Which of the following should a nursing assistant do when caring for a resident who is comatose?

This chapter focuses on the key principles involved in providing resident care as tested on the CNA Clinical Skills Test . Topics include Personal Care Skills, Restorative Skills, Psychosocial Skills, and Recording and Reporting.

Nearly half of the written exam (WE) contains questions about your nursing skills. This chapter focuses on the key principles involved in providing resident care, organized into the following categories:

• Personal Care Skills
• Restorative Skills
• Psychosocial Skills
• Recording and Reporting

You must also review all skills as outlined in the performance checklists in Chapter 6, “Clinical Skills Performance Checklists.” Critical steps for safe skills performance often reflect the key principles reviewed here; these critical steps must be met to successfully pass the Clinical Skills Test (CST), which tests your competencies in the following categories.

Personal Care Skills

The focus of this category is a review of direct care you provide residents on a daily basis to promote their health and well-being.

Activities of Daily Living (ADLs)

Assisting residents with activities of daily living (ADLs) is one of your primary responsibilities. The sections that follow describe the skills involved with ADLs.

Hygiene

It is important for residents to feel clean and fresh. Equally important is to keep the residents free from disease due to harmful bacteria that can enter the body through any skin break, which includes mucous membranes that line any body cavity. With aging, the skin produces less oil, which makes it dry, requiring less frequent bathing. This does not mean that a daily partial bath is not needed to freshen the mouth and perineal area (area of the body that includes the male and female genitalia and the anus). Cleanliness also removes body sweat, odors, and other secretions. Morning care (AM care) that includes washing the resident’s face and hands followed by tooth brushing or denture care before eating breakfast helps decrease harmful bacteria, maintain a pleasant appearance, and increase a sense of well-being for the resident. Hygiene care before bedtime, often called HS (hour of sleep) care, accomplishes the same goals and promotes rest and sleep. HS care also might include a back rub or other form of massage to relax the resident.

Bathing

The resident’s bath schedule as determined by the care plan might require a complete bath, shower, or a partial bath. Remember the general goals of skin care when bathing the resident, that is, to remove pathogens and promote comfort. Bathing promotes cleanliness, helps improve circulation by stimulating the muscles, provides exercise for the joints and limbs, and gives you the opportunity to inspect the resident’s skin, mobility, and other signs of health and well-being. It also provides a time for personal interaction with residents that helps increase their self-esteem.

With each type of bath, safety, security, and privacy are key considerations. Allow the resident to participate in all aspects of personal care and grooming to promote self control. Residents have taken care of themselves all of their lives and need to feel they can be independent as much as possible. Independence, decision-making, and self-control are also known as having autonomy. Feeling secure is second only to being safe from harm. Protect residents from accidents while bathing, which includes falls, and from undue exposure due to failure to provide privacy during the bathing procedure. Posting privacy signs, using a privacy curtain, or closing the door, as well as shielding the body while bathing, are all essential steps to ensure privacy.

Skin care involves keen observation of any breaks in the skin or other abnormalities that might indicate injury or disease. Keeping the skin moist but not wet, dry in the axilla (armpits) and perineum, and free from pressure are very important steps to protect the resident. Be sparing with lotions or other emollients for keeping skin supple. Avoid talcs, powders, or other products that can cake within skin folds. Areas, such as the axilla, beneath the breasts, the genitalia, buttocks, and other skin creases, are warm and moist, which can encourage bacterial growth.

A skin break can result in a pressure ulcer (also called a bedsore, or decubitus ulcer) found over any bony part, such as the tailbone (coccyx), hip, back, elbow, breasts, spine, shoulder, or the back or side of the head. The term bedsore is misleading because a pressure ulcer can occur outside of bed by prolonged sitting or any pressure on the skin that decreases the blood supply to that area. Follow the facility’s protocol for care of residents who are high risk, often evaluated according to the Braden scale, a guide used by the licensed nurse for describing the skin’s risk for breakdown. Residents who are immobile (cannot move or walk), have a poor nutrition status, or have trouble healing are considered high risk for pressure ulcers and must be observed closely for any skin breakdown. Pressure ulcers are very painful and difficult to heal, leading to other complications and misery for the resident. The best approach to bedsores is prevention. Additional steps to prevent bedsores are incorporated into personal skills such as positioning and turning the immobile resident, protecting bony prominences from undue pressure, using protective devices and equipment, and keeping the resident dry, comfortable, well nourished, and hydrated as outlined in Chapter 5, “Specialized Care.”

The following are other general principles that apply to bathing and grooming:

• Use standard precautions for personal care.
• Keep bathwater temperature at a safe level.
• Use mild soaps or other cleansers per facility policy, watching for resident allergies to bath products.
• When cleansing the body, wash from the cleanest area to the dirtiest area.
• For the complete bed bath, change water, wash cloth, and gloves prior to bathing the lower body and extremities.
• If assisting the resident to bathe, provide for rest so as not to overly tire the resident.

• Avoid touching the floor with bath towels, the remote shower spray head, or other bath equipment because the floor is considered contaminated.
• Disinfect the tub, shower, and other bath articles following the bath or shower.
• Promptly remove soiled bath linens.
• Report and record the bath/grooming procedure and the resident’s response.

Oral Care

Residents might need assistance with oral care, which can include brushing the resident’s teeth or denture care. Dentures are false teeth, which might replace all or part of the resident’s own teeth; they are necessary for proper eating, to retain the shape of the face, and to promote a positive self-image. Handle dentures gently by washing and rinsing them in warm (tepid) water to avoid damaging the dentures; store them in a designated container labeled with the resident’s name.

In addition to teeth brushing, keep the mouth moist and free of debris. Dry mucous membranes in the mouth encourage bad breath and skin breakdown along with tooth decay. Depending on the resident’s condition, you might need to provide oral care hourly or every two hours.

Because the comatose resident breathes through the mouth, frequent oral care is needed to help clear secretions and keep the mouth and membranes well hydrated.

Grooming

Grooming includes hair care, shaving, nail care, and eyeglasses and hearing aid care. A resident who is well-groomed feels better and has a more positive outlook and self-esteem. Grooming principles mirror those for ADLs in general regarding standard precautions, providing privacy for the resident, and encouraging the resident to participate in ADLs as much as possible, which includes making choices that will increase satisfaction and compliance with the daily care plan. Remember to dress residents appropriately and comfortably in their own clothing. Consider weather and environmental changes for each resident; make clothing adjustments accordingly to maintain a comfortable body temperature. As some residents might lose body fat, they can become chilled more easily, requiring a light wrap, sweater, or extra bed covering. Always check with the residents to determine their clothing and comfort needs.

Shaving

Shaving residents requires careful technique to avoid accidental nicking of the skin, which can create an entry for pathogens. Residents who have prolonged blood clotting for any reason might be required to shave with an electric razor. Check the resident’s care plan for directions on how to manage his shaving needs.

Nail Care

Like skin care, nail care requires careful cleansing, frequently accomplished when washing the resident’s hands. Keeping nails trimmed and clean can improve appearance while preventing injury or infection transmitted by dirty, unkempt nails. Soaking the resident’s hands and feet in warm water helps loosen debris and eases nail trimming and cuticle care.

Aging can cause the toenails to become thick and difficult to manage. Despite the need to keep nails trimmed, special consideration must be made for residents with diabetes because their toenails must be trimmed very carefully to avoid cuts on the foot that, due to poor circulation or diabetes, might not heal properly. Consult the facility’s policy for nail care required for residents with special conditions such as diabetes. Refer to Chapter 5 for more information on foot care for the diabetic resident.

Hair Care

Clean hair that is neatly combed helps improve the self-image of residents and contributes to their general well-being. Each facility has a policy for hair care, including shampooing. In some facilities, shampooing the hair might require a doctor’s order. Many residents might have their hair washed, set, and combed by a beautician who provides cosmetology services in the long-term care facility. Being sensitive to each resident’s unique grooming needs is the hallmark of effective nursing assistant practice. Consult with the resident and family to learn the best approach for hair care, realizing that not all hair can be managed in the same way by different races or cultures. Please consult with the licensed nurse when deciding the most effective approach.

Nutrition

Food is necessary for life. The fuel needed for adequate life functions comes from calories in food, defined as units of heat measurement. Caloric intake through foods gives the body the energy it needs. Elders, like younger adults, need the same kinds of nutrients, including vitamins and minerals. However, in the long-term care setting, residents must depend on care givers for their nutritional needs. Although the diet of each resident must contain a balance of proteins for cell growth and healing, carbohydrates for ready energy, and fats for fueling the cells, the caloric needs of residents vary according to their activity level and their health status. Nutrition also includes fluid intake to maintain adequate hydration needed for all cellular functions in the body, especially digestion of foods. Fluid intake is required to replace losses through perspiration, respirations, evaporation, and normal elimination. Fluid intake also helps regulate body temperature as well as the moisture in the skin and mucous membrane. Aging can affect the sense of taste, smell, and thirst, which can cause a decrease in solid food and fluid intake. Other factors can affect resident nutrition such as level of awareness, dentition, and the ability to chew properly; cultural considerations (religion, personal preferences, and family traditions); emotional well-being (depression, isolation, frustration, and anger); and the long-term care environment. If the resident’s care plan specifies a special diet, the resident might not be satisfied with the diet and refuse to follow it. This is an example of noncompliance, meaning the resident does not adhere to the diet order. Noncompliance with diet can lead to malnutrition (inadequate consumption or absorption of food) or dehydration, meaning there is not enough fluid in the body that can cause serious problems in all body systems. Edema, opposite of dehydration, occurs when there is too much fluid in the body from excessive fluid intake or from accumulation of fluid in the body tissues. Remember these factors when assisting the resident with meals, fluids, and snacks to help maintain adequate nutritional status. The following guidelines can help achieve this goal:

• Diet permitting, offer the resident choices in the menu to encourage independence and sense of control.
• Make mealtime as pleasant an experience as possible. If dining in the room, remove noxious odors, bedpans, urinals, and anything that could negatively affect the resident’s appetite. If eating in the dining room, seat residents together who encourage pleasant social interaction.
• If dining alone, encourage social interaction with the resident, offering assistance as needed and conversation that helps increase resident satisfaction with the dining experience.
• Present food as attractively as possible.
• Keep hot foods hot and cold foods cold.
• Offer fluids as often as possible according to the diet order.
• Assist with feeding as needed to encourage adequate nutrition.

• Be patient with slow eaters and praise progress as needed to help increase motivation.
• Encourage physical activity to help improve the appetite.
• Individualize approaches to meals that recognize cultural needs, for example, offering a Kosher diet, involving family or friends to assist with meals or feeding, praying before eating, and so on.
• If diet permits, encourage family members or friends to bring favorite foods from home or the community that appeal to the resident.

As with other nursing skills, accurately record and report all dietary intake, including fluids. Review the I & O skill in Chapter 6, “Clinical Skills Performance Checklists,” for critical steps regarding charting meal consumption.

Toileting

Aging can affect the nervous system that controls elimination of body wastes like urine and feces (also known as stool or solid waste). The urge or need to void, or urinate (pass urine from the body) or defecate (pass feces from the body) decreases with age, often meaning that the resident is not aware of voiding or defecating until it actually happens. Decreased appetite and thirst, coupled with less food and fluid intake as well as slower digestion of foods, contribute to elimination problems. Infirmity or being unable to get to the toilet in time to avoid accidental soiling of clothing by urine or feces is not only potentially dangerous due to the increased risk of falls but also embarrassing for the resident.

Other factors might interfere with normal elimination, such as certain medications that could cause constipation or diarrhea, inactivity, pelvic muscle weakness due to aging, and nervous disorders. Small, watery leakage of stool could indicate a fecal impaction, a condition in which hard feces is trapped in the large intestine and rectum and cannot be pushed out by the resident. Diarrhea, on the other hand, results when food wastes pass too quickly through the intestine so that water is not reabsorbed adequately. This causes a watery brown liquid to be expelled, which leads to local skin irritation and a dangerous imbalance in the resident’s fluid and electrolyte status. Both conditions require immediate reporting to the licensed nurse as well as prompt intervention to prevent further complications.

Remember the following principles when assisting the resident with toileting:

• Assisting the resident to void or defecate on a routine, timely basis to maintain normal elimination pattern and avoid accidents
• Being alert to individual toileting needs and prepare accordingly to help prevent accidents
• Observing standard precautions when handling urine or stool
• Using a bedpan, urinal, or bedside commode (portable toilet), and other procedures to maintain a normal elimination schedule
• Performing careful skin care following voiding or defecating
• Observing, reporting, and recording excess or decreased output

Chapter 5 reviews guidelines for special care regarding elimination (for example, catheter care, ostomy care, enema procedure, and so on).

Rest, Sleep, and Comfort

Elders need as much sleep as other adults. Their ability to sleep might be influenced by the long-term care environment, especially when newly admitted, their activity level, their general state of health, and their individual habits. Naps or rest periods are essential for health and well-being and should be included in the resident’s care plan. However, excessive napping during the day can interfere with sleep as well as signaling a febrile illness or neurological complication. Residents might also awaken from sleep confused or delirious, meaning a state of agitated confusion. This situation is a sign of decreased oxygen to the brain that leads to the confusion. Report any change in consciousness (the awakened state), awareness or alertness, sleepiness for no obvious reason, and the inability to respond verbally.

Pain or discomfort can also interfere with rest and sleep. Pain might go unreported by the resident whose pain tolerance (ability to carry out activities or rest despite pain) is high or who has lost the ability to perceive pain. Likewise the resident might deny pain but act in other ways that indicate discomfort, which might include loss of appetite, refusal to participate in recreational activities, inability to sleep (insomnia), or withdrawing from social contact. Residents might also be less likely to report pain if they believe they will be labeled as complainers.

Physical signs of pain include increased pulse (tachycardia), increased respirations (tachypnea), difficulty breathing (dyspnea), and high blood pressure (hypertension). Sweating, crying, grunting, moaning, and other indicators of distress can indicate pain as well. The nurse can assess the resident’s pain on a scale of 0–5 (zero meaning no pain to a score of five, which means it hurts enough to cry). The nurse might administer an analgesic, a drug to relieve pain. If the resident receives analgesia, you must assist the nurse in observing the resident’s response to the medication, any dramatic change in the resident’s vital signs after receiving the medication, and the resident’s report of pain relief. Any abnormal reactions (known as ADEs or adverse drug effects) to analgesia can include a sudden drop in blood pressure or respirations, dyspnea (rapid breathing), a rash on the body, and emotional distress. These signs require immediate intervention, so report them immediately to the nurse. Skills related to respiratory distress or cardiac emergencies are discussed in Chapter 5. You can assist the resident to rest more comfortably by changing the resident’s position, offering diversion activities (reading, listening to music, meditation, and so on), providing a massage, and creating a quiet environment.

The following are general principles of care to promote rest and sleep:

• Maintaining the individual resident’s routine to promote safety and security that encourages rest and sleep
• Arranging the resident’s environment to decrease noise and confusion
• Pacing resident activities to arrange for rest periods during the day and an effective sleep schedule
• Using positioning devices to increase comfort
• Offering emotional support when the resident is experiencing pain and discomfort
• Promoting safety by keeping the bed in the lowest position; locking the wheelchair when the resident is sitting; keeping the urinal, bed pan, or bedside commode near the bed; and keeping a night light on for the resident when visiting the restroom during the night
• Arranging care routines to encourage rest, for example, spacing ADLs, recreational activities, and visiting times