discuss how a nurse applies critical thinking when providing hygiene

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What is Critical Thinking in Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

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Antimicrobial Resistance and Infection Control: Abstracts from the 2nd International Conference on Prevention and Infection Control (ICPIC 2013)

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P176: Thinking critically on the issue of hand hygiene: a case study of a clinical seminar, for nursing students, on the subject of infection control and prevention

• I Livshiz Riven 1 , 2 ,
• N Hurvitz 1 ,
• A Kopitman 3 ,
• JL Reishtein 1 ,
• V Shor 1 &
• R Nativ 2  

Antimicrobial Resistance and Infection Control volume  2 , Article number:  P176 ( 2013 ) Cite this article

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Introduction

In the complex world of modern healthcare it is vital that nurses possess good critical thinking skills. Infection control and prevention (IC&P) in healthcare is a high impact issue, and adherence of health care workers to Hand Hygiene (HH) guidelines is a major topic.

Development of nursing students' ability to apply critical thinking skills in a clinical seminar on the subject of IC&P, using the example of adherence to HH guidelines.

A 4-credit course on the subject of IC&P was offered to third year baccalaureate nursing students as a clinical seminar. During the first semester students learned to critically evaluate published research and academic writing. During the second semester the students performed a research project, as part of the activities of the IC&P Program in a large tertiary hospital. The students examined the attitudes, knowledge, and practices regarding HH among nurses and nursing aides in the obstetric division. They also wrote a portfolio about their experiences.

Seventeen students (20% of the class) chose the IC&P clinical seminar. Towards the end of the seminar students prepared a critical analysis of the literature and their findings and explanations. They presented HH compliance rates, and analyzed the nurses' knowledge, attitudes, and beliefs regarding HH. They found a growing awareness of infection control needs and that nurses know that compliance is lower than desirable; some believe this is due to workloads and others that HH isn't always necessary for healthy patients (mothers). All of the students felt that the course contributed to their ability to critically evaluate behaviors and beliefs regarding the HH challenges.

This course succeeded in making students recognize the need to challenge common health care setting reasoning. It was a successful collaboration between the nursing education system and the healthcare service with awakened awareness to sub-textual information in the context of HH.

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I Livshiz Riven, N Hurvitz, JL Reishtein & V Shor

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Riven, I.L., Hurvitz, N., Kopitman, A. et al. P176: Thinking critically on the issue of hand hygiene: a case study of a clinical seminar, for nursing students, on the subject of infection control and prevention. Antimicrob Resist Infect Control 2 (Suppl 1), P176 (2013). https://doi.org/10.1186/2047-2994-2-S1-P176

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What is Critical Thinking in Nursing? (Explained W/ Examples)

Last updated on August 23rd, 2023

Critical thinking is a foundational skill applicable across various domains, including education, problem-solving, decision-making, and professional fields such as science, business, healthcare, and more.

It plays a crucial role in promoting logical and rational thinking, fostering informed decision-making, and enabling individuals to navigate complex and rapidly changing environments.

In this article, we will look at what is critical thinking in nursing practice, its importance, and how it enables nurses to excel in their roles while also positively impacting patient outcomes.

What is Critical Thinking?

Critical thinking is a cognitive process that involves analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

It’s a mental activity that goes beyond simple memorization or acceptance of information at face value.

Critical thinking involves careful, reflective, and logical thinking to understand complex problems, consider various perspectives, and arrive at well-reasoned conclusions or solutions.

Key aspects of critical thinking include:

• Analysis: Critical thinking begins with the thorough examination of information, ideas, or situations. It involves breaking down complex concepts into smaller parts to better understand their components and relationships.
• Evaluation: Critical thinkers assess the quality and reliability of information or arguments. They weigh evidence, identify strengths and weaknesses, and determine the credibility of sources.
• Synthesis: Critical thinking involves combining different pieces of information or ideas to create a new understanding or perspective. This involves connecting the dots between various sources and integrating them into a coherent whole.
• Inference: Critical thinkers draw logical and well-supported conclusions based on the information and evidence available. They use reasoning to make educated guesses about situations where complete information might be lacking.
• Problem-Solving: Critical thinking is essential in solving complex problems. It allows individuals to identify and define problems, generate potential solutions, evaluate the pros and cons of each solution, and choose the most appropriate course of action.
• Creativity: Critical thinking involves thinking outside the box and considering alternative viewpoints or approaches. It encourages the exploration of new ideas and solutions beyond conventional thinking.
• Reflection: Critical thinkers engage in self-assessment and reflection on their thought processes. They consider their own biases, assumptions, and potential errors in reasoning, aiming to improve their thinking skills over time.
• Open-Mindedness: Critical thinkers approach ideas and information with an open mind, willing to consider different viewpoints and perspectives even if they challenge their own beliefs.
• Effective Communication: Critical thinkers can articulate their thoughts and reasoning clearly and persuasively to others. They can express complex ideas in a coherent and understandable manner.
• Continuous Learning: Critical thinking encourages a commitment to ongoing learning and intellectual growth. It involves seeking out new knowledge, refining thinking skills, and staying receptive to new information.

Definition of Critical Thinking

Critical thinking is an intellectual process of analyzing, evaluating, and synthesizing information to make reasoned and informed decisions.

What is Critical Thinking in Nursing?

Critical thinking in nursing is a vital cognitive skill that involves analyzing, evaluating, and making reasoned decisions about patient care.

It’s an essential aspect of a nurse’s professional practice as it enables them to provide safe and effective care to patients.

Critical thinking involves a careful and deliberate thought process to gather and assess information, consider alternative solutions, and make informed decisions based on evidence and sound judgment.

This skill helps nurses to:

• Assess Information: Critical thinking allows nurses to thoroughly assess patient information, including medical history, symptoms, and test results. By analyzing this data, nurses can identify patterns, discrepancies, and potential issues that may require further investigation.
• Diagnose: Nurses use critical thinking to analyze patient data and collaboratively work with other healthcare professionals to formulate accurate nursing diagnoses. This is crucial for developing appropriate care plans that address the unique needs of each patient.
• Plan and Implement Care: Once a nursing diagnosis is established, critical thinking helps nurses develop effective care plans. They consider various interventions and treatment options, considering the patient’s preferences, medical history, and evidence-based practices.
• Evaluate Outcomes: After implementing interventions, critical thinking enables nurses to evaluate the outcomes of their actions. If the desired outcomes are not achieved, nurses can adapt their approach and make necessary changes to the care plan.
• Prioritize Care: In busy healthcare environments, nurses often face situations where they must prioritize patient care. Critical thinking helps them determine which patients require immediate attention and which interventions are most essential.
• Communicate Effectively: Critical thinking skills allow nurses to communicate clearly and confidently with patients, their families, and other members of the healthcare team. They can explain complex medical information and treatment plans in a way that is easily understood by all parties involved.
• Identify Problems: Nurses use critical thinking to identify potential complications or problems in a patient’s condition. This early recognition can lead to timely interventions and prevent further deterioration.
• Collaborate: Healthcare is a collaborative effort involving various professionals. Critical thinking enables nurses to actively participate in interdisciplinary discussions, share their insights, and contribute to holistic patient care.
• Ethical Decision-Making: Critical thinking helps nurses navigate ethical dilemmas that can arise in patient care. They can analyze different perspectives, consider ethical principles, and make morally sound decisions.
• Continual Learning: Critical thinking encourages nurses to seek out new knowledge, stay up-to-date with the latest research and medical advancements, and incorporate evidence-based practices into their care.

In summary, critical thinking is an integral skill for nurses, allowing them to provide high-quality, patient-centered care by analyzing information, making informed decisions, and adapting their approaches as needed.

It’s a dynamic process that enhances clinical reasoning , problem-solving, and overall patient outcomes.

What are the Levels of Critical Thinking in Nursing?

The development of critical thinking in nursing practice involves progressing through three levels: basic, complex, and commitment.

The Kataoka-Yahiro and Saylor model outlines this progression.

1. Basic Critical Thinking:

At this level, learners trust experts for solutions. Thinking is based on rules and principles. For instance, nursing students may strictly follow a procedure manual without personalization, as they lack experience. Answers are seen as right or wrong, and the opinions of experts are accepted.

2. Complex Critical Thinking:

Learners start to analyze choices independently and think creatively. They recognize conflicting solutions and weigh benefits and risks. Thinking becomes innovative, with a willingness to consider various approaches in complex situations.

3. Commitment:

At this level, individuals anticipate decision points without external help and take responsibility for their choices. They choose actions or beliefs based on available alternatives, considering consequences and accountability.

As nurses gain knowledge and experience, their critical thinking evolves from relying on experts to independent analysis and decision-making, ultimately leading to committed and accountable choices in patient care.

Why Critical Thinking is Important in Nursing?

Critical thinking is important in nursing for several crucial reasons:

Patient Safety:

Nursing decisions directly impact patient well-being. Critical thinking helps nurses identify potential risks, make informed choices, and prevent errors.

Clinical Judgment:

Nursing decisions often involve evaluating information from various sources, such as patient history, lab results, and medical literature.

Critical thinking assists nurses in critically appraising this information, distinguishing credible sources, and making rational judgments that align with evidence-based practices.

Enhances Decision-Making:

In nursing, critical thinking allows nurses to gather relevant patient information, assess it objectively, and weigh different options based on evidence and analysis.

This process empowers them to make informed decisions about patient care, treatment plans, and interventions, ultimately leading to better outcomes.

Promotes Problem-Solving:

Nurses encounter complex patient issues that require effective problem-solving.

Critical thinking equips them to break down problems into manageable parts, analyze root causes, and explore creative solutions that consider the unique needs of each patient.

Drives Creativity:

Nursing care is not always straightforward. Critical thinking encourages nurses to think creatively and explore innovative approaches to challenges, especially when standard protocols might not suffice for unique patient situations.

Fosters Effective Communication:

Communication is central to nursing. Critical thinking enables nurses to clearly express their thoughts, provide logical explanations for their decisions, and engage in meaningful dialogues with patients, families, and other healthcare professionals.

Aids Learning:

Nursing is a field of continuous learning. Critical thinking encourages nurses to engage in ongoing self-directed education, seeking out new knowledge, embracing new techniques, and staying current with the latest research and developments.

Improves Relationships:

Open-mindedness and empathy are essential in nursing relationships.

Critical thinking encourages nurses to consider diverse viewpoints, understand patients’ perspectives, and communicate compassionately, leading to stronger therapeutic relationships.

Empowers Independence:

Nursing often requires autonomous decision-making. Critical thinking empowers nurses to analyze situations independently, make judgments without undue influence, and take responsibility for their actions.

Facilitates Adaptability:

Healthcare environments are ever-changing. Critical thinking equips nurses with the ability to quickly assess new information, adjust care plans, and navigate unexpected situations while maintaining patient safety and well-being.

Strengthens Critical Analysis:

In the era of vast information, nurses must discern reliable data from misinformation.

Critical thinking helps them scrutinize sources, question assumptions, and make well-founded choices based on credible information.

How to Apply Critical Thinking in Nursing? (With Examples)

Here are some examples of how nurses can apply critical thinking.

Assess Patient Data:

Critical Thinking Action: Carefully review patient history, symptoms, and test results.

Example: A nurse notices a change in a diabetic patient’s blood sugar levels. Instead of just administering insulin, the nurse considers recent dietary changes, activity levels, and possible medication interactions before adjusting the treatment plan.

Diagnose Patient Needs:

Critical Thinking Action: Analyze patient data to identify potential nursing diagnoses.

Example: After reviewing a patient’s lab results, vital signs, and observations, a nurse identifies “ Risk for Impaired Skin Integrity ” due to the patient’s limited mobility.

Plan and Implement Care:

Critical Thinking Action: Develop a care plan based on patient needs and evidence-based practices.

Example: For a patient at risk of falls, the nurse plans interventions such as hourly rounding, non-slip footwear, and bed alarms to ensure patient safety.

Evaluate Interventions:

Critical Thinking Action: Assess the effectiveness of interventions and modify the care plan as needed.

Example: After administering pain medication, the nurse evaluates its impact on the patient’s comfort level and considers adjusting the dosage or trying an alternative pain management approach.

Prioritize Care:

Critical Thinking Action: Determine the order of interventions based on patient acuity and needs.

Example: In a busy emergency department, the nurse triages patients by considering the severity of their conditions, ensuring that critical cases receive immediate attention.

Collaborate with the Healthcare Team:

Critical Thinking Action: Participate in interdisciplinary discussions and share insights.

Example: During rounds, a nurse provides input on a patient’s response to treatment, which prompts the team to adjust the care plan for better outcomes.

Ethical Decision-Making:

Critical Thinking Action: Analyze ethical dilemmas and make morally sound choices.

Example: When a terminally ill patient expresses a desire to stop treatment, the nurse engages in ethical discussions, respecting the patient’s autonomy and ensuring proper end-of-life care.

Patient Education:

Critical Thinking Action: Tailor patient education to individual needs and comprehension levels.

Example: A nurse uses visual aids and simplified language to explain medication administration to a patient with limited literacy skills.

Adapt to Changes:

Critical Thinking Action: Quickly adjust care plans when patient conditions change.

Example: During post-operative recovery, a nurse notices signs of infection and promptly informs the healthcare team to initiate appropriate treatment adjustments.

Critical Analysis of Information:

Critical Thinking Action: Evaluate information sources for reliability and relevance.

Example: When presented with conflicting research studies, a nurse critically examines the methodologies and sample sizes to determine which study is more credible.

Making Sense of Critical Thinking Skills

What is the purpose of critical thinking in nursing.

The purpose of critical thinking in nursing is to enable nurses to effectively analyze, interpret, and evaluate patient information, make informed clinical judgments, develop appropriate care plans, prioritize interventions, and adapt their approaches as needed, thereby ensuring safe, evidence-based, and patient-centered care.

Why critical thinking is important in nursing?

Critical thinking is important in nursing because it promotes safe decision-making, accurate clinical judgment, problem-solving, evidence-based practice, holistic patient care, ethical reasoning, collaboration, and adapting to dynamic healthcare environments.

Critical thinking skill also enhances patient safety, improves outcomes, and supports nurses’ professional growth.

How is critical thinking used in the nursing process?

Critical thinking is integral to the nursing process as it guides nurses through the systematic approach of assessing, diagnosing, planning, implementing, and evaluating patient care. It involves:

• Assessment: Critical thinking enables nurses to gather and interpret patient data accurately, recognizing relevant patterns and cues.
• Diagnosis: Nurses use critical thinking to analyze patient data, identify nursing diagnoses, and differentiate actual issues from potential complications.
• Planning: Critical thinking helps nurses develop tailored care plans, selecting appropriate interventions based on patient needs and evidence.
• Implementation: Nurses make informed decisions during interventions, considering patient responses and adjusting plans as needed.
• Evaluation: Critical thinking supports the assessment of patient outcomes, determining the effectiveness of intervention, and adapting care accordingly.

Throughout the nursing process , critical thinking ensures comprehensive, patient-centered care and fosters continuous improvement in clinical judgment and decision-making.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

An example of the critical thinking attitude of independent thinking in nursing practice could be:

A nurse is caring for a patient with a complex medical history who is experiencing a new set of symptoms. The nurse carefully reviews the patient’s history, recent test results, and medication list.

While discussing the case with the healthcare team, the nurse realizes that the current treatment plan might not be addressing all aspects of the patient’s condition.

Instead of simply following the established protocol, the nurse independently considers alternative approaches based on their assessment.

The nurse proposes a modification to the treatment plan, citing the rationale and evidence supporting the change.

This demonstrates independent thinking by critically evaluating the situation, challenging assumptions, and advocating for a more personalized and effective patient care approach.

How to use Costa’s level of questioning for critical thinking in nursing?

Costa’s levels of questioning can be applied in nursing to facilitate critical thinking and stimulate a deeper understanding of patient situations. The levels of questioning are as follows:

• 15 Attitudes of Critical Thinking in Nursing (Explained W/ Examples)
• Nursing Concept Map (FREE Template)
• Clinical Reasoning In Nursing (Explained W/ Example)
• 8 Stages Of The Clinical Reasoning Cycle
• How To Improve Critical Thinking Skills In Nursing? 24 Strategies With Examples
• What is the “5 Whys” Technique?
• What Are Socratic Questions?

Critical thinking in nursing is the foundation that underpins safe, effective, and patient-centered care.

Critical thinking skills empower nurses to navigate the complexities of their profession while consistently providing high-quality care to diverse patient populations.

Reading Recommendation

Potter, P.A., Perry, A.G., Stockert, P. and Hall, A. (2013) Fundamentals of Nursing

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Critical Thinking in Nursing

• First Online: 02 January 2023

Cite this chapter

• Şefika Dilek Güven 3  

Part of the book series: Integrated Science ((IS,volume 12))

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Critical thinking is an integral part of nursing, especially in terms of professionalization and independent clinical decision-making. It is necessary to think critically to provide adequate, creative, and effective nursing care when making the right decisions for practices and care in the clinical setting and solving various ethical issues encountered. Nurses should develop their critical thinking skills so that they can analyze the problems of the current century, keep up with new developments and changes, cope with nursing problems they encounter, identify more complex patient care needs, provide more systematic care, give the most appropriate patient care in line with the education they have received, and make clinical decisions. The present chapter briefly examines critical thinking, how it relates to nursing, and which skills nurses need to develop as critical thinkers.

Graphical Abstract/Art Performance

Critical thinking in nursing.

This painting shows a nurse and how she is thinking critically. On the right side are the stages of critical thinking and on the left side, there are challenges that a nurse might face. The entire background is also painted in several colors to represent a kind of intellectual puzzle. It is made using colored pencils and markers.

(Adapted with permission from the Association of Science and Art (ASA), Universal Scientific Education and Research Network (USERN); Painting by Mahshad Naserpour).

Unless the individuals of a nation thinkers, the masses can be drawn in any direction. Mustafa Kemal Atatürk

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Güven, Ş.D. (2023). Critical Thinking in Nursing. In: Rezaei, N. (eds) Brain, Decision Making and Mental Health. Integrated Science, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-031-15959-6_10

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

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Chapter 5: Provide for Personal Care Needs of Clients

5.1. introduction to provide for personal care needs of clients, learning objectives.

• Provide for personal grooming and hygiene

• Assist with nutrition and fluid needs

• Assist client with bowel and bladder elimination

• Maintain a urinary catheter

• Assist client with bowel and bladder retraining

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

5.2. ACTIVITIES OF DAILY LIVING (ADLS)

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

Activities of Daily Living

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

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

• Toileting, changing incontinence brief (if used), and providing perineal care
• Performing oral and/or denture care (before or after breakfast based on resident’s preference)
• Assisting with a partial bath, full bath, or shower depending on the resident’s personal schedule
• Changing the client’s hospital gown or assisting with dressing
• Assisting with grooming, such as shaving or hair care, and applying makeup, accessories, or jewelry per resident preference
• Assisting with eating breakfast
• Providing hand hygiene to the resident as needed
• Assisting with attending activities, physical therapy (PT), and occupational therapy (OT)
• Making the bed and tidying the resident’s room

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

• Assisting with lunch and dinner
• Assisting with oral and denture care before bed
• Helping with oral care after meals if resident prefers
• Washing face and removing makeup if worn
• Changing into gown or pajamas
• Providing hand hygiene to resident as needed
• Tidying the resident’s room

5.3. PERSON-CENTERED CARE

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

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

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

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

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

5.4. PRE- AND POST-PROCEDURAL STEPS

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

• Important aspects of care won’t be overlooked.
• Dignity for the client and respect for their preferences are provided.
• Risk for transmission of pathogens is reduced.
• Safety is provided.
• Necessary equipment and supplies are present.

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

• S upplies: Many supplies are kept in the resident’s room, but ask yourself if anything is needed that is not available in the room. Being prepared prevents disruption of the procedure and possible delays that can result in discomfort for the resident.
• K nock: Always knock before entering a room, even if the door is open. Knocking maintains dignity for the client and shows respect for their privacy.
• W ash: Always perform hand hygiene when entering the resident’s room to reduce the risk of transmitting pathogens from other residents, equipment, or environmental surfaces.
• I ntroduce and Identify: Introduce yourself to the resident with your name and your title or position at the facility. Identify the client following facility policy. For example, properly identifying a client in a hospital setting may include asking them their name and date or birth and checking their medical ID band. However, in a long-term care setting, some residents may have cognitive or sensory deficits and may not correctly state their own name, so asking their name is not always a safe manner to identify them. Instead, identification in long-term care settings is typically performed by using a photograph in the medical record or by asking another experienced staff member to confirm identification.
• P rivacy: Provide privacy by closing the door and pulling the privacy curtain to ensure dignity when providing personal care.
• E xplain: Explain what care you will be providing so the resident can ask questions or decline care if it is not desired at that time.

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

• C omfort: Ask if the resident is comfortable and if they need anything else such as tissues, water, TV remote, etc.
• L ight, Lock, and Low: Place the resident’s call light within reach so they can call for staff when they need assistance. Check the brakes on the bed to ensure they are locked, and the bed won’t move. Place the bed in the lowest position. These and other measures such as ensuring bed and/or chair alarms are in place and turned on are vital for ensuring patient safety. If a resident decides to self-transfer out of bed instead of requesting assistance, locking and lowering the bed will reduce the risk of injury because it is lower to the floor and won’t move suddenly out from underneath them.
• O pen: Open the door and privacy curtain. For safety reasons, residents must be within staff eyesight when they are alone in their rooms, unless they are physically able to move independently.
• W ash: Perform hand hygiene before leaving the room to reduce the risk of transmitting pathogens to another resident, equipment, or environmental surfaces.
• D ocument: Ask yourself if you provided any cares that should be documented in the medical record or if you need to report anything to the nurse or other staff member.  Routine cares  (i.e., those cares provided to every resident every day) are not necessarily documented unless they are declined or something out of the ordinary occurred or was observed. Follow agency policy regarding documentation.

5.5. SKIN CARE

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

Layers of the Skin

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

Pressure Injury

Age-Related Changes in the Skin

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

Age-Related Changes in Skin

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

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

Skin Care Needs of Older Adults

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

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

Chronic Conditions Affecting Skin Integrity

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

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

Wounds on the Foot of a Client With Diabetes

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

5.6. TYPES OF BATHS AND TECHNIQUES

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

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

Shower Chair With Transfer Bench

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

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

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

Considerations During Bathing

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

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

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

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

• Report any open or reddened areas; dry, flaky skin; bruises; rashes; or irritation. Check all areas of the skin, especially where moisture can be trapped, such as underneath breasts, in abdominal and groin folds, in armpits, and between the toes. If a client has an existing wound or skin breakdown, the nurse should be notified prior to the bath so that an assessment can be completed.
• Report any foul odors that remain after bathing.
• Report subjective or objective signs of pain. For example, the client may pull away when a painful area on their body is touched with a washcloth.
• Report changes in behavior, such as withdrawal or agitation during bathing.
• Report any discharge from any mucous membranes.

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

5.7. ASSISTING WITH NUTRITION AND FLUID NEEDS

Mealtime should be as enjoyable as possible, especially for those clients requiring assistance. As with any other aspect of providing personal care, nursing assistants should use empathy. Think about what it would feel like if you had cognitive or sensory deficits and could not ask for what you want to eat even though it is on the plate in front of you. Recognize how the presentation of the food and the table influence one’s appetite. Consider with whom you like to share your meal. All these factors should be considered when feeding a resident.

Avoid using feeding techniques that are used with young children, such as making noises, moving utensils like airplanes, etc. Residents should be offered a clothing protector to avoid soiling their clothes or gown, but to maintain their dignity, these protectors should never be referred to as a “bib.”

When the meal is ready to consume, describe to the resident what they have on their tray to eat and drink. If the client is visually impaired, use the  clock method  to describe their plate so they know where each food is located. For example, the nursing assistant can state, “Your mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your plate.” If a resident has an order for a  pureed diet  (i.e., all food is blended to smooth consistency), know what each food is and name it when assisting the resident.

Nutritional requirements for each resident are determined by the dietary staff. Each resident has a specific type of diet ordered, including texture and consistency of liquids. It is imperative for nursing assistants to check the resident’s care plan to know what type of diet is currently ordered and be familiar with the appearance of these types of diets. These steps ensure the correct foods and fluids are provided to residents and reduces the risk of choking and aspiration.  Aspiration  refers to inadvertently breathing fluid or food into the airway instead of swallowing it. Diets are further discussed in  Chapter 6 . See the “ Preparing Clients for Meals and Assisting With Feeding ” checklist for specific steps when assisting clients with feeding.

Things to observe for and report during feeding include the following:

• Coughing or frequent clearing of the throat while eating. This may be a sign of aspiration.
• A  wet voice , meaning vocalization with sounds as if food or fluids remain in the mouth or throat.
• Difficulty swallowing.
• Pain with chewing or swallowing.
• Broken or cracked teeth or dentures that don’t fit properly.
• Changes in appetite.

Thinking back to Maslow’s Hierarchy, physiological needs such as food and fluids are the basis of a healthy existence. Digestive, circulatory, and urinary system changes related to aging will be discussed further in  Chapter 11 , but aging can pose several risk factors to nutritional and fluid intake. Poor dentition can cause changes in food choices. Someone with missing, cracked, or painful teeth, ill-fitting dentures, or other oral concerns may choose softer foods. A declining sense of smell, taste, or vision can decrease appetite. Pain with movement or other factors that limit mobility may make elimination difficult, which may be a factor in decreasing intake, so toileting needs are less frequent. These are just a few of the aging issues that can lead to malnutrition, dehydration, or both in aging clients and those unable to care for themselves.

Feeding Aids

There are several assistive devices that allow residents to more easily feed themselves.

Built-up handles  allow the use of utensils by individuals with limited functional ability of their fingers to hold a smaller handle (such as for someone with severe arthritis). Silverware with prebuilt handles can be purchased, or a foam tube can be placed around regular silverware and removed for washing.

Weighted silverware  has a weighted handle for individuals with tremors or unsteady hands. The weight slows down the shaking and allows food to remain on the utensil. See Figure 5.7 [ 1 ] for an image of built-up handles and weighted silverware.

Built-Up and Weighted Silverware

Swivel spoons  rotate so if the resident’s hand shakes, the spoon doesn’t move, and the food remains on the utensil. See an image of a swivel spoon in Figure 5.8 .[ 2 ]

Swivel Spoon

Covered cups  prevent liquids from spilling due to tremors and also slow down the rate of fluid leaving the cup. For example, individuals with aspiration risk (as discussed in Chapter 6.2, “ Nutrition and Fluid Needs ”) may be permitted to drink regular liquids out of a covered cup rather than requiring thickened liquids. See an image of a covered cup in Figure 5.9 .[ 3 ]

Covered Cup

Nosey cups  are used for clients with limited neck mobility. The nosey cup allows them to drink all of the fluid in the cup without tipping their head back. The cut-out portion of the cup fits around the person’s nose so it can be tilted up to finish the fluid. See an image of a nosey cup in Figure 5.10 .[ 4 ]

Figure 5.10

Plate guards  are used for individuals who can use only one hand or who have difficulty maneuvering utensils. Food can be pushed onto the utensil by pushing it against the plate guard. The plate guard can be placed on any plate (such as the image of the plate in Figure 5.11 [ 5 ]), or it may be on a special plate made with the guard built on the plate surface (as in Figure 5.12 [ 6 ]).

Figure 5.11

Plate Guard

Figure 5.12

Built-Up Plate

Documentation of Food and Fluids

Documentation of food and fluids gives insight to the overall health and well-being of clients. It gives nurses, dieticians, health care providers, and other staff insight into possible health concerns. Documenting intake is an important responsibility of nurse aides. Unless otherwise indicated, food intake is documented by estimating to the nearest 25% of intake. It is also appropriate to note that a resident only ate “bites of food.” See Figures 5.13 – 5.16[ 7 ] for examples of food intake.

Figure 5.13

25% intake or “bites”

Figure 5.14

Figure 5.15

Figure 5.16

100% intake

Any fluids documented in health care are converted to milliliters (mL) or cubic centimeters (cc). Milliliters and cubic centimeters are the same units, so 1 mL = 1 cc. Typically, fluids are measured in ounces in the United States, so a conversion is necessary. To do so, multiple the number of ounces by 30, as 1 ounce = 30 cc = 30 mL. Examples of fluid conversions are provided in Table 5.7 .

Conversions of Ounces to Milliliters (mL) or Cubic Centimeters (cc)

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In addition to beverages, anything that melts at room or body temperature is documented as fluids. This includes food items such as clear broth, ice chips, ice cream, popsicles, and Jell-O. However, soup is documented as part of the client’s food intake.

5.8. ASSISTANCE WITH TOILETING

Just as there are several bathing techniques based on a resident’s functioning and mobility, there are multiple methods for assisting residents with their bladder and bowel elimination. Regardless of the method used, residents should be offered toileting assistance at least every two hours. The following subsections provide an overview of each toileting method and when it may be implemented.

The resident should be able to stand independently, walk, or pivot transfer with assistance. A mechanical lift that assists with bearing weight may also be used to place a resident on the toilet.

Bedpans are used for residents who cannot bear weight or prefer to stay in bed, such as when having to urinate during the night. Residents who require a full body lift to transfer typically require the use of a bedpan, but there are also toileting slings to assist a fully dependent resident to use a toilet or commode. See Figure 5.17 [ 1 ] for an image of two types of bedpans. The image on the left is a standard bedpan and the image on the right is called a fracture pan. Fracture bedpans are smaller than standard bedpans and have one flat end. They are designed for individuals recovering from a hip fracture or hip replacement.

Figure 5.17

Bedpan Examples

For residents with strong hip mobility who require a bedpan, ask them to bend their knees and push their hips upwards. While they are raised, place a barrier (e.g., a towel, waterproof soaker pad, disposable pad, etc.) under them and then place a standard bedpan underneath their buttocks. Ensure the handle of the fracture pan (or the opening of the rim on a full bedpan) is pointed towards the foot of the bed before they lower themselves onto the bedpan. For residents with limited hip mobility, use their lift sheet to roll them away from you towards a raised side rail. While they are lying on their side and holding the side rail, return the lift sheet on top of the bed and then place a barrier on top of the lift sheet. Place a fracture pan behind the resident’s buttocks and then gently roll both the resident and the fracture pan back to the bed surface, ensuring proper placement of the pan.

Please see  Skills Checklist  for additional information.

A  commode  looks like a toilet, but it is a movable device with a bucket underneath the seat. See Figure 5.18 [ 2 ] for an image of a commode. Commodes are typically placed near the bed for residents who have limited weight-bearing ability, do not want to share a bathroom with another resident, or have urge incontinence.  Urge incontinence  means that as soon as the person feels the need to empty their bladder, they have very little time before urine escapes.

Figure 5.18

Bedside Commode

Incontinence Briefs or Pads

Incontinence briefs or pads  are disposable products used for residents who have little to no control over bladder or bowel function and are worn in, or in place of, their underwear. Please see  Skills Checklist  for additional information.

Urinary Catheter

A urinary catheter is a device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag. Urinary catheters are used sparingly due to increased risk of urinary tract infections. Catheters are typically used for clients with urinary retention, have a wound near the perineal area that may become infected due to incontinence, or have a neurological condition that does not allow them to control their bladder function. See Figure 5.19 [ 3 ] for an illustration of an indwelling urinary catheter attached to a collection bag. Nursing assistants may assist in emptying/documenting urine output from the collection bag or providing catheter care according to agency policy. Please see  5.25 Skills Checklist  for additional information.

Figure 5.19

Indwelling Urinary Catheter With a Collection Bag

A  urostomy  is placed surgically to collect urine from the ureters when the bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag. See Figure 5.20 [ 4 ] for an illustration of a urostomy.

Figure 5.20

A  colostomy  is placed surgically when colon function is impaired. A piece of the colon is diverted to an artificial opening in the abdominal wall called a stoma, and feces is collected in a pouch.

Considerations When Assisting Clients With Toileting

Nursing assistants must consider a resident’s privacy and dignity when assisting with toileting just as they do with bathing. Most residents prefer to be alone when urinating or defecating. Privacy can be provided by closing the bathroom door if the resident is able to be left alone. If the resident is not safe to be left alone, close the door as much as possible while keeping the resident within eyesight. Maintain awareness of a resident who is toileting or on the bedpan so they do not need to wait for assistance with perineal care after elimination and will not develop any skin issues from sitting on a hard surface.

To maintain dignity, nurse aides should be careful when explaining and providing care related to toileting. For example, a disposable brief should never be referred to as a diaper; acceptable terms include a brief, pad, liner, or disposable underwear. Additionally, a nurse aide should never show reluctance or appear burdened when providing toileting assistance, no matter how often a resident feels the need to be toileted or requires perineal care due to incontinence.

Bladder and Bowel Retraining

Clients who are dependent on others for assistance with elimination should be taken to the bathroom or offered toileting options every two hours. Incontinence is a very personal matter and can be embarrassing for clients. Nursing assistants should use therapeutic communication when assisting clients with toileting.

When indicated, clients may undergo bladder and bowel retraining to regain control of elimination. There are several strategies used to promote bladder continence. The nurse aide may assist the nurse with one of the strategies called timed voiding.  Timed voiding  encourages the patient to urinate on a set schedule, such as every hour, whether they feel the urge to urinate or not. The time between bathroom trips is gradually extended with the general goal of achieving four hours between voiding. Timed voiding helps to control urge and overflow incontinence as the brain is trained to be less sensitive to the sensation of the bladder walls expanding as they fill.[ 5 ]

Bowel retraining involves teaching the body to have a bowel movement at a certain time of the day. This training includes encouraging clients to go to the bathroom when feeling the urge to do so and not ignoring the urge. For some individuals, it is helpful to schedule this consistent time in the morning when the natural urge occurs after drinking warm fluids or eating breakfast. For other people, especially those with a neurological cause, a laxative may be scheduled regularly to stimulate the urge to have a bowel movement on a regular basis and prevent constipation. The nurse should communicate to the nursing assistant when bowel retraining is in place, or a laxative is administered to a client so they are aware of the client’s need to defecate.[ 6 ]

Urinary Tract Infection (UTI)[ 7 ]

A  urinary tract infection (UTI)  is a common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the bladder or kidneys. Infections can affect several parts of the urinary tract, but the most common type is a bladder infection. Kidney infections are more serious than a bladder infection because they can have long-lasting effects on the kidneys.

Some people are at higher risk of getting a UTI. UTIs are more common in females because their urethras are shorter and closer to the rectum, which makes it easier for bacteria to enter the urinary tract. Providing improper perineal care is a common cause of a UTI. Nursing assistants must be diligent and assist with perineal hygiene as needed to prevent infections. Other factors that can increase the risk of UTIs include the following:

• A previous UTI
• Sexual activity, especially with a new sexual partner
• Age (Older adults and young children are at higher risk)
• Urinary retention
• Low fluid intake
• Structural problems in the urinary tract, such as prostate enlargement

Symptoms of a UTI should be reported to the nurse immediately and include the following:

• Pain or burning while urinating (dysuria)
• Frequent urination (frequency)
• Urgency with small amounts of urine
• Bloody urine
• Pressure or cramping in the groin or lower abdomen
• Confusion or altered mental status in older adults

Symptoms of a more serious kidney infection (called pyelonephritis) include fever above 101 degrees F (38.3 degrees C), shaking chills, lower back pain or flank pain (i.e., on the sides of the back), and nausea or vomiting.

It is important to remember that older adults with a UTI may not exhibit these common symptoms but instead demonstrate an increased level of confusion. Older adults often become weaker when they have a UTI and may fall. If you notice increased weakness or a change in the level of confusion in an older client, report these symptoms to the nurse immediately. If not treated quickly, UTIs can spread to the blood (called septicemia), leading to life-threatening infection called  sepsis .

When a patient has symptoms related to a possible UTI, the health care provider will order diagnostic tests, such as a urine dip, urinalysis, or urine culture. See the subsection below on “Specimen Collection,” which details how nursing aides assist with these tests. Antibiotics are prescribed for urinary tract infections and are administered by the nurse. Nursing assistants should encourage clients with UTIs to drink extra fluids to help flush bacteria from the urinary tract, and toileting should be offered more frequently with proper perineal care.

Observation and Documentation of Urinary Output

When assisting residents with urinary elimination, their urine should be observed for the characteristics described in Table 5.8 . Terms used to document these characteristics are included.

Characteristics of urine can be indicative of a urinary tract infection or dehydration and should be reported to the nurse. Dark urine, minimal urine output, or the infrequent need to void can be signs of dehydration. Characteristics of an infection are described in the previous “Urinary Tract Infection (UTI)” subsection. If noted and reported promptly, fluids can be encouraged to help treat these conditions.

Urine Characteristics

If a resident is regularly incontinent and uses a brief or disposable pad for elimination, the nursing assistant should document the number of times the resident is incontinent rather than recording the amount. For a continent resident, use a toilet hat to measure urine output as described in the “Specimen Collection” subsection below. If the resident uses a commode or bedpan, place a graduated cylinder on a barrier, carefully pour the urine into the graduated cylinder, and observe and document the characteristics. See Figure 5.21 [ 8 ] for an image of a graduated cylinder.

Figure 5.21

Graduated Cylinder

Observation and Documentation of Stool

Similar to urine, stool output and characteristics can indicate underlying health concerns. Risk factors to healthy stool elimination will be discussed further in the “ Digestive System ” section in Chapter 11, but slowing of the digestive system, decreased intake, and lower mobility can all contribute to constipation and even cause bowel obstruction. Documentation and reporting of unusual characteristics can assist nurses in providing interventions that can prevent more serious health concerns.

Elimination patterns vary for each individual, but a typical range for bowel elimination is twice daily to once every other day. When regular bowel movements do not occur, stool becomes hardened in the colon, making it difficult to push out, especially for those who are physically declined. Stool should be soft and formed when eliminated to prevent additional problems like hemorrhoids. Stool that is loose or liquid may indicate an infection or other chronic intestinal issues.

Nursing assistants should note the size of a client’s bowel movement as “small,” “medium,” or “large” as an estimation. Using agency protocol, the consistency of the stool should also be documented. The Bristol Stool Chart is a common tool used to easily observe and document the consistency of stool. See Figure 5.22 [ 9 ] for an image of the Bristol Stool Chart. Additionally, if any blood or dark tarry stool is observed, this should be reported immediately to the nurse.

Figure 5.22

Bristol Stool Chart

Specimen Collection[ 10 ]

Urinary samples.

Urinary samples may need to be collected to detect infection. When needed, obtain a toilet hat (see Figure 5.23 “ Toilet Hat ” and “ Commode with Toilet Hat ” by Landon Cerny are licensed under   CC BY 4.0 [/footnote] . Ask the nurse to label a specimen cup before collecting urine (see Figure 5.24 [ 11 ]).

Figure 5.23

Figure 5.24.

Specimen Cup

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

Stool Samples

Stool samples are collected from patients to test for cancer, parasites, or for occult blood (i.e., hidden blood). The Guaiac-Based Fecal Occult Blood Test (gFOBT) is a commonly used test to find hidden blood in the stool that is not visibly apparent. As a screening test for colon cancer, it is typically obtained by the patient in their home using samples from three different bowel movements. Nursing assistants may collect gFOBT specimens for clients.

Before the test, the nurse should verify that the client has avoided red meat for three days and has not taken aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for seven days prior to the test. (Blood from the meat can cause a false positive test, and aspirin and NSAIDS can cause bleeding, also leading to a false positive result.) Vitamin C (more than 250 mg a day) from supplements, citrus fruits, or citrus juices should be avoided for 3 to 7 days before testing because it can affect the chemicals in the test and make the result negative, even if blood is present.

To perform a gFOBT in an inpatient setting, perform the following steps.

• Verify with the nurse that the client has met dietary and medication requirements.
• Explain the procedure to the client. Assist the resident to a clean, dry commode and instruct them not to put any toilet paper in the commode, as this may alter the test result. Request they use the call light when they have had a bowel movement.
• Review the manufacturer’s instructions with the nurse.
• Label the card with the patient’s name and medical information per agency policy. Open the flap of the guaiac test card.
• Apply nonsterile gloves. Use the applicator stick to apply a thin smear of the stool specimen to one of the squares of filter paper on the card. Obtain a second specimen from a different part of the stool and apply it to the second square of filter paper on the card. (Occult blood isn’t typically equally dispersed throughout the stool.)
• Place the labeled test card in a transport bag.
• Remove gloves and perform hand hygiene.
• Give the transport bag to the nurse to send to the laboratory for analysis.

5.9. SKILLS CHECKLIST: PARTIAL BATH

Gather Supplies: Wash basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, clean clothes or gown, and linen bag or hamper. See Figure 5.25 [ 1 ] at the end of this checklist for an image of a wash basin.

Routine Pre-Procedure Steps:

• Knock on the client’s door.
• Perform hand hygiene.
• Introduce yourself and identify the resident.
• Maintain respectful, courteous, and professional communication at all times.
• Provide for privacy.
• Explain the procedure to the client.

Procedure Steps:

• Put on gloves.
• Fill the basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Raise the bed height to a working height.
• Keep the resident covered as much as possible using a bath blanket or bed linens.
• Wash the resident’s face using water only.
• Pat dry the face.
• Remove the gown from one arm, keeping the rest of the body covered.
• Place a towel under one arm, only exposing the arm.
• Wet a washcloth, put soap on the washcloth, and wash the arm with soap.
• Wash the hand with soap.
• Wash the underarm with soap. Place the washcloth containing soap on the edge of the basin or barrier.
• Rinse the arm with the second washcloth.
• Rinse the hand.
• Rinse the underarm.
• Pat dry the arm.
• Pat dry the hand.
• Pat dry the underarm.
• Move to the other side of the bed and repeat actions on the other side of the body.
• Dispose of the gown into a linen bag or laundry hamper.
• Ask the resident if they would like lotion. When applying lotion, wear gloves.
• Assist the resident to put on a clean gown or clothes.
• While wearing gloves, empty the equipment.
• Rinse the equipment.
• Dry the basin.
• Return the equipment to storage.
• Dispose of soiled linen in the designated laundry hamper.
• Remove the gloves, turning them inside out.

Post-Procedure Steps:

• Check for resident comfort and if anything else is needed.
• Be sure the bed is low and locked. Check the brakes.
• Place the call light or signaling device within reach of the resident.
• Open the door and privacy curtain.
• Document and report any skin issues or changes noted with the resident.

Figure 5.25

View a youtube video[ 2 ] of an instructor demonstrating a partial bath:.

5.10. SKILLS CHECKLIST: FULL BED BATH

Gather Supplies: Basin, warm water, soap, shampoo and conditioner if used, lotion, six washcloths, two towels, barrier, gloves, clean clothes or gown, and linen bag or hamper

• Place a towel under one leg, keeping the rest of the body covered with the bath blanket.
• Wash the leg with soap, only exposing the leg.
• Wash the feet with soap.
• Rinse the leg and feet.
• Pat the leg and feet dry.
• Repeat on the other leg.
• Raise the side rail on one side of the bed.
• Move to the opposite side of the bed and assist the resident to roll on their side using a lift sheet or other supportive device.
• Wash the back while keeping the rest of the body covered.
• Rinse the back.
• Pat the back dry.
• Dispose of the gown and used linens into the linen bag or laundry hamper.
• Ask the resident if they would like lotion. If applying lotion, wear gloves.
• Perform perineal care using clean linens according to Chapters  5 ​.18  &  5 ​.19  “Perineal Care Skills Checklists.”
• Assist the resident to put on a clean gown or clothes and apply an incontinence product if needed.

Note: Shampooing can be done before washing face, after washing back, or after perineal care per resident preference. See “ Shampoo Skills Checklist ” for specific steps.

View a YouTube video[ 1 ] of an instructor demonstrating a full bed bath:

5.11. SKILLS CHECKLIST: SHOWER

Gather Supplies: Soap, shampoo and conditioner if used, lotion, two washcloths, several towels, barrier, gloves, clean clothes or gown, and linen bag or hamper

• Knock on the resident’s door.
• Explain the procedure to the resident.
• Assist the resident to the shower per facility protocol. See the “ Considerations During Bathing ” subsection in this chapter and implement comfort measures. Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Repeatedly check the water temperature throughout the shower.
• Wet a washcloth and wash the face without soap.
• Put soap on the washcloth and wash the resident, starting with their upper body and then their legs.
• Lift any skin-on-skin areas and wash gently with soap.
• Wash the front of the perineal area.
• Reach through the bottom of the shower chair and wash the rectal area from front to back.
• Put on clean gloves.
• Rinse the resident starting with the upper body, followed by the legs, front perineal area, and rectal area.
• Change the gloves and perform hand hygiene if the perineal area was touched during rinsing.
• Turn off the water and place warm towels to cover the resident
• Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair and avoiding getting the gown or clothes wet.
• Place nonskid footwear on the client.
• Assist the resident to stand per their care plan.
• Dry the back of their legs
• Dry the perineal area from front to back
• Finish putting on clothes.
• Assist the resident to a wheelchair or other preferred surface, changing gloves and performing hand hygiene as soon as the resident is safely seated.
• Place all linens and soiled gown or clothing in a linen bag or designated hamper.
• Sanitize the shower chair per facility policy.
• Check for resident comfort and ask if anything else is needed.

5.12. SKILLS CHECKLIST: TUB BATH

Gather Supplies: Soap, shampoo and conditioner if used, lotion, four washcloths, four towels, barrier, gloves, clean clothes or gown, and linen bag or hamper

• Keep the resident covered as long as possible and have the resident test the water temperature on their fingers. Assist the resident to the tub per facility protocol. See the subsection in this chapter called “ Considerations During Bathing ” for comfort measures. Repeatedly check the water temperature throughout the bath.
• Wash the client’s face with a washcloth and no soap.
• Put soap on the washcloth and wash the resident starting with their upper body and then their legs.
• Perineal care can be performed in the bed prior to the bath. See Skills Checklists  5 ​.18  and  5 ​.19  for perineal care specifics.
• Wash the client’s hair. See the “ Shampoo ” checklist for specific steps.
• Drain the tub per facility protocol and rinse the resident.
• Place warm towels to cover the resident.
• Assist the resident to put on a clean gown or clothes, keeping a dry towel over the back of the shower chair to prevent getting the gown or clothes wet.
• Dry the back of their legs.
• Dry the perineal area from front to back.
• Sanitize the bath chair per facility policy.
• Remove the gloves by turning them inside out.

5.13. SKILLS CHECKLIST: SHAMPOO

Gather Supplies: Shampoo basin if in bed, shampoo, conditioner if used, two washcloths or small towels, one large towel, gloves, and linen bag

• Place a basin underneath the client’s head and neck if they are in bed and place the drain over the garbage can located on the floor.
• Give the client a dry washcloth or towel to cover their face if desired.
• Check the water temperature for safety and comfort. Have the resident check the water temperature by placing their hand in the water in the basin or putting a wet washcloth on the back of their hand. Ask the resident if the temperature is comfortable to them.
• Wet their hair with a wet washcloth or by gently pouring water over their hair.
• Apply shampoo and lather while massaging scalp gently.
• Rinse their hair.
• Apply conditioner if used, massaging the scalp gently.
• Dry their hair gently and style it per the resident’s preference.
• Dispose of soiled linen in a designated laundry hamper.
• Ensure the bed is low and locked. Check the brakes.
• Document and report any skin or scalp issues or changes noted with the resident.

5.14. SKILLS CHECKLIST: FOOT CARE

Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, and linen bag or hamper

• Fill a foot basin with warm water and place it on a flat surface with a barrier underneath. Have the resident check the water temperature by placing their hand in the basin or putting a wet washcloth on the back of their hand.
• Remove their socks.
• Immerse their feet in warm water for 5 to 20 minutes.
• Use water and a soapy washcloth.
• Wash each foot and between the toes.
• Rinse the entire foot with the wet washcloth, including between the toes.
• Dry the foot thoroughly, including between the toes.
• Massage the lotion over the foot but avoid applying any lotion between the toes.
• Wipe off any excess lotion with a dry towel.
• Replace the socks or preferred footwear.
• Document and report any skin or nail issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating foot care:

5.15. SKILLS CHECKLIST: NAIL CARE

NOTE: Nail care for clients with diabetes should be performed by a Registered Nurse (RN).

Gather Supplies: Basin, warm water, soap, lotion, two washcloths, one towel, barrier, gloves, manicure stick, emery board, nail clipper, and linen bag or hamper

• Have the resident perform hand hygiene with sanitizer.
• Immerse the client’s hands in warm water for 5 to 20 minutes.
• Place their hand on a barrier.
• Using a manicure stick, clean underneath each nail, wiping any debris on the barrier after each nail.
• If necessary, trim nails using a clipper. Sanitize the clipper prior to and after use.
• Using an emery board, file each nail from the outside of the nail towards the middle of the nail.
• Check each nail for snags and file until smooth.
• Rinse the hand in water, return to the barrier, and dry.
• Repeat the procedure for the second hand.
• Offer lotion. If applying lotion, wear gloves.
• Rub the lotion gently into the skin if requested.
• Perform hand hygiene

View a YouTube video[ 1 ] of an instructor demonstrating nail care:

5.16. SKILLS CHECKLIST: SKIN CARE

Gather Supplies: Gloves and lotion

• Perform hand hygiene and put on gloves.
• Position the resident as needed and only expose the skin that will be moisturized.
• Place a quarter-sized circle of lotion on one palm.
• Rub the hands together to warm the lotion.
• Apply the lotion to dry skin but avoid getting lotion between the toes.
• Use additional lotion, warming between your hands as needed, until all dry skin has been moisturized.
• Wipe off any excess lotion gently with a dry towel.

It is important to properly clean the wash basin and other supplies after performing any type of skin care to prevent the spread of infection.

View a YouTube video[ 1 ] of an instructor demonstrating cleaning supplies after performing skin care:

5.17. SKILLS CHECKLIST: BACK RUB

• Move to the opposite side of the bed and assist the resident to roll towards the raised side rail.
• Only expose the resident’s back from the shoulders to the top of the hips.
• Begin with long, gentle strokes starting at the top of hips and moving to the top of the shoulders. Repeat about five times.
• Throughout the back rub, ask the resident if there is any pain or discomfort. If pain is present, stop the procedure and report it to the nurse.
• Apply more lotion to gloved hands as needed to reduce friction on the resident’s skin.
• Make large circles with both hands from the top of hips to the top of shoulders. Repeat about five times.
• Apply additional lotion to gloved hands as needed to reduce friction on resident’s skin.
• Make small circles with both hands from the top of the hips to the top of the shoulders. Repeat about five times.
• Apply additional lotion to gloved hands if needed to reduce friction on resident skin.
• End with long, gentle strokes starting at the top of hips and moving to the top of shoulders. Repeat about five times.
• Cover the resident completely per resident preference.
• Assist the resident to their preferred position.
• Lower the side rail that was raised.

View a YouTube video[ 1 ] of an instructor demonstrating a backrub:

5.18. SKILLS CHECKLIST: PERINEAL CARE (FEMALE)

Gather Supplies: Basin, warm water, soap, four washcloths, one towel, barrier, gloves, and linen bag or hamper

• Raise one side rail of the bed after checking the resident’s mobility and their preferred side to lie on.
• Raise the bed height if needed.
• Turn the resident or raise their hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their buttocks.
• Expose their perineum only.
• Separate the labia.
• Clean one side of the labia from top to bottom.
• Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom.
• Using a clean portion of the first washcloth, clean the vaginal area from top to bottom.
• Put the first washcloth in the linen bag.
• Using the second clean washcloth, rinse one side of the labia from top to bottom.
• Using a clean portion of the second washcloth, rinse the other side of the labia from top to bottom.
• Using a clean portion of the second washcloth, rinse the vaginal area from top to bottom.
• Put the second washcloth in the linen bag.
• Avoid overexposure throughout the procedure.
• Cover the exposed area with the bath blanket.
• Assist the resident to turn onto their side facing away from you and ask the resident to hold onto the raised side rail.
• Using the third clean washcloth, apply water and soap.
• Using a clean portion of the third washcloth, clean one side of the buttock, wiping away from vagina.
• Using a clean portion of the third washcloth, clean the other side of the buttock, wiping away from the vagina.
• Using a clean portion of the third washcloth, clean the rectal area wiping away from the vagina.
• Put the third washcloth in the linen bag.
• Using the fourth washcloth, rinse one side of the buttock wiping away from the vagina.
• Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the vagina.
• Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from vagina.
• Put the fourth washcloth in the linen bag.
• Safely remove the waterproof pad from under the buttocks.
• Position the resident on her back.
• Empty the equipment.
• Dry the equipment.
• Dispose of the gloves in an appropriate container.

Post- Procedure Steps:

View a YouTube video[ 1 ] of an instructor demonstrating female perineal care:

5.19. SKILLS CHECKLIST: PERINEAL CARE (MALE)

• Raise one side rail of the bed. Check the resident’s mobility and their preferred side to lie on.
• Turn the resident or raise the hips and place a barrier (a towel, waterproof soaker pad, disposable pad, etc.) under their buttocks.
• Expose the perineum only.
• Using a clean portion of the first washcloth, start from the urethra and clean in a circular motion toward their scrotum.
• Using a clean portion of the first washcloth, clean one groin fold and the scrotum.
• Using a clean portion of the first washcloth, clean the other groin fold and the other side of scrotum.
• Put the first washcloth in a linen bag.
• Using the second clean washcloth, rinse from the urethra in a circular motion toward the scrotum.
• Using a clean portion of the second washcloth, rinse one groin fold and the scrotum.
• Using a clean portion of the second washcloth, rinse the other groin fold and the other side of the scrotum.
• Assist the resident to turn onto their side away from you and ask the resident to hold onto the raised side rail.
• Using a clean portion of the third washcloth, clean one side of the buttock wiping away from the urethra.
• Using a clean portion of the third washcloth, clean the other side of the buttock wiping away from the urethra.
• Using a clean portion of the third washcloth, clean the rectal area wiping away from the urethra.
• Using the fourth washcloth, rinse one side of the buttock wiping away from the urethra.
• Using a clean portion of the fourth washcloth, rinse the other side of the buttock wiping away from the urethra.
• Using a clean portion of the fourth washcloth, rinse the rectal area wiping away from the urethra.
• Position the resident on his back.
• Dispose of gloves in an appropriate container.

View a YouTube video[ 1 ] of an instructor demonstrating male perineal care:

5.20. SKILLS CHECKLIST: ORAL CARE

Gather Supplies: Gloves, toothbrush, toothpaste, emesis/oral basin, cup of water, clothing protector (towel), barrier (paper towel), and linen bag or hamper

• Place all supplies on a barrier.
• If the resident is in bed, elevate the head of the bed if it is permissible per the care plan.
• Cover the resident’s chest with a towel to keep their clothing or gown clean.
• Wet the toothbrush in the sink or in a cup of water.
• Apply a small amount of toothpaste to the toothbrush.
• Brush the resident’s teeth, including the inner, outer, and chewing surfaces of all upper and lower teeth.
• After each quadrant of the mouth (i.e., lower right, lower left, upper right, or upper left), allow the resident to rinse with water and spit into an emesis basin if needed.
• Clean the resident’s tongue being careful not to cause the resident to gag.
• Assist the resident in rinsing their mouth.
• Wipe the resident’s mouth with the towel on their chest.
• Remove the towel and place it in a linen bag.
• Empty the emesis basin.
• Rinse the emesis basin.
• Dry the emesis basin.
• Rinse the toothbrush.
• Document and report any oral issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating oral care:

5.21. SKILLS CHECKLIST: DENTURE CARE

Gather Supplies: Gloves, denture brush, denture toothpaste if available, dentures, denture cup, denture cleansing tablet if desired, emesis/oral basin, oral swab, cup of water, clothing protector (towel), barrier (paper towel), sink liner (paper towel or washcloth), and linen bag or hamper. See Figure 5.26 [ 1 ] at the end of this checklist for an image of an oral swab.

• Place a clothing protector on the resident.
• Line the sink with a washcloth or paper towel.
• Remove dentures from the cup or remove them from the resident’s mouth and place them in the denture cup or emesis basin.
• Handle the dentures carefully to avoid damage or contamination.
• Wet the denture brush and apply denture toothpaste if available. Water alone is acceptable to clean dentures if toothpaste is not available.
• Thoroughly brush the inner, outer, and chewing surfaces of each denture.
• Rinse the dentures using clean, cool water and place them on a clean barrier or in an emesis basin.
• Rinse the denture cup.
• Place the dentures in a rinsed cup.
• Wet an oral swab and gently clean all surfaces of the resident’s gums and tongue.
• Allow the resident to rinse and spit into the emesis basin.
• Place the dentures in the resident’s mouth if desired.
• Wipe the resident’s mouth and remove the clothing protector, placing it in an appropriate container.
• In the evening, place the dentures in the denture cup and add cool, clean water to the denture cup to cover the dentures.
• Put a denture cleansing tablet in the cup, if desired.
• Rinse the equipment (denture brush and emesis basin).
• Discard the protective lining in an appropriate container.

Figure 5.26

View a youtube video[ 2 ] of an instructor demonstrating denture care:.

5.22. SKILLS CHECKLIST: PREPARING CLIENTS FOR MEALS AND ASSISTING WITH FEEDING

Gather Supplies: Clothing protector, meal, diet card, eating utensils, sanitizer or soapy and wet washcloths

• Knock on the resident’s door unless they are in the dining room.
• Verify the name on the diet card matches the resident.
• Verify the diet, diet texture, and liquid consistency matches the diet card.
• Position the resident in an upright position, at least 45 degrees.
• Place a clothing protector on the resident if desired (e.g., a paper or cloth towel or a large napkin).
• Ask the resident if they would like oral care before eating.
• Assist the resident to clean their hands before feeding using sanitizer or soapy and wet washcloths.
• Position yourself at eye level facing the resident.
• Describe the foods and fluids being offered to the resident.
• Offer small amounts of food at a reasonable rate.
• Offer fluids frequently.
• Allow the resident time to chew and swallow.
• Wipe the resident’s face whenever necessary.
• Continue to alternate foods and fluids until the resident indicates they are full.
• Clean the resident’s face and hands.
• Ask the resident if they would like oral care.
• Leave the resident with their head elevated at least 30 degrees.
• Record the intake as a percentage of total solid food eaten.
• Record the sum of estimated fluid intakes in mL or cc.
• If in the resident’s room, ensure the bed is low and locked. Check the brakes.
• Document and report any feeding issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating preparing clients for meals and assistance with feeding:

5.23. SKILLS CHECKLIST: CHOKING MANEUVER

Call out for help or tell another staff member to get the nurse if you think a resident is choking. If no nurse is available, direct someone to call 911 while proceeding with the following steps.

Until help arrives, stand behind the victim with one leg forward between the victim’s legs.

For a child, move down to their level and keep your head to one side.

Reach around their abdomen and locate the navel.

Place the thumb side of your fist against their abdomen just above the navel.

Grasp your fist with your other hand and thrust inward and upward into the victim’s abdomen with quick jerks.

For a responsive pregnant victim, any victim you cannot get your arms around, or for anyone in whom abdominal thrusts are not effective, give chest thrusts while standing behind them. Avoid squeezing the ribs with your arms.

Continue thrusts until the victim expels the object or becomes unresponsive.

If the person becomes unconscious, notify the nurse. If no nurse is available, call 911.

View a YouTube video[ 1 ] of an instructor demonstrating the choking maneuver:

5.24. SKILLS CHECKLIST: CATHETER CARE

Gather Supplies: Basin, warm water, soap, two washcloths, one towel, barrier, gloves, and linen bag or hamper

• Expose only the urethra and catheter.
• Follow the tubing from the resident toward the drainage bag, ensuring that the tubing is at a lower level as it goes toward the bag. Be sure no kinks or elevation can cause backflow to the bladder.
• Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, or disposable pad) under their buttocks.
• Use the first washcloth with soap and water to carefully wash around the catheter where it exits the urethra.
• Hold the catheter where it exits the urethra with one hand.
• While holding the catheter, clean 3-4 inches down the catheter tube.
• Clean with strokes moving away from the urethra.
• Use a clean portion of washcloth for each stroke.
• Put the soiled first washcloth in the linen bag.
• Wet the second washcloth and rinse, using strokes only away from the urethra while continuing to hold the catheter where it exits the urethra.
• Rinse using a clean portion of washcloth for each stroke.
• Put the soiled second washcloth in the linen bag.
• Pat dry with a towel.
• Do not allow the tube to be pulled at any time during the procedure.
• Replace the gown over the resident’s perineal area.
• While wearing gloves, empty the basin.
• Rinse the basin.
• Document and report any issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating catheter care:

5.25. SKILLS CHECKLIST: EMPTYING CATHETER DRAINAGE BAG

Gather Supplies: Gloves, two barriers, graduated cylinder, and alcohol swab

• Place a barrier (e.g., paper towel or disposable pad) on the floor under the drainage bag.
• Place the graduated cylinder on the barrier.
• Open the drain to allow the urine to flow into the graduated cylinder.
• Avoid touching the tip of the tubing to the sides of the graduated cylinder.
• Close the drain.
• Wipe the drain with an alcohol wipe.
• Wipe the drain holder, if present, with an alcohol wipe.
• Replace the drain into the holder.
• Place a clean barrier on a level, flat surface.
• With the graduated cylinder at eye level, read the amount of output.
• Note the characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine.
• Empty the urine in the graduated cylinder into the toilet.
• Rinse the graduated cylinder and empty it into the toilet.
• Document urinary output in mL and report any issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating emptying catheter drainage bag:

5.26. SKILLS CHECKLIST: ASSISTING WITH A BEDPAN

Gather Supplies: Gloves, bedpan, barrier, and toilet tissue

• Turn the resident or raise their hips and place a barrier (e.g., a towel, waterproof soaker pad, disposable pad) under their buttocks.
• Position the resident on the bedpan/fracture pan correctly. The deeper portion of the bedpan should be directed toward their toes, and the resident should be centered on the bedpan. For fracture bedpans, the handle should be directed toward their toes.
• Raise the head of the bed to a comfortable level.
• Cover the resident with linens or a bath blanket.
• Leave toilet tissue within reach of the resident.
• Leave the call light within reach of the resident.
• Wait nearby allowing for resident privacy.
• When the resident signals, return and assist the resident to perform hand hygiene.
• Discard the soiled linen in the designated laundry hamper.
• Gently remove the bedpan/fracture pan.
• Assist with perineal care.
• Empty the bedpan into the toilet or into a graduated cylinder if output is being recorded. Note the amount and characteristics (i.e., color, clarity, sediment, or unusual odor) of the urine. Empty the urine from the graduated cylinder used into the toilet.
• Rinse the equipment used and empty the rinse water into the toilet.

View a YouTube video[ 1 ] of an instructor demonstrating assisting with a bedpan:

5.27. SKILLS CHECKLIST: ASSISTING WITH A URINAL

Gather Supplies: Gloves, urinal, and barrier

• Assist the resident to their preferred position of comfort and mobility status (e.g., seated on the side of the bed, lying in bed, or standing).
• Place the urinal with the shaft of the penis well within the opening. Keep the urinal level to prevent urine spillage while the resident is urinating. If the resident has discomfort, a washcloth can be placed around the rim of the urinal to prevent skin issues.
• Provide privacy while the resident voids.
• Place a barrier on a flat surface.
• Place the urinal on the barrier.
• With the urinal at eye level, read the amount of urine and note its characteristics (i.e., color, clarity, sediment, or unusual odor).
• Empty the urinal into the toilet.
• Rinse the urinal and empty the rinse water into the toilet.
• Return the urinal to storage.
• Document urinary output in mL and report any skin issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating assisting with a urinal:

5.28. SKILLS CHECKLIST: CHANGING INCONTINENCE BRIEF

Gather Supplies: Gloves and brief

• If the resident is in bed, raise one side rail.
• Moving to the opposite side of bed, assist the resident to raise their hips or turn towards the side rail. Remove the soiled brief.
• Place a new brief under the resident’s buttocks and center the brief. Gently tuck the tabs under the resident.
• Assist the resident to roll onto their back.
• Position the brief over the front of the resident and secure the brief with tabs.
• Document output from the soiled brief and report any skin issues or changes noted with the resident.

View a YouTube video[ 1 ] of an instructor demonstrating changing incontinence brief:

5.29. SKILLS CHECKLIST: DRESSING A CLIENT WHO NEEDS TOTAL ASSISTANCE

Gather Supplies: Resident clothing, socks and footwear, and hamper

• Raise the bed height.
• Keep the resident covered while removing their gown.
• Remove the gown from the unaffected (most mobile) side first.
• Place the used gown in a designated laundry hamper.
• Ask the resident their preferences for desired clothing.
• Start dressing them on their affected (least mobile) side first. Insert their hand through the sleeve of their shirt and grasp the hand of the resident to guide it through the sleeve.
• Put pants on both legs, starting with the affected (least mobile) side first. If the resident is able, assist them to raise their buttocks. If they are unable to raise their hips, put the side rail on their unaffected (most mobile) side up. Assist the resident to turn towards the side rail. Pull the pants over their buttocks and up to their waist.
• While still on the unaffected (most mobile) side, tuck the resident’s shirt underneath their unaffected side.
• Assist the resident onto their back.
• Raise the side rail if the resident is unable to lift their hips.
• Move to the unaffected side of the resident.
• Place their unaffected arm in the shirt sleeve, grasping the hand of the resident. Finish putting on their shirt by buttoning and zipping closures.
• Assist the resident to turn onto their affected side and pull their pants up to their waist.
• Return the resident to lying on their back.
• Put on the resident’s socks. Draw the socks up the resident’s foot until they are smooth.
• Put on the resident’s nonskid footwear by slipping each nonskid footwear on the resident’s feet.
• Leave only when the resident is properly dressed.

View a YouTube video[ 1 ] of an instructor demonstrating dressing a client who needs total assistance:

5.30. SKILLS CHECKLIST: SHAVING WITH AN ELECTRIC RAZOR

Gather Supplies: Gloves, clothing protector (towel), razor, and hamper

• Sit the resident upright and place a clothing protector over their chest.
• Hold the shaver at a right angle to the resident’s face, using your free hand to pull their skin taught as you shave. This will minimize snagging and the risk of cutting the resident.
• Shave all areas of the face and neck per resident preference.
• Gather the clothing protector so their whiskers do not fall onto their clothing.
• Place the clothing protector in the designated hamper.
• Clean the razor per facility guidelines and charge or plug it in.

View a YouTube video[ 1 ] of an instructor demonstrating shaving with an electric razor:

5.31. LEARNING ACTIVITIES

V. GLOSSARY

Hygiene, grooming, dressing, fluid and nutritional intake, mobility, and elimination needs of clients.

Personal care performed in the morning.

Inadvertently breathing fluid or food into the airway instead of swallowing it.

A method used with clients with visual impairments to describe where the food on their plate is located. For example, state, “Your mashed potatoes are at 10 o’clock, the green beans are at 2 o’clock, and the meat loaf is at 6 o’clock on your plate.”

An acronym to consider after providing personal care but before leaving the room that stands for Comfort; Light, Lock and Low; Open; Wash; and Document.

A surgically placed opening when a client’s colon function is impaired. A piece of the colon is diverted to an artificial opening in the abdominal wall called a stoma, and feces is collected in a pouch.

A movable device with a bucket underneath the seat that is used for elimination when the client has difficulty getting to the bathroom.

A bath provided in bed for clients who have difficulty getting out of bed, are experiencing excessive pain, or have other physical or cognitive issues that make other types of bathing less tolerable.

Maintaining a resident’s appearance through shaving, hair, and nail care.

Keeping the body clean and reducing pathogens by performing tasks such as bathing and oral care.

Skin that is damaged or not healing normally. An example of impaired skin integrity is a pressure injury (also called a bedsore or pressure ulcer) with damage to the skin and surrounding tissue.

Disposable products used for clients with little to no control over bladder or bowel function.

Washing the face, underarms, arms, hands, and perineal area. Partial baths are given daily to maintain hygiene. They preserve skin integrity by not drying out skin with excessive soap and water use.

The genital and anal area.

Care that a client needs to maintain hygiene, well-being, self-esteem, and dignity.

A care approach that considers the whole person, not just their physical and medical needs. It also refers to a person’ autonomy to make decisions about their care, as well as participate in their own care.

Personal care performed in the evening.

A diet order indicating all food is blended to smooth consistency.

Personal cares provided to every resident every day, such as assisting them in getting dressed for breakfast.

Life-threatening infection that has spread throughout the body.

An acronym to consider before providing cares to clients that stands for Supplies, Knock, Wash, Introduce, Privacy, and Explain.

Encourages the patient to urinate on a set schedule.

A condition where as soon as the person feels the need to empty their bladder they have very little time before urine escapes.

A device placed into the bladder by a nurse using sterile technique that allows the urine to drain into a collection bag.

A common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the bladder or kidneys.

A surgically placed opening to collect urine from a person’s ureters when their bladder is diseased or has been removed. Urostomies are typically located on the lower right side of the abdomen, and urine is collected into a drainage bag.

Vocalization with sounds as if food or fluids remain in the mouth or throat.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Reuter-Sandquist M; Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Assistant [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 5: Provide for Personal Care Needs of Clients.
• PDF version of this title (164M)

In this Page

• INTRODUCTION TO PROVIDE FOR PERSONAL CARE NEEDS OF CLIENTS
• ACTIVITIES OF DAILY LIVING (ADLS)
• PERSON-CENTERED CARE
• PRE- AND POST-PROCEDURAL STEPS
• TYPES OF BATHS AND TECHNIQUES
• ASSISTING WITH NUTRITION AND FLUID NEEDS
• ASSISTANCE WITH TOILETING
• SKILLS CHECKLIST: PARTIAL BATH
• SKILLS CHECKLIST: FULL BED BATH
• SKILLS CHECKLIST: SHOWER
• SKILLS CHECKLIST: TUB BATH
• SKILLS CHECKLIST: SHAMPOO
• SKILLS CHECKLIST: FOOT CARE
• SKILLS CHECKLIST: NAIL CARE
• SKILLS CHECKLIST: SKIN CARE
• SKILLS CHECKLIST: BACK RUB
• SKILLS CHECKLIST: PERINEAL CARE (FEMALE)
• SKILLS CHECKLIST: PERINEAL CARE (MALE)
• SKILLS CHECKLIST: ORAL CARE
• SKILLS CHECKLIST: DENTURE CARE
• SKILLS CHECKLIST: PREPARING CLIENTS FOR MEALS AND ASSISTING WITH FEEDING
• SKILLS CHECKLIST: CHOKING MANEUVER
• SKILLS CHECKLIST: CATHETER CARE
• SKILLS CHECKLIST: EMPTYING CATHETER DRAINAGE BAG
• SKILLS CHECKLIST: ASSISTING WITH A BEDPAN
• SKILLS CHECKLIST: ASSISTING WITH A URINAL
• SKILLS CHECKLIST: CHANGING INCONTINENCE BRIEF
• SKILLS CHECKLIST: DRESSING A CLIENT WHO NEEDS TOTAL ASSISTANCE
• SKILLS CHECKLIST: SHAVING WITH AN ELECTRIC RAZOR
• LEARNING ACTIVITIES

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Why Critical Thinking in Nursing Is Important

8 examples of critical thinking in nursing, improving the quality of patient care, the importance of critical thinking in nursing.

Jul 24, 2024

While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.

“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen . “Critical thinking is a crucial and essential skill for nurses.”

The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”

An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.

“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary , professor of surgery at Johns Hopkins University School of Medicine.

Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.

“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP . “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.

Key Nursing Critical Thinking Skills

Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

• Interpretation: Understanding the meaning of information or events.
• Analysis: Investigating a course of action based on objective and subjective data.
• Evaluation: Assessing the value of information and its credibility.
• Inference: Making logical deductions about the impact of care decisions.
• Explanation: Translating complicated and often complex medical information to patients and families in a way they can understand to make decisions about patient care.
• Self-Regulation: Avoiding the impact of unconscious bias with cognitive awareness.

These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.

It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.

Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.

Example #1: Patient Assessments

“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you’re not quite sