (to provide privacy and warmth). Ask the 17. Pull up the top linens and remove the bath blanket.
person to hold the edge of the bath blanket (or tuck
the edges under the person’s shoulders) while you
fold the top linens down to the bottom of the bed. COMPLETION
9. Help the person to remove his top. 18. Ensure the person’s comfort and good body
alignment.
10. Help the person turn onto one side so that his back
is facing you. Adjust the bath blanket so that only the 19. Adjust equipment for safety: Lower the bed to the
person’s back is exposed. level specified in the person’s care plan. Make sure
the wheels on the bed are locked. Place the person’s
11. Put on the gloves, if you are using them.
method of calling for help within reach. Lower or
12. Squeeze some lotion onto the palm of your hand raise the side rails according to the person’s
and distribute it over your hands by rubbing your care plan.
palms together.
20. Clean up your work area.
13. Put your hands at the base of the person’s spine.
21. Wash your hands.
Rub the lotion into the person’s back, moving up the
spine to the shoulders, and then down the sides of 22. Report and record.

Chapter 13 | Assisting with Personal Cleanliness and Grooming | 227

C HA P T E R
Assisting with Meals
14 and Fluids
After reading this chapter, you will have the information needed to:
■ Describe general types of nutrients that are essential for health.
■ Explain general principles of a healthy diet, and describe two tools that can be used
to help plan a healthy diet.
■ Describe factors that can affect the choices a person makes about food.
Goals ■ Describe orders that may be in place concerning diet and nutrition.
■ Describe common therapeutic diets, and explain the reasons each of these diets may
be prescribed.
■ List reasons why meal time may be a difficult time for a person who is receiving
health care.

228 | | Nurse Assistant Training

 ■ Describe actions a nurse assistant can take to make meal time as pleasant as possible
for the person, and explain why this is important.
■ Describe how to prepare a person for a meal, how to serve a meal and how to assist
the person with eating.
■ Describe how to estimate, report and record a person’s food intake.
■ Explain the importance of maintaining fluid balance, and describe actions a nurse
Goals assistant can take to ensure that a person takes in enough fluids.
■ Describe how to measure and record a person’s fluid intake.
■ Describe the nurse assistant’s role in caring for a person who is receiving intravenous
(IV) therapy or enteral nutrition (tube feedings).
After practicing the corresponding skill, you will have the information needed to:
■ Help a person to eat.

Key Terms:
nutrition fiber anorexia fluid balance

nutrients calorie nausea dehydration

diet dietitian malnutrition edema

glucose appetite therapeutic diet

To get all the necessary nutrients, a person needs to

Victor Minnetti and his wife, Angela, live by eat a variety of foods. No single food or group of foods
themselves in a large two-bedroom apartment. supplies all the nutrients the body needs. Different types
Mr. Minnetti, who is 79 years old, had a heart attack of nutrients include the following:
2 weeks ago, and has recently come home from the
■ Carbohydrates supply the body with glucose,
hospital. Mrs. Minnetti, who is 72 years old, has
the body’s most basic source of energy. The most
severe arthritis that makes taking care of herself, her
nutritious sources of carbohydrates include whole
husband and their home difficult. You are a home
grains (such as whole wheat bread, brown rice
health care aide, and one of your assignments today
and oatmeal) and fruits and vegetables, because
is to help both Mr. and Mrs. Minnetti with bathing,
in addition to providing energy, these types of
grooming and meals. The nurse has told you that the
carbohydrates also supply fiber, a substance that
doctor has prescribed a low-salt, low-fat diet for
helps the digestive tract function properly and
Mr. Minnetti. When you mention this to
lowers risk for heart disease and diabetes. Other,
Mrs. Minnetti, she says, “He’s going to hate this diet.
less nutritious sources of carbohydrates include
He just loves his butter and that salt shaker. And
table sugar, white bread, white rice and white pasta.
meals are really a big part of what we do.”
■ Proteins help the body to build muscle and other
body tissue. For this reason, proteins are especially
important when a person is healing from an injury
or surgery. Proteins are also an important source
of energy for the body. Common foods that supply
WHAT IS GOOD NUTRITION? proteins include meat, poultry, fish, beans, eggs and
Nutrition is the process of taking in and using dairy products.
nutrients, which are substances that the body needs to ■ Fats are a concentrated source of energy. Fat in
grow, maintain itself and stay healthy. Nutrients can be the diet helps us to feel full and makes food taste
obtained through vitamin and mineral supplements, but better. Fat also helps the body use certain vitamins
our main and best source of nutrients is through diet more efficiently, helps to keep us warm and protects
(that is, the food we eat and the beverages we drink). our internal organs. For good health, however, only a
Eating a healthy, nutritious diet (that is, one that contains small amount of fat is needed each day, and healthy
a wide variety of nutrients) helps to maintain good health fats should be chosen over unhealthy ones. Examples
and can improve poor health. of healthy fats include olive oil, canola oil and peanut

Chapter 14 | Assisting with Meals and Fluids | 229

 oil. Examples of less healthy fats include butter, food and the ingredients in the food (Figure 14-2).
margarine, lard and the fat found in red meats. Reading these labels can help people make good
■ Minerals and vitamins are small molecules that choices about nutrition. These labels are also an
help to regulate body functions and form cells important tool for people who are trying to manage
and tissues. Examples of minerals include iron, their weight, because they give information about
calcium, sodium, potassium and iodine. Examples appropriate serving sizes and the number of calories
of vitamins include vitamins A, B, C, D, E and K. the food contains. A calorie is the unit of measure
Minerals and vitamins are found in many different used to describe the amount of energy a food
types of foods. Good sources include whole supplies. Taking in more calories than the body uses
grains, fruits and vegetables, lean meats and through daily activity leads to weight gain, because
dairy products. the excess calories are stored in the body as fat.
Although the general principles of following a healthy
diet are the same for everyone, the types of nutrients and
PLANNING A HEALTHY DIET the number of calories a person needs to take in each
A healthy diet helps to ensure that we consume the day can vary according to the person’s gender, age and
nutrients we need in the right amounts to stay healthy (or situation. For example:
to regain health). It also helps to maintain a healthy body ■ Men tend to need more calories than women do.
weight (that is, a body weight that is not too high or too ■ Infants, children and teenagers have increased needs
low). Being overweight or underweight puts a person for nutrients and calories because they are growing.
at risk for health problems. Two tools that are available
■ Pregnant women and women who are breastfeeding
to help people plan a healthy diet include MyPlate and
require more of certain types of nutrients, such as
nutrition labels.
protein and calcium.
■ MyPlate was developed by the United States ■ People who are ill or injured will have different
government to help Americans “build a healthy nutritional needs, depending on what type of illness
plate” (Figure 14-1). MyPlate focuses on five food
groups that supply important nutrients (fruits,
vegetables, grains, protein foods and dairy) and
uses a place setting to show how much of each food
group should be eaten (relative to the other food
groups) at each meal. MyPlate encourages people
to choose fruits, vegetables, whole grains, lean
meats and low-fat dairy over less nutritious foods,
and to cut back on sodium, unhealthy fats and
added sugars.
■ Nutrition labels. All packaged foods are required to
have a nutrition label that provides information about
serving size, calories, the nutrients supplied by the

Figure 14-2 Nutrition labels provide information about the ingredients

in packaged foods, the nutrients and calories the food provides and the
Figure 14-1 MyPlate helps Americans to make healthy food choices. recommended serving size.

230 | | Nurse Assistant Training

 or injury they have. For example, a person who is ELDER CARE NOTE. Older people often have
recovering from an injury, burn or surgery usually several risk factors for malnutrition (failure to
requires more protein and calories because the take in enough of the right kinds of nutrients
body is using a great deal of energy to repair the to stay healthy). Being on a fixed income may
damaged tissues. make it difficult for an older person to afford
■ Older people who are frail usually do not need to take in food. Physical disabilities (such as those
as many calories, because they are usually less active. caused by stroke, vision loss or tooth loss)
may make it harder for the person to prepare
A dietitian (a health care professional who has
food, or to chew and swallow it. Emotional
specialized knowledge and training in the field of
difficulties (such as grief, depression and
nutrition) is often consulted when it is necessary to plan
loneliness) can cause the person to lose
a diet for a person with special needs.
interest in eating. Conditions that affect
the person’s memory, such as dementia,
can cause the person to forget how to eat.
FACTORS THAT AFFECT WHAT Sensory changes that occur with aging, such
as decreased senses of taste and smell, can
AND HOW WE EAT also negatively affect a person’s appetite. When
People differ in what they eat, when they eat and how caring for an older person, be alert to signs
they prepare food. As a nurse assistant, you will play that the person may not be getting enough to
an important role in encouraging those in your care to eat (such as weight loss or a lack of interest in
eat a diet that helps them to maintain or regain health. food), and report any concerns to the nurse right
Knowing about the factors that can affect the choices a away. Also, make a special effort to make meal
person makes about food can help you to respect those time enjoyable for the person.
choices when you are providing care. This knowledge
can also help you identify reasons why a person may
not be eating a healthy diet, and take steps to help the
person eat more healthfully. Examples of factors that can As you prepare lunch, Mrs. Minnetti sits at the
affect what and how a person eats include: kitchen table and talks with you. She says, “I’m really
grateful you’re here. To be honest with you, I’ve been
■ Personal taste. Each person has certain likes and having more and more trouble managing. My arthritis
dislikes when it comes to food. One person may not is so bad I can’t lift my cast-iron skillet anymore, and
like green beans, while another may not like chocolate. I have trouble chopping vegetables and using the can
■ Allergies and intolerances. Some people may opener. Before Victor’s hospitalization and before you
have reactions that can range from unpleasant to came to help, we were eating a lot of frozen dinners
life-threatening if they eat certain foods. because it was all I could manage on some days.”
■ Culture and religion. A person’s food choices, How did Mrs. Minnetti’s increasing difficulty
likes and dislikes are influenced by social customs, with preparing meals affect the choices Mr.
religious practices and the availability of ingredients. and Mrs. Minnetti made about food?
Culture and religion can also affect how foods are
prepared and when they are served. Mrs. Minnetti said to you, “Meals are a really
■ Budget. People make choices about food based on big part of what we do.” What other factors
what they can afford. might influence the choices Mr. and Mrs.
Minnetti make about food?
■ Willingness or ability to cook. Many people rely
on prepared convenience foods or restaurant meals Think about the choices you make regarding
because they lack the time, interest, strength or skills food. What influences these choices?
needed to cook.
■ Appetite. A person’s desire for food, or appetite,
influences what and how a person eats. Physical and
emotional factors can cause a person’s appetite to
increase or decrease. Anorexia, a loss of appetite, SPECIAL ORDERS CONCERNING
is very common among people who are receiving
health care. Factors that can contribute to anorexia
NUTRITION
include pain, nausea (a sick feeling in the stomach When a person is receiving health care, there may be
often accompanied by the urge to vomit), medication special orders in place. Examples include orders for
side effects, depression or an impaired sense of therapeutic diets, meal supplements, thickened liquids or
taste or smell. NPO (nothing by mouth) status.

Chapter 14 | Assisting with Meals and Fluids | 231

Therapeutic Diets ELDER CARE NOTE. Although following a
therapeutic diet when one has been ordered
A therapeutic diet is a special diet that is ordered to is important for the person’s health, a balance
help a person regain or maintain her health. The person’s needs to be maintained between meeting
primary care provider orders the therapeutic diet, and the nutritional requirements and maintaining the
dietitian helps to plan meals that meet the requirements person’s quality of life. Particularly with an older
of the diet but also suit the person’s individual tastes person, the health care team may decide to
and needs. When you are caring for a person who is take the person off the therapeutic diet if the
receiving a therapeutic diet, you will need to be familiar special diet seems to be negatively affecting
with the type of therapeutic diet that was ordered, the person’s desire to eat and ability to enjoy
and also the reason why the therapeutic diet was her food. Often in older people, the risks
ordered. This knowledge will help you to identify errors associated with malnutrition and weight loss
(for example, a mix-up with meal trays) and reinforce (resulting from loss of a desire to eat because
information the nurse has given the person about the the therapeutic diet is unappealing) are greater
reason for, and benefits of, the therapeutic diet. It is than the risks associated with not following the
important to help and encourage the person to follow therapeutic diet. If an older person in your care
any therapeutic diet that has been ordered, because not is on a therapeutic diet but does not seem to be
following the diet can cause health problems. Commonly taking in adequate amounts of food or enjoying
ordered therapeutic diets are summarized in Box 14-1. his meals, make the nurse aware of this.

▼ Box 14-1 Commonly Ordered Therapeutic Diets

Soft, Mechanical or Pureed Diet. Food can be prepared Carbohydrate-Controlled Diet. This diet is ordered for
in special ways to make it easier for a person to chew, people with diabetes. The dietician determines the amount
swallow and digest. A soft diet includes soft and mashed of carbohydrates, fat and protein the person can have each
foods, such as hot breakfast cereal and mashed potatoes. A day based on the person’s activity level and nutritional needs.
mechanical diet includes foods that are chopped very small, Meals are planned so that the person’s daily budget of
or ground up (such as ground meat). A pureed diet includes carbohydrates, fat and protein is spaced throughout the day
foods that are blended to a very smooth consistency, similar to help keep blood glucose levels steady.
to that of pudding or a milkshake. A pureed diet can look very
Calorie-Restricted Diet. A diet with 1,200, 1,500, 1,800
unappealing, but keeping the individual foods separate from
or 2,000 calories per day may be ordered for a person
one another and having a positive attitude toward the food
who needs to control his weight. The primary care provider
can help the person accept it.
or dietitian may recommend multivitamin and mineral
Liquid Diet. A liquid diet may be ordered for a person who supplements for a daily diet of 1,200 calories or fewer.
has digestive problems or has had recent surgery. A clear For minor calorie restriction, the doctor may order a regular
liquid diet or a full liquid diet may be ordered. A clear liquid no-concentrated-sweets (NCS) diet that eliminates only
diet includes liquids you can see through, such as broth, sweets, such as candy and cookies.
gelatin, tea, clear carbonated sodas and clear juices (for
Heart Healthy Diet. A heart healthy diet is usually
example, apple, grape, cranberry). A full liquid diet includes
ordered for people with heart disease. Foods on this diet
fruit juices such as orange and grapefruit juice, strained
are naturally low in unhealthy fats. Lean meats, low-fat or
soups, ice cream, milk and thinned cooked cereal. Because
non-fat dairy products, fruits, vegetables and whole grains
a liquid diet does not provide adequate nutrition, it is usually
are encouraged. Cooking techniques that involve the use
only used for 1 to 2 days.
of additional fats (such as frying) are avoided. Although
Sodium-Restricted Diet. Sodium may be limited for people unhealthy fats like butter should be avoided, spreads
with high blood pressure or kidney or heart disease. Foods in and condiments that contain healthy fats can be used
this diet must be prepared with no added salt, and foods that in moderation.
are naturally high in sodium (such as lunch meat, cured meats,
High-Protein Diet. A doctor prescribes this diet for people
pickles and cheeses) should be avoided. The person is usually
who do not eat enough protein or who need additional
not allowed to add salt to foods at the table, but the primary
protein to rebuild injured tissue.
care provider may approve the use of a salt substitute. Often
foods are prepared with or accompanied by other spices to
increase flavor and make up for the lack of salt.

232 | | Nurse Assistant Training

Meal Supplements tissues of the mouth moist can help. Be sensitive
to the person’s discomfort, and encourage visitors
When a person has not been eating well or is losing to enjoy their own food or beverages outside of the
weight because of an illness, the person’s primary person’s room. To remind everyone that the person
care provider may order a meal supplement. These may not eat or drink, post a sign on the room door
supplements, which are similar in taste and appearance saying “NPO.”
to a milkshake, are usually high in calories, fat and
protein. The meal supplement may be given with or
between meals, as a snack. If a meal supplement has You finish preparing lunch and go to help
been ordered for one of the people in your care, be sure Mr. Minnetti to the table. When he sits down, he
to serve the supplement at the specified time. If the looks at his plate with disappointment. “I was
person declines the supplement, you should report this really hoping for a ham and cheese sandwich and
to the nurse. a dill pickle,” he tells you. He picks at his meal and
leaves most of it uneaten. He says, “It just has no
taste!”After Mr. Minnetti leaves the room, Mrs.
Thickened Liquids Minnetti says to you, “Do you see what I mean?
I’m afraid if he can’t have what he is used to eating,
Some medical conditions, such as stroke, may make it
he might not eat. I don’t want mealtimes to become
difficult for a person to swallow liquids without choking.
a battleground.”
For these people, the person’s primary care provider may
order the use of a thickening agent. The thickening agent Consider the role that meals and eating
is added to liquids to thicken them and make them easier play in your life. How would you feel if you
for the person to swallow. Liquids can be thickened to couldn’t eat certain foods that you enjoy?
different consistencies:
How might you approach Mr. Minnetti to
■ A nectar consistency is like thin, runny syrup. The ease this transition?
liquid pours in a ribbon-like stream.
Is there anyone else on the health care team
■ A honey consistency is thicker than a nectar
you could ask for help?
consistency. The liquid drizzles slowly when poured.
■ A pudding consistency is very thick. The liquid does
not pour and must be eaten with a spoon.
The person’s primary care provider will specify which
consistency should be used. Follow your employer’s MEAL TIME WHEN A PERSON IS
policies and procedures related to thickening liquids. If
you are permitted to use a thickening agent to thicken
RECEIVING HEALTH CARE
the person’s liquids, follow the directions on the Meal time can be difficult for a person who is receiving
container of thickening agent exactly. These directions health care. As you have already learned, many physical
will tell you how much product to add to achieve the and emotional factors can cause a person who is
necessary consistency. receiving health care to have little or no appetite. For a
person who is ill or has a physical disability, the act of
eating can require a great deal of physical effort and
NPO Status can be very tiring and frustrating. The person may be
embarrassed about needing help with an activity as
NPO stands for nil per os, or “nothing by mouth” in basic as eating.
Latin. When a person is placed on NPO status, he
is not allowed to have anything, not even water, by There are two major goals for meal times when a person
mouth for the specified amount of time. NPO status is receiving health care. First, you want to make the meal
is most often ordered for several hours before a as positive and pleasurable an experience as possible for
person has surgery or other procedures (such as the person. Secondly, you want to maintain or improve
some diagnostic procedures) that involve general the person’s food intake. Usually, achieving the first goal
anesthesia. This is because the anesthesia may cause can help you to achieve the second. To make the meal as
the person to vomit, which can lead to aspiration and positive and pleasurable an experience as possible:
complications such as pneumonia. It is safer for the ■ Involve the person in decisions about when to eat,
person if he goes into the surgery or procedure with what to eat and where to eat as much as possible.
an empty stomach.
■ Support rituals and traditions the person may have
Being on NPO status can be uncomfortable for the related to eating and mealtimes, such as giving
person. Providing frequent mouth care to keep the thanks before a meal.

Chapter 14 | Assisting with Meals and Fluids | 233

■ Take steps to promote the person’s dignity and self- Serving the Meal
esteem throughout the meal.
■ Help the person to enjoy the company of others Once these preparations are completed, it is time
during the meal (even if the only other person to get the person’s meal tray. Make sure you are
present is you). delivering the right meal tray to the person by
checking the name on the card on the meal tray
■ Present the meal attractively (for example, by (Figure 14-3). If the person is on a therapeutic diet,
removing items from the meal tray and placing make sure that the diet noted on the card is the same
them on the table to create a more home-like one the person is supposed to be receiving. If you
environment if you work in a facility setting, or by suspect that an error has been made, check with the
planning, preparing and serving visually appealing nurse before serving the meal. It is possible that the
meals if you work in a home setting). person’s diet has been changed, but if not, you will
■ Create a pleasant, clean, relaxing environment need to obtain a replacement meal with the correct
for eating. diet. Organize your time so that you can help the
person to eat shortly after delivering the tray. Foods
are much more appealing when they are served at the
Preparing the Person for proper temperature.
the Meal
There is more to assisting a person with meals than Assisting the Person to Eat
simply getting the meal tray and putting it down in front
of her. Before the meal is even served, there are several Many people will be able to eat on their own, if you help
things that must be done to help prepare the person for them with tasks such as opening cartons, cutting up
the meal. Give yourself adequate time to accomplish the meat or identifying the location of items on the table
following before the meal: and on the plate. The use of assistive devices for eating
(Table 14-1) can further increase the person’s ability to
■ Ensure the person’s physical comfort by assisting eat independently. At each meal, talk with the person
her to use the bathroom and wash her hands before about the amount of help he needs, because he may
the meal. have different needs at different meals. For example,
■ Provide mouth care, because a clean mouth makes at lunchtime the person may be able to eat a sandwich
food taste better. If the person wears dentures, make by himself, but at dinnertime he may need help cutting
sure the dentures are clean and in place. his meat. Always encourage the people in your care to
■ Assist the person with putting on glasses or do as much as they can for themselves. Even when a
inserting a hearing aid, if she uses these devices. person is totally dependent on you to feed him, involve
him in the process as much as possible (for example,
■ Create a comfortable, pleasant environment for
by asking him to hold his napkin). This helps to promote
eating. If the person will be taking the meal in her
independence and protect the person’s dignity and self-
room, make sure the room is neat, clean and free of
esteem. Remember that meals are not just about the
odors. Make sure there is adequate lighting.
food. Being in the company of others and socializing
■ Position the person properly for eating. In many
long-term care facilities, residents go to the dining
room to eat. Even if they must be taken to the dining
room in a wheelchair, they are often encouraged to
move from the wheelchair to a regular dining chair
during the meal. Whether the person is eating in the
dining room or in her room, help the person into a
comfortable, upright, sitting position, with her head
up and her hips at a 90-degree angle. This position
makes it easier for the person to chew, swallow, and
manage eating utensils. If the person is seated in
a chair, make sure her feet are flat on the floor, and
have her rest her elbows or forearms on the table if
she needs support.
■ If the person would like to use a clothing protector
to protect her clothing from spills, assist her with
putting the clothing protector on. To protect the
person’s dignity, avoid referring to the clothing Figure 14-3 Always make sure you are serving the right meal tray to the
protector as a bib. right person.

234 | | Nurse Assistant Training

Table 14-1 Assistive Devices for Eating
Problem Device What It Does How to Improvise
The person has Plate guard The raised rim gives the Have the person hold a piece
trouble getting food person something to push of bread on the plate to push
on the utensil the food against the food against

Scoop dish The rounded side gives the

person something to push
the food against

Spork The end of the utensil allows

the person to spear or
scoop food

The plate slips or Suction base The suction base holds the Place a wet washcloth under
moves plate securely to the table the plate

The person has Built-up handle utensil The larger handle is easier Use foam rubber or leather to
trouble grasping to hold build up the handle of a standard
the utensil utensil, or place the handle of the
utensil through a tennis ball

Vertical or horizontal palm The handle slips over the

self-handle utensils palm of the hand so the
person does not have to
grasp it

Utensil holder The holder slips over the

person’s palm and the
utensil is placed in the
holder, making the utensil
easier to grasp

Continued on next page

Chapter 14 | Assisting with Meals and Fluids | 235

Table 14-1 Assistive Devices for Eating continued

Problem Device What It Does How to Improvise

Universal cuff The strap is fastened to
the person’s hand and the
utensil is placed in the
strap, making the utensil
easier to grasp

The person has trouble Swivel fork or spoon The end of the fork or Rest the person’s elbow on a
keeping food on the spoon remains level even soft, spongy surface (such as
utensil because of a if the person’s hand shakes a piece of foam or a sponge)
tremor or weakness to lessen tremors; help to
steady the person’s hand
as needed

The person is only able Rocker knife The person rocks the
to use one hand to sharp edge of the knife
cut food back and forth over the food
to cut it

The person has trouble Modified drinking cup The handles make it easier
drinking without for the person to grasp
spilling the liquid the cup, and the cover
and spout keep the liquid
from spilling

Commercial straw holder The holder goes across Secure plastic wrap over the
the rim of the cup to keep rim of the cup with a rubber
the straw in place band and poke a straw
through the plastic wrap

The person has Extension utensil The handle extends to make

limited arm movement it easier for the person to
and cannot reach bring the food to the mouth
his mouth

236 | | Nurse Assistant Training

 Figure 14-4 Being in the company of others and socializing during
meals is important.

are important during the meal as well (Figure 14-4). Sit

down and take the time to talk with the person during Figure 14-5 Describing the location of items on the table and on the
the meal, even if he cannot answer you. plate in terms of a clock face is useful when assisting a person who is
visually impaired to eat. For example, here the chicken is at 12:00, the
Avoid rushing the person during the meal. Observe the potatoes are at 4:00, and the green beans are at 7:00. The coffee is
at 1:00 and the water is at 2:00.
person to determine whether he needs help eating. If the
person does not eat a certain food, ask him why. Sometimes
■ Describe the location of the eating utensils.
people leave part of a meal uneaten because they get too
tired to finish. In this case, the person may eat more if you ■ During the meal, occasionally check on the person
offer to help. Or the person may just not care for the food. to see whether he has overlooked some of the food,
If the person simply did not care for the food, ask if there and if so, offer assistance.
is something else you can get him to eat that he might find
more appetizing. Knowing why a person did not eat part
Helping a person who has difficulty
or all of a meal can help the health care team plan future swallowing
meals that will be more appealing to the person, or address A person who has had a stroke that has resulted in
other issues that may be affecting the person’s appetite. speech difficulties may also have trouble swallowing
food. A person who has difficulty swallowing may be on
When the person has finished eating, remove the dishes a soft diet, and there may also be orders to use liquid
and tidy up the table. Assist the person with mouth care thickeners. When helping a person who has trouble
and changing any articles of clothing that became soiled swallowing during meal time:
during the meal.
■ Remain with the person while he is eating.
Skill 14-1 describes step-by-step how to assist a person ■ If the person is working with a speech therapist to
during mealtime. Special considerations during mealtime relearn safe swallowing techniques, make sure you
for people with specific conditions are described in the are aware of these techniques so that you can help
sections that follow. the person practice them.
■ If liquid thickeners have been ordered, make sure
Helping a person who is visually that all of the liquids on the tray, including soup, are
impaired thickened before serving them.
A person with visual impairment can usually eat
■ Encourage the person to chew slowly and thoroughly.
independently if he has no other disabilities. To help
the person during meal time, you may only need to do ■ Eliminate distractions, such as television or many
the following: visitors, so that the person can concentrate on eating.
■ Keep the person’s head elevated during eating and
■ Identify the location of foods on the table and on the
for at least 30 minutes after eating.
plate. Describe their locations as if the plate were
the face of a clock (Figure 14-5). Helping a person in isolation
■ Cut up meats or anything else that needs cutting. Before bringing a meal tray to a person who is in
■ Open containers. isolation, put on the necessary personal protective

Chapter 14 | Assisting with Meals and Fluids | 237

equipment (PPE). Because the person’s ability to
socialize with others is limited, offer the person Observations Into Action!
companionship during the meal. When the person has When you are assisting a person with eating, be sure
finished eating, dispose of any leftover food or liquid to report any of the following observations to the
per your employer’s policy. Double-bag reusable and nurse right away:
disposable eating utensils, plates and cups for washing
or disposal, per your employer’s policy. { Lack of appetite
{ Sudden change in appetite
{ Difficulty chewing or swallowing
Monitoring Food Intake { Difficulty managing, or extreme frustration
In most facilities, you will be required to estimate, report with using, assistive devices for eating
and record the amount of food the person ate at each { Refusal to eat a therapeutic diet, or
meal. You may be asked to estimate how much of the decreased food intake while on a
total meal the person ate, and give a rough percentage therapeutic diet
(Figure 14-6). Usually, you will be required to report a { Food intake of less than 70% at a meal
food intake of less than 70% to the nurse.
For some people in your care, you may be required
to estimate the percentage eaten of each food that (such as fruits and vegetables, soups, ice cream
was served. For example, you might say that the and gelatin).
person ate 50% of the pork chop, 50% of the mixed
vegetables, 100% of the mashed potatoes and 100%
of the pudding. Fluid Balance
Fluid balance occurs when the amount of fluids a
person takes in equals the amount of fluids the person
loses. Each day, we lose fluid in the form of urine, sweat,
THE IMPORTANCE OF FLUIDS bowel movements and breath vapor. To maintain a state
Earlier you learned about key nutrients that are of fluid balance, we must take in enough fluid each day
supplied by food and beverages. In addition to to equal, or balance, these losses. When fluid balance is
supplying the body with nutrients, foods and not maintained, the person develops either dehydration
beverages supply the body with water. Water is (too little fluid in the body) or edema (too much fluid in
extremely important to life. A person can actually live the body).
longer without food than he can without water. Every
cell in our bodies contains water, and water forms the Dehydration
basis for many important body fluids, including blood Dehydration can result from conditions such as
(which circulates oxygen and nutrients throughout vomiting, diarrhea, fever or severe blood loss. A very
the body), sweat (which helps to cool the body) and common cause of dehydration, however, is simply not
urine (which helps to remove wastes from the body). drinking enough fluids. Many people who are receiving
We take in the water our bodies need through health care have conditions that put them at risk for
drinking (water, as well as other beverages) and not drinking enough fluids and becoming dehydrated.
through eating foods that have high water contents For example, a person who has problems with mobility
or other disabilities may have a difficult time getting
up to get a drink. The person may also cut back on
fluids because she is trying to reduce the number of
times she needs to get up and go to the bathroom, or
she is afraid that she will not be able to make it to the
bathroom in time. Some people who are incontinent of
urine may also reduce their fluid intake because they
think this will lower their risk for having an episode of
incontinence. However, it is important to know that
decreasing fluid intake does not decrease incontinence,
nor does it decrease trips to the bathroom. In fact,
the opposite may be true. As the urine becomes more
Figure 14-6 Food intake is usually stated as a percentage of the total concentrated, it irritates the bladder and may increase
foods offered. (A) This person ate about 90% of what he was offered.
(B) This person ate about 70% of what he was offered. A food intake the urge to urinate, resulting in the need to urinate
of less than 70% usually must be reported to the nurse. more frequently.

238 | | Nurse Assistant Training

As a nurse assistant, you will play an important role If a person becomes dehydrated, the person’s primary
in helping to ensure that those in your care take in care provider may give an order to “encourage fluids”
enough fluids. or “push fluids.” This means that the person should be
urged to drink as much fluid as possible. Encourage the
■ Frequently offer fluids that the person likes at the
person to drink each time you enter the room and again
temperature she prefers (Figure 14-7).
on your way out. Keep a record of the amount of fluid the
■ Encourage the person to drink plenty of fluids with person does drink.
each meal.
■ Frequently provide the person with a pitcher of
clean, fresh water. Encourage the person to drink Observations Into Action!
each time you enter the room.
■ Be sure the person has a clean drinking glass or Dehydration is a serious condition. If you suspect
cup within easy reach. Refill the glass if the person that a person in your care is dehydrated, tell
cannot do it. A drinking straw or a plastic water the nurse immediately. Signs and symptoms of
bottle with a screw-on lid and a straw may make it dehydration include the following:
easier for some people to drink independently. { Confusion
■ If the person frequently refuses beverages, check { Poor skin turgor (the skin does not return
with the nurse to see if you can offer fluid-rich foods to its normal shape when gently squeezed
instead, such as ice cream, popsicles, gelatin or fruit. or pinched)
{ Passing of small amounts of dark-colored
urine
{ Constipation
{ Drowsiness
{ Very dry skin or chapped lips
{ Elevated temperature

Edema
Edema, or the state of retaining too much water, can
result from medical conditions (such as chronic heart
failure or kidney disease) that make it hard for the body
to rid itself of excess water. The person’s primary care
provider may place restrictions on the amount of fluid the
person is allowed to have each day. When you are caring
for a person and fluid restrictions are in place, the nurse
Figure 14-7 A person may hesitate to ask for a drink but will accept one
will tell you how much fluid the person is allowed to have
if it is offered. over the course of your shift. Offer small amounts of fluid
at regular intervals. This will help to prevent the person
ELDER CARE NOTE. In an older person, from becoming too thirsty.
dehydration can occur rapidly and be life-
threatening. Many older people often are not Measuring and Recording
as quick to feel thirst as younger people are,
so they may not be drinking enough fluids
Fluid Intake
to begin with. This, combined with health When orders to encourage or restrict fluids are
concerns that might cause the person to in place, you will need to measure and record the
reduce his fluid intake, puts the older person at person’s fluid intake. A person’s fluid intake includes all
high risk for dehydration. When you are caring of the liquids the person drinks, as well as foods that
for an older person, offer the person a drink are primarily liquid (such as soups) or that are liquid
every time you interact with the person, and at body temperature (such as ice cream or popsicles).
make sure the person always has fresh water Although in everyday life fluids are usually measured
within reach. However, be aware that even in ounces (oz), in health care, fluids are measured and
when offered water, many older people will say recorded in milliliters (mL) or cubic centimeters (cc).
“I’m not thirsty” or “I’ve already had too much to A milliliter (mL) is equal to a cubic centimeter (cc).
drink today.” You may need to be persistent in One ounce equals 30 milliliters or 30 cubic
encouraging the person to drink. centimeters. Follow your employer’s policy regarding

Chapter 14 | Assisting with Meals and Fluids | 239

which abbreviation (mL or cc) to use when administering fluids. A small catheter (tube) is placed in
documenting fluid intake. a vein on the back of the person’s hand or in the person’s
arm. Fluid drips slowly from the IV bag, through the IV
With prepackaged items, printed information on the
tubing and into the catheter. Sometimes medications
container indicates how much it holds. For example, a
may be administered through the IV tubing as well.
small prepackaged milk container contains 8 ounces,
Although you will not be responsible for administering
or 240 mL (remember, there are 30 mL in an ounce). In
IV therapy, you may care for a person who is receiving
other cases, you will need to determine how much fluid
IV therapy.
the container holds. Most facilities have a list you can
check to determine the amount of fluid the cups, glasses
and bowls in use in the facility hold. If you are caring for
a person in her home and need to measure fluid intake, Observations Into Action!
you can determine the amount of fluid the person’s cups,
When caring for a person who is receiving IV therapy,
glasses and bowls hold by filling them with water and
be sure to report any of the following observations
then pouring the water into a measuring cup.
to the nurse right away:
To measure and record fluid intake, observe how much { Disconnected IV line
fluid the person consumes at each meal and in between { Empty fluid bag
meals. For example, if a person had 8 oz (240 mL) of milk,
4 oz (120 mL) of coffee and 12 oz (360 mL) of soup with
{ Pain, swelling or redness at the IV site
lunch, you would record the person’s fluid intake at lunch
time as 720 mL. Then, if the person had another 8 oz
(240 mL) of tea in between lunch and dinner, you would Enteral Nutrition
record the person’s fluid intake as 240 mL. Sometimes
Enteral nutrition is often called tube feeding because the
the person may not consume all of the fluid in the
person receives nutrition (in the form of a nutrient-rich
container. In this case, estimate how much of the total was
formula) and fluids through a tube that is placed directly
consumed. For example, if the person only drank about
into the stomach or intestines. If the person will only
half of his coffee at lunch, you would estimate the amount
need enteral nutrition for a few days, a nasogastric or
to be 2 oz (60 mL) instead of the full 4 oz (120 mL).
nasointestinal tube may be used. These types of tubes
are inserted through the person’s nose and passed down
the person’s throat to the stomach or the intestines. If the
OTHER WAYS OF PROVIDING person is expected to require enteral nutrition for more
NUTRITION AND FLUIDS than a few days, a gastrostomy tube may be used. This
type of feeding tube is inserted directly into the stomach
Some people will have conditions that make it
through an incision made in the abdomen. The tube is
impossible for them to take food and fluids by mouth. For
clamped and held in place by sutures (stitches) and
these people, intravenous (IV) therapy or enteral nutrition
covered with a dressing.
(tube feedings) may be ordered.
You will not be responsible for administering enteral
nutrition; however, you may care for a person who is
Intravenous Therapy receiving enteral nutrition. Guidelines for caring for a
Although a person’s nutritional needs cannot be person who is receiving enteral nutrition are given in
met using IV therapy, IV therapy is very useful for Box 14-2.

Box 14-2 Nurse Assistant DO’s and DON’Ts

Enteral Nutrition
DON’T give the person any food or fluids DO keep the head of the person’s bed DO find out from the nurse how to care
by mouth. elevated (in low Fowler’s position) for at for the gastrostomy tube insertion site.
least 30 minutes after the nurse administers
DO remember that only the nurse may DON’T get the dressing covering the
a tube feeding. This helps prevent aspiration.
give the person formula or fluids through gastrostomy tube insertion site wet.
the tube. DO position a person with a gastrostomy
tube so that he is not lying on the tube.

240 | | Nurse Assistant Training

 5. Mrs. Powell has had little appetite since her
Observations Into Action! husband of 65 years passed away recently. What
When caring for a person who is receiving enteral action could a nurse assistant take to encourage
nutrition, be sure to report any of the following Mrs. Powell to eat?
observations to the nurse right away: a. Remind Mrs. Powell that if she does not eat, she
{ Pain or discomfort in the abdomen could get sick.
{ Nausea b. Sit with Mrs. Powell while she is eating and
make pleasant conversation.
{ Excessive gas
c. Explain to Mrs. Powell the importance of
{ Redness, irritation or drainage around the
following the MyPlate guidelines.
tube insertion site
d. Tell Mrs. Powell that if she does not finish her
{ The person repeatedly tries to pull out the
meal, she cannot have dessert.
feeding tube

6. All of the following can affect a person’s

appetite EXCEPT:
a. Medications the person is taking.
CHECK YOUR UNDERSTANDING b. An inability to smell the food.
c. Pain.
Questions for Review d. The person’s fluid balance.

1. Which nutrient helps the body build and 7. Which therapeutic diet might be ordered for a
repair tissue? person who has trouble chewing or swallowing
a. Carbohydrates food?
b. Fat a. A carbohydrate-controlled diet
c. Protein b. A liquid diet
d. Water c. A soft, mechanical or pureed diet
d. A high-protein diet
2. A healthy diet is one that:
a. The person will eat. 8. The doctor has ordered a meal supplement shake
b. Emphasizes whole grains, fruits and vegetables, for Mrs. Johnson, to be served between lunch and
lean meats and low-fat dairy. dinner. Today when you tell Mrs. Johnson it is time
for her shake, she shakes her head and says she
c. The person’s primary care provider prescribes.
does not want it today. What should you do?
d. The person grew up eating.
a. Report Mrs. Johnson’s refusal of the shake to
3. Which nutrient supplies the body with its most the nurse.
basic form of energy? b. Return the shake to the refrigerator and try
a. Carbohydrates offering it to Mrs. Johnson again later.
b. Vitamins and minerals c. Record Mrs. Johnson’s refusal of the shake in
c. Protein her chart, but do not report it to the nurse.
d. Fat d. Nothing; it is all right if Mrs. Johnson skips the
shake because it might spoil her appetite for dinner.
4. All of the following can affect the choices a 9. Which of the following should you do when
person makes about food EXCEPT: assisting with a meal for a person who cannot see?
a. The person’s height. a. Tell the person loudly what you are feeding him,
b. The person’s culture. as you feed it to him.
c. The person’s religious beliefs. b. Orient the person to the location of items on
d. The person’s ability to prepare food. the plate and on the table, using the clock face
method.
c. Insist that the person wear a clothing protector,
because he is likely to spill food on himself.
d. Make sure all of the liquids on the tray have
been thickened.

Chapter 14 | Assisting with Meals and Fluids | 241

10. Mr. Singer has orders to have his fluid intake Questions to Ask Yourself
measured. At breakfast, Mr. Singer drinks an
8-oz carton of milk, a glass of orange juice and 1. You notice that Mr. Rivera did not eat much
a cup of coffee. The glass holds 180 mL and the of his breakfast or lunch. He says he feels okay
coffee cup holds 120 mL. How much fluid, in mL, and asks you not to worry. What should you do?
did Mr. Singer drink? 2. Mrs. Garcia eats very little. She says she is not
a. 308 mL hungry. You suspect that she may tire easily and find
b. 300 mL it difficult to feed herself. You offer to help her eat,
c. 540 mL but she says she is too old to be fed like a baby.
What should you do?
d. 18 mL
3. Because of Parkinson’s disease, Mr. Linkins
11. Which of the following is a sign of dehydration? has a great deal of difficulty using utensils
a. Swelling in the feet and ankles to eat. His hand shakes, and food falls off the
b. Frequent urination utensil before he can get it to his mouth. What
types of assistive devices would you expect the
c. Loss of appetite
occupational therapist will recommend for
d. Confusion
Mr. Linkins?
12. Mrs. Welker is receiving enteral nutrition through 4. Mrs. Woods is a new resident at the long-term
a gastrostomy tube. Which of the following care facility where you work. When you go to
actions should the nurse assistant take? get her ready to go to the dining room for dinner,
a. Keep Mrs. Welker lying flat for 30 minutes after she tells you that she doesn’t want to go and she
a tube feeding. doesn’t feel like eating. She says, “My family just
b. Give Mrs. Welker water by mouth. put me here to die anyway.” How would you
respond to Mrs. Woods? What feelings could be
c. Use cotton balls moistened with alcohol to clean
contributing to Mrs. Woods’ refusal to go to the
around Mrs. Welker’s mouth and nose.
dining room and loss of appetite? Is there anything
d. Keep the head of the bed elevated for you could do to help Mrs. Woods feel better about
30 minutes following a tube feeding. her current situation?

242 | | Nurse Assistant Training

 SKILLS

Skill 14-1
Helping a Person to Eat

PREPARATION 9. If the person would like to use a clothing protector,

assist him in putting the clothing protector on.
1. Wash your hands.
10. Obtain the person’s meal.
2. Gather your supplies:
11. Check the name and the diet noted on the card on
■ Assistive devices for eating, if used the meal tray to ensure that everything is correct.
■ Clothing protector, if used If you suspect a problem with the meal tray, speak
with the nurse and then correct any problems with
3. Knock, greet the person and ensure privacy. the tray.
4. Explain the procedure. 12. Uncover the meal tray and help the person get ready
5. Adjust equipment for body mechanics and safety: to eat. Unwrap utensils and hand the napkin to the
If the person will be getting out of bed to eat, lower person. Assist the person with opening containers,
the bed to the level specified in the person’s care cutting foods and seasoning the food or applying
plan. If the person will be staying in bed, raise the condiments as needed. If thickened liquids have
bed to a comfortable working height. Make sure the been ordered for the person and you are allowed to
wheels on the bed are locked. use a thickening agent to thicken the liquids, prepare
the liquids by adding the thickening agent in the
specified amounts.
PROCEDURE
13. If the person cannot readily identify the foods on
6. Help the person prepare for the meal by assisting the plate, tell her what foods and drinks have been
him with mouth care, toileting and hand washing. If served and where they are on the plate.
the person will be going to the dining room to eat,
14. Assist the person with eating as needed.
help him with dressing and grooming as well.
■ If the person can eat independently:
7. If the person will be eating in her room, prepare the
room. Remove any source of unpleasant odors and Make sure the person has everything he needs
make sure there is adequate lighting. If the person (such as assistive devices for eating). Place the
will be staying in bed to eat, change any soiled person’s method of calling for help within reach
linens (or straighten clean linens). and tell him you will be back to check on him.
8. Position the person for eating. ■ If the person needs your help to eat:
■ If the person goes to the dining room: Help { Sit down next to the person.
the person to the dining room. If a wheelchair is { Help the person to have a few sips of liquid.
used to transport the person to the dining room, Ask the person which liquid he would like to
assist the person to move from the wheelchair try first. If the person uses a straw, place the
to a regular dining chair at the table, per your straw in his mouth so that he can suck and
employer’s policy. swallow the liquid as desired. If the person
■ If the person stays in the room and eats sucks too much liquid, you may need to
in bed: Raise the head of the bed to Fowler’s pinch off the straw and pull it away so that
position, and position the over-bed table at he can swallow. If the person is drinking hot
an appropriate height over the bed. liquids through a straw, stir the liquid with the
■ If the person stays in the room but gets straw before offering it to him. This helps to
out of bed to eat: Assist the person to transfer distribute the heat evenly and prevent burns.
from the bed to the chair. Position the over-bed
table at an appropriate height over the chair.

Continued on next page

Chapter 14 | Assisting with Meals and Fluids | 243

SKILLS

Skill 14-1
Helping a Person to Eat Continued
{ Ask the person which food he would like to 15. Check the person’s food and fluid intake. If the
try first. Fill a spoon only one-third full. Touch person has not eaten one or more items that were
the spoon to the person’s lower lip and then served, offer to obtain substitute items that might be
to his tongue to let him know where the food more appealing to the person.
is and when to open his mouth (Figure 1). 16. When the person has finished eating, note and write
Allow time between bites for the person to down the person’s food and fluid intake.
chew and swallow. Help the person to wipe 17. Remove the tray and the clothing protector (if used).
his mouth with the napkin as needed.
18. If the person ate in the dining room, assist the
{ After a few bites of food, offer the person a person back to his room.
few sips of liquid. Continue in this way until
19. Assist the person with mouth care as needed.
the person tells you he has had enough to
eat and drink.
COMPLETION
20. Ensure the person’s comfort and good body
alignment.
21. Adjust equipment for safety: Lower the bed to
the level specified in the person’s care plan. Make
sure the wheels on the bed are locked. Place the
person’s method of calling for help within reach.
Lower or raise the side rails according to the
person’s care plan.
22. Clean up your work area.
23. Wash your hands.
24. Report and record.
Figure 1

244 | | Nurse Assistant Training

 C H A PT E R
Assisting with
Elimination 15
After reading this chapter, you will have the information needed to:
■ Assist people in your care with elimination in a sensitive, professional way.
■ Describe the characteristics of normal urine and feces.
■ Explain the importance of knowing a person’s regular elimination pattern.
■ List actions nurse assistants can take to promote normal elimination.
Goals ■ Define the word incontinence and describe the care needs of a person who
is incontinent.
■ Describe the signs and symptoms of a urinary tract infection and actions nurse assistants
can take to help prevent those in their care from developing urinary tract infections.
■ Describe care measures for a person who has diarrhea.
Continued on next page

Chapter 15 | Assisting with Elimination | 245

 Continued from previous page

■ Describe actions nurse assistants can take to prevent those in their care from
becoming constipated or developing a fecal impaction.
■ List observations that a nurse assistant may make while assisting a person with
elimination that should be reported to the nurse right away.
■ Describe the care needs of a person with an indwelling urinary catheter.
■ Explain what an ostomy appliance is and how to care for a person who has
an ostomy appliance.
■ Describe types of enemas and precautions that should be taken when administering
an enema.
Goals After practicing the corresponding skills, you will have the information needed to:
■ Help a person use a toilet, portable commode, bedpan or urinal.
■ Apply a condom catheter.
■ Measure urine output.
■ Obtain urine and stool specimens.
■ Provide catheter care for a person with a urinary catheter.
■ Empty a urine drainage bag.
■ Change an ostomy appliance.
■ Give a tap water, soap solution or commercially prepared enema.

Key Terms:
urine incontinence fecal impaction ostomy appliance

feces condom catheter indwelling urinary enema

catheter
urination diarrhea
stoma
defecation constipation

kidneys, which filter the blood to remove dissolved waste

It is almost the end of your shift, but before products and excess fluid. Feces are formed through the
you leave you decide to check in on Mrs. Doris process of digesting food. As food passes through the
Wilson one last time. Mrs. Wilson was admitted to digestive tract, the usable parts of the food are absorbed
Morningside yesterday, and she’s been feeling a little into the body, and the unusable parts of the food are
homesick. When you knock on Mrs. Wilson’s door and eliminated as feces. (Feces are also sometimes referred
ask if you can come in, Mrs. Wilson answers you in a to as stool after they leave the body.) Urine and feces are
quivering voice and you can tell she has been crying. removed from the body through the processes of urinary
You enter the room and see a puddle of urine on the and bowel elimination, respectively.
floor. Mrs. Wilson is sitting on the chair near the bed in
Most people consider elimination to be a personal, private
her wet clothes. She looks up and says, “I tried to get to
matter. In a health care setting, it may become more difficult
the bathroom by myself and I just couldn’t make it in
for the person to keep elimination personal and private.
time. I’m so embarrassed.” And she starts to cry again.
Some people receiving health care will need to ask for
You pat Mrs. Wilson on the shoulder and say, “Don’t
help each time they need to use the bathroom. Others may
worry, Mrs. Wilson. It’s OK. Here, let me help you.”
not be able to get out of bed or walk the distance to the
bathroom, and will have to use a bedpan, urinal or portable
commode while being separated from others in the room by
only a privacy curtain. Members of the health care team may
INTRODUCTION TO ELIMINATION ask the person questions about her elimination habits, or
Waste products such as urine (liquid body waste) and request samples of urine or feces. As you can see, a person
feces (solid body waste) are formed as the result of who is receiving health care may be required to think and
normal processes in the body. Urine is formed by the talk about elimination much more than she normally would.

246 | | Nurse Assistant Training

A person who needs help with elimination may feel and recognize changes in it. To learn about a person’s
embarrassed, helpless or angry. Be sensitive to the elimination pattern, ask these questions:
person’s feelings about needing help with a very personal
■ How often do you urinate?
function, and take steps to protect the person’s privacy and
dignity. Treating elimination as a routine, normal occurrence ■ Is there anything special about your urination habits
and maintaining a positive, professional attitude can help that I should know?
to lessen the person’s embarrassment and help him to feel ■ How often do you have a bowel movement?
better about needing help with elimination. Although it is ■ What time of day do you usually have a
normal for you to feel embarrassed or uncomfortable while bowel movement?
assisting another person with elimination, especially at first, ■ Is there anything special about your bowel
try not to show your feelings. If the person senses that you movement habits that I should know?
are embarrassed or uncomfortable, he will likely become
more embarrassed and uncomfortable as well. If the person cannot provide the information, ask the
person’s family members or check the person’s chart to
When discussing elimination, use professional language. determine a pattern.
Passing urine is referred to as urination or voiding.
Passing feces is referred to as defecation, or having Normal elimination is important for the person’s health
a bowel movement. Always use professional language and comfort. As a nurse assistant, there are many things
when you are communicating with other members of you can do to help promote normal elimination for the
the health care team about elimination. When you are people in your care.
communicating with those in your care about elimination, ■ Maintain the person’s normal elimination pattern.
it is always correct to use professional language, but in A change in routine can disrupt a person’s elimination
some situations it is okay to use terms preferred by the pattern, leading to problems such as constipation
person, if doing so helps to ensure clear communication (difficulty having a bowel movement) or incontinence
and gain the person’s cooperation. For example, when (the inability to control the release of urine or feces).
discussing elimination with a person who has dementia, Take the person’s normal elimination pattern into account
your meaning may be clearer and you may get a better when planning care, rather than trying to have the
response if you use terms that are familiar to her. person adapt to a schedule that is convenient for you.
Also, answer requests for help promptly (Figure 15-1).

PROMOTING NORMAL
ELIMINATION
Normal urine ranges in color from pale to deep yellow and
has a slight odor. It is clear, not cloudy. In the morning, the
color of urine is darker, and it may have a strong odor. As
the day goes on, the urine becomes lighter in color and
the odor lessens. This is because decreased fluid intake
at night causes urine to become more concentrated (that
is, it contains less water). During the day, when the person
drinks more fluids, the urine becomes more diluted (that is, it
contains more water). The more dilute the urine, the lighter it
is in color and the less odor it has. Feces are normally brown
in color, soft in texture and formed, with a distinctive odor.
All of us follow fairly predictable patterns for elimination
of urine and feces, although elimination patterns vary
from person to person. When describing a person’s
urinary elimination pattern, you note the number of
times each day the person typically voids and how
much time passes between voiding. When describing a
person’s bowel elimination pattern, you note what time
the person usually has a bowel movement, and how
frequently bowel movements occur. Some people have
bowel movements every day, others every 2 to 3 days.
You must learn the elimination pattern of each person Figure 15-1 Respond to a person’s request for help with elimination
in your care so that you can help maintain the pattern promptly.

Chapter 15 | Assisting with Elimination | 247

 Holding urine or feces is uncomfortable for the Regular urination helps to flush bacteria from the
person, and can disrupt the person’s normal urinary tract that can cause infection. Feces
elimination pattern. that are soft are easier to pass, helping
■ Encourage adequate fluid intake. Drinking to prevent constipation.
enough fluid helps to promote regular urination ■ Encourage exercise and foods that are high
and helps to keep the feces soft (Figure 15-2). in fiber. Getting up and moving helps to promote
regular bowel movements. The fiber in foods such
as whole grains, fruits and vegetables helps to keep
the feces moist, making them easier to pass and
preventing constipation.
■ Provide privacy. A sense of privacy makes it easier
for the person to urinate or have a bowel movement.
■ Promote comfort. Being chilled or feeling
rushed can make it difficult for a person to
urinate or have a bowel movement. Make sure
the person is warm enough, and give him plenty
of time to meet his elimination needs. If you are
aware of routines the person follows related to
elimination (for example, some people like to read
while using the toilet), help the person maintain
those habits.
General guidelines for assisting a person with elimination
Figure 15-2 Taking in enough fluid helps to prevent problems are given in Box 15-1.
with elimination.

Box 15-1 Nurse Assistant DO’s and DON’Ts

Assisting with Elimination
DO maintain a professional attitude DO learn about the person’s normal on her regularly so that you do not leave
when assisting a person with elimination patterns and habits, and help her stranded on the bedpan or alone in
elimination. Treating the person the person maintain these patterns and the bathroom for too long.
with kindness and respect and habits to the greatest extent possible.
DO offer frequent assistance with
treating the task as something normal
DO promote healthy elimination by elimination. Some people may be
and routine helps to put the person
encouraging fluids, high-fiber foods (such reluctant to ask for help, even if they
at ease and lessens feelings of
as fruits, vegetables and whole grains) need it. Accepting an offer of help may
embarrassment.
and regular exercise. be easier for them.
DO take measures to protect the
DO answer requests for help promptly. DO observe the characteristics and
person’s privacy and dignity. Shut
Doing so helps the person maintain her amount of urine and feces before
doors and pull privacy curtains. If safety
normal elimination pattern and helps to emptying a urinal, bedpan or commode
considerations allow, leave the room
prevent problems such as falls (which container or flushing the toilet. Changes
(but check on the person frequently,
could occur if the person cannot wait any in urine or feces could be a sign of a
and make sure the call signal is within
longer and tries to get up to go to the health problem and should be reported to
the person’s reach). Be sensitive to how
bathroom unassisted) and episodes of the nurse.
the person may feel about discussing
incontinence (which could happen if the
her elimination needs and habits when DO follow standard precautions
person simply cannot hold the urine or
other people are present. Approach when you are assisting a person
feces any longer).
unpleasant tasks (such as cleaning up a with elimination.
bowel movement) positively, and make DO follow the toileting plan as written in
sure that your facial expressions and DON’T place equipment used for
the person’s care plan.
gestures do not show displeasure with elimination, such as bedpans or urinals,
the person or the task. DO give the person plenty of time to take on the person’s bedside table or over-bed
care of her elimination needs, but check table, even if they are clean.

248 | | Nurse Assistant Training

 After you finish getting Mrs. Wilson into
clean, dry clothes, you sit beside her on the bed
and say, “Now, Mrs. Wilson, I know it can be
embarrassing or difficult to have to ask for help,
especially with something as personal as needing to
use the bathroom. But we’re here to help, and we’d
much rather you call us when you need us, rather
than risk a fall trying to get to the bathroom on your
own.” Mrs. Wilson nods and says, “I know. It’s just so
embarrassing to have to ask for help. You’ve been so
kind. I guess my new situation is just going to take a
little getting used to.”

What could you do or say to make it easier for

Mrs. Wilson to ask for help with elimination?

It is always important to answer requests for Figure 15-3 Before leaving a person alone in the bathroom, make sure
help promptly. List some reasons why this the toilet paper and call signal are within reach. Stay close by and check
on the person every 5 minutes.
is especially important when the person is
calling for help with elimination.
assistance. When the person is ready, put on gloves and
Mrs. Wilson was obviously very embarrassed assist the person with wiping, if necessary. Help the person
and upset by her accident, and she to stand up, if necessary, and adjust clothing as needed.
appreciated your kind and caring response. Give the person the opportunity to wash her hands before
In what other ways could you help to protect leaving the bathroom.
Mrs. Wilson’s dignity and self-respect?

Assisting a Person to Use a

Portable Commode
ASSISTING THE PERSON TO A portable commode looks like a chair with a toilet seat
USE A TOILET, A PORTABLE (Figure 15-4). Under the seat is a collection container that
can be removed for emptying and cleaning. A portable
COMMODE, A BEDPAN OR commode is used for a person who is able to get out
A URINAL of bed, but is not able to transfer the distance to the
bathroom. To use the commode, the person must be able
to stand and pivot, and sit up with little assistance. Skill
Assisting a Person to Use 15-1 describes step-by-step how to help a person to use
the Toilet a portable commode.
Many of the people in your care will be able to use the
toilet to meet their elimination needs, although they may
need your help to get to the bathroom safely, move clothing
out of the way, sit down on the toilet or get up from it. Some
men may need you to help them stand while they urinate.
When assisting a person to use the toilet, help him to put
on a robe and slippers before transferring to the bathroom.
For safety reasons, you may have to remain in the bathroom
with the person. If you need to remain in the bathroom with
the person, you may be able to turn your back (to give the
person a sense of privacy) while still keeping a hand on the
person’s arm (so that you can feel if the person starts to
stand up unassisted). If it is safe to leave the person alone
in the bathroom, make sure the call light and toilet paper
are within reach, and reassure the person that you will be
nearby if she needs help (Figure 15-3). Stay outside the
bathroom door and check on the person every 5 minutes
to make sure she is okay and to see whether she needs Figure 15-4 A portable commode.

Chapter 15 | Assisting with Elimination | 249

Assisting a Person to Use Skill 15-2 describes how to assist a person with using
a bedpan, and Skill 15-3 describes how to assist a man
a Bedpan or Urinal with using a urinal.
Bedpans and urinals are used for people who cannot
get out of bed to meet their elimination needs. A man
may use a urinal to urinate and a bedpan to have a bowel
movement. A woman uses a bedpan for both types of
PROBLEMS WITH ELIMINATION
elimination. Using a bedpan is not very comfortable. In Common problems with elimination include incontinence,
addition to being uncomfortable, it often feels unnatural urinary tract infections, diarrhea, constipation and
to the person to urinate or have a bowel movement while fecal impaction.
lying in bed. These factors can make elimination more
difficult for the person.
Incontinence
The urinal rests between the man’s legs. The man places
his penis in the opening (or you may need to help him Incontinence is the inability to control the release
do this). A bedpan is positioned underneath the person’s of urine or feces. Incontinence can be temporary or it
buttocks. There are two different styles of bedpans: can be permanent. When it is permanent, incontinence
a standard bedpan and a fracture pan (Figure 15-5). is a leading cause of admission to long-term care
A fracture pan, which is thinner than a standard bedpan facilities. It can be very frustrating to care for a person
and wedge-shaped, is used when the person has a who is incontinent, but it is important to remember
condition that makes positioning a regular bedpan that the person cannot help her condition. In fact, the
underneath the person difficult. A regular bedpan is person may be very embarrassed by her condition.
placed with the narrow end pointing toward the person’s Although many of the people you will care for who
feet, while a fracture pan is placed with the narrow end are incontinent will be elderly, incontinence is not an
pointing toward the person’s head. expected consequence of aging. Several factors can
lead to incontinence:
Check at least every 5 minutes on a person who is using
a bedpan or urinal. Help the person off the bedpan or ■ Acute conditions, such as a urinary tract infection
remove the urinal as soon as the person is finished or diarrhea, that can cause the person to urinate or
using it. Sitting on a bedpan or having a urinal in place have a bowel movement almost immediately after
causes pressure that can put the person at risk for recognizing the need to go to the bathroom
developing pressure ulcers, so it is important to remove ■ Certain medications, which can also produce an
that pressure source as soon as possible. urgent need to use the bathroom
■ Conditions such as confusion or dementia that reduce
ELDER CARE NOTE. Remember that elderly the person’s ability to interpret the feeling of having to
skin is fragile and can tear and bruise easily. go to the bathroom and make it hard for the person to
Use special care when positioning the bedpan remember how to call for help, find the bathroom and
under the person, and remove the bedpan as remember how to move clothing out of the way
soon as the person is finished using it. ■ Conditions such as arthritis that limit a person’s mobility,
making it difficult for the person to reach the bathroom
in time or move clothing out of the way in time
■ Brain, spinal cord or nerve damage that prevents
the person from feeling the urge to urinate or have a
bowel movement
■ Weakness of the muscles that normally prevent the
involuntary release of urine or feces

Bladder or bowel training programs

and scheduled toileting programs
A bladder or bowel training program is usually developed
for a person who is incontinent of urine or feces and
has the ability to recognize the urge to eliminate and
to retrain the muscles used to control elimination. The
bladder or bowel training program helps the person to
regain control over elimination by promoting urination or
Figure 15-5 A standard bedpan and a fracture pan. defecation at predictable times. For example, as part of

250 | | Nurse Assistant Training

a bladder training program, you may be required to give Change soiled pads or briefs promptly and provide
the person the opportunity to urinate at regular intervals good perineal care to prevent skin breakdown.
according to the schedule specified in the person’s care ■ A condom catheter may be used for a man who is
plan. You would assist the person to the bathroom (or incontinent of urine. The condom catheter consists of
offer a bedpan, urinal or portable commode) and allow the a condom-like device, tubing and a drainage bag
person sufficient time to urinate each time. Supporting a (Figure 15-6). The condom fits over the man’s penis
bladder training program means following the schedule and is attached to the tubing, which is connected
during the night as well (if the person typically gets up to a urine drainage bag. A large urine drainage bag
during the night to urinate), although the intervals between (the same type that is used with an indwelling urinary
using the toilet may be longer during the night. A bowel catheter) may be attached to the system, or a leg
training program works in much the same way as a bladder bag may be used. A leg bag is strapped to the man’s
training program, except the person is only assisted to thigh, so it can be worn underneath pants. Because
use the toilet (or bedpan or bedside commode) during the the leg bag is small, it must be emptied frequently (for
time when a bowel movement is expected, based on the example, every few hours, depending on the person’s
person’s usual bowel elimination pattern. urine output). Remove the condom once daily to
A person with dementia may become incontinent because clean the skin, and then apply a new condom. When
she cannot recognize the urge to eliminate or remember applying the condom, make sure the skin is dry so
how to control the muscles used for elimination. In this that the adhesive will stick during application. Unroll
situation, a training program will not work. Instead, a the condom completely, so that it does not interfere
scheduled toileting program is set up for the person. The with the person’s circulation. Check the person
scheduled toileting program, which also involves giving frequently to make sure the condom is not too tight
the person the opportunity to eliminate at regular intervals and that circulation is good. If you notice any swelling
based on the person’s past elimination patterns, helps to or color change in the man’s penis, remove the
maintain the person’s dignity by reducing the likelihood condom and report your observations to the nurse.
that an episode of incontinence will occur. Skill 15-4 describes step-by-step how to apply
a condom catheter.
Both training programs and scheduled toileting programs
are based on accurate assessment of the person’s Caring for a person with incontinence
elimination patterns. As a nurse assistant, you will When caring for a person who is incontinent, change
be involved in gathering data about when the person soiled clothing promptly and provide good perineal care
normally eliminates in preparation for placing the person to prevent embarrassing odors and protect the person’s
on either type of program, and you will play a very self-esteem. Dry clothing and good skin care are also
important role in helping the person adhere to the plan important to prevent skin breakdown, which can put the
by assisting the person with elimination at the scheduled person at risk for pressure ulcers.
times. Following a bladder or bowel training or scheduled
toileting program when a person is incontinent is an
important part of providing restorative care.

Products used for managing

incontinence
Even when a bowel or bladder training or scheduled
toileting program is in place, the person may still have
episodes of incontinence. Different products are available
to help manage incontinence, including incontinence
pads, incontinence briefs and condom catheters.
■ Incontinence pads are absorbent pads that
are placed inside the person’s underpants to
absorb urine and pull it away from the person’s
skin. Incontinence briefs are worn instead of
underpants, and like incontinence pads, they absorb
urine and help to keep the person’s skin dry. To
protect the person’s self-esteem, always refer to
adult briefs as briefs, not diapers. Incontinence
pads and briefs should be used according to the Figure 15-6 A condom catheter may be used for a man who is
person’s care plan, and never for staff convenience. incontinent of urine.

Chapter 15 | Assisting with Elimination | 251

Be aware that incontinence is a condition that People who have indwelling urinary catheters are at
the person cannot correct easily or sometimes at high risk for developing urinary tract infections, because
all. When the person experiences an episode of the catheter tubing provides a direct pathway into the
incontinence, never scold the person. Avoid saying urinary system for bacteria. Later in this chapter, you will
things like, “I was just down the hall; I wish you would learn more about indwelling urinary catheters and how
have waited.” If the person could have waited, he to provide care for a person who has one. Many of the
would have! Soiling garments and leaving puddles care principles you will learn have to do with preventing
are not normal behaviors for adults. People who are urinary tract infections.
aware of their episodes of incontinence are often very
Incomplete emptying of the bladder can also put a
embarrassed and feel very bad about themselves and
person at risk for developing a urinary tract infection.
their condition.
For example, in men, an enlarged prostate gland can
squeeze against the urethra, making it difficult for
the man to empty his bladder completely each time
You leave Mrs. Wilson’s room and stop by the he urinates. When you are assisting a person with
nurse’s station on your way to clock out to report elimination, always give the person enough time to empty
Mrs. Wilson’s episode of incontinence to the nurse. the bladder as completely as possible. Making sure the
The nurse says, “You know, episodes like this are person takes in enough fluids can also help to prevent
pretty common with new residents. Sometimes just urinary tract infections, because frequent urination helps
being in a new, unfamiliar place is enough to cause a to flush out any bacteria that may gain access to the
resident to develop temporary incontinence. I know urinary tract.
Mrs. Wilson has been having a hard time settling
You may be the first to become aware that a person in
in. Thank you for taking the time to reassure her.
your care has developed a urinary tract infection. Signs
We’ll keep an eye on her and rule out any physical
and symptoms of a urinary tract infection include:
causes for the incontinence, but I’m pretty sure this
is a one-time occurrence. Now you go and enjoy your ■ Pain or a burning sensation when urinating.
daughter’s concert tonight!” ■ A frequent and often urgent need to urinate.
What else could potentially be a cause for ■ The ability to pass only a small amount of urine,
Mrs. Wilson’s incontinence? despite feeling the need to urinate.
■ Cloudy, dark yellow and possibly foul-smelling urine.
■ Mucus (which gives the urine a milky appearance) or
blood in the urine.
Urinary Tract Infections ■ Fever.
A urinary tract infection occurs when bacteria gain ■ New unusual behaviors in a person with dementia,
access to the urinary system. A urinary tract infection such as leaning to one side (this occurs because
can occur in any part of the urinary system—the the person cannot accurately identify the source of
kidneys (which filter the blood to produce urine), the her discomfort and her only way of expressing this
ureters (the tubes that carry the urine from the kidneys discomfort is through behavior).
to the bladder), the bladder (where the urine is stored) ■ Changes in mental status (especially in
or the urethra (the tube that carries urine out of the older people).
body). Figure B-8 in Appendix B shows the
urinary system.
ELDER CARE NOTE. Urinary tract infections
Urinary tract infections are often caused by bacteria in are very common in older people. However, an
feces. When the person has a bowel movement, the area older person with a urinary tract infection may
around the anus becomes contaminated with bacteria. It not have these common signs and symptoms.
is very easy, especially in women, for the bacteria on the The only sign of a urinary tract infection in an
skin to then enter the urethra. Once inside the urethra, older person may be a change in the person’s
the bacteria can travel to any part of the urinary system mental status (such as confusion in a person
and cause a urinary tract infection. To help prevent who is not normally confused).
urinary tract infections, always encourage the people in
your care to wipe from front to back after having a bowel
movement. And when you are assisting a person with If a person develops any signs or symptoms of a urinary
perineal care, remember to always clean from the urethra tract infection, be sure to report them to the nurse right
outward, and to use a clean part of the washcloth for away so that steps can be taken to diagnose and treat
each pass. the infection.

252 | | Nurse Assistant Training

Diarrhea ■ Aging
■ Certain medications
Diarrhea is the frequent passage of loose, watery
feces that are often foul-smelling and accompanied by A person who is constipated feels uncomfortable and may
cramping. Common causes of diarrhea include infections be irritable. He may complain that his abdomen feels hard.
(such as Clostridium difficile, or “C diff”), food poisoning When he tries to move his bowels, he may feel pain, which
(which is caused by eating or drinking contaminated is caused by straining to eliminate the hard, dry feces.
food or water) and medical conditions (such as irritable A laxative or an enema may be prescribed to relieve the
bowel syndrome). Some medications and treatments constipation. A laxative is a medication that is taken orally
(such as cancer treatments) may also cause diarrhea. to produce a bowel movement. An enema is a solution that
is placed into the rectum to cause a bowel movement.
Sometimes no medical treatment is prescribed for
diarrhea, and the diarrhea is simply allowed to run its
course. The person may be put on a clear liquid diet to Fecal Impaction
rest the bowel and replace fluids. However, ongoing Fecal impaction is a more serious form of constipation
diarrhea that is not relieved can cause the person to that occurs when constipation is not relieved. The
become dehydrated, especially if the person is young, feces continue to build up in the bowel until the
elderly or frail. In this case, a medication may be bowel is almost completely blocked. A person with
prescribed for the person to stop the diarrhea. fecal impaction has pain, discomfort and abdominal
You can help a person who has diarrhea by swelling. The person may pass small amounts of watery,
understanding the discomfort associated with it. diarrhea-like feces around the impacted mass, but this
Respond promptly to the person’s requests for help with diarrhea-like discharge should not be confused for a
elimination. After the person has a bowel movement, bowel movement. To treat fecal impaction, a special type
provide good perineal care. Be gentle, because the skin of enema may be ordered to soften the feces. Often,
around the anus may be irritated and sore. an enema alone is not enough to clear the bowel. The
nurse or doctor may need to insert a finger into the
When assisting a person who has diarrhea with person’s anus and scoop the feces out piece by piece.
elimination, always take standard precautions because This procedure is called disimpaction and it can be very
the diarrhea may be caused by viruses or bacteria that uncomfortable for the person. As a nurse assistant, you
can be transmitted to others. For example, C. difficile, will play a very important role in helping to prevent fecal
a type of bacteria, is a common cause of diarrhea in impaction from occurring by reporting changes in the
people who are receiving health care. “C. diff” is highly person’s normal bowel elimination pattern to the nurse
contagious and hard to kill. When you are caring for promptly. This will allow constipation to be treated before
a person who is known to have “C. diff,” remember to it develops into a fecal impaction.
wash your hands with soap and water (instead of using
an alcohol-based hand rub) and use a disinfectant
containing bleach to clean hard surfaces. Observations Into Action!
Whenever you assist a person with elimination,
observe for changes that could be a sign of a
Constipation problem. Report any of the following:
The difficult elimination of hard, dry feces is called { Urine that is cloudy, or that has an unusual
constipation. It occurs when feces move too slowly color or odor
th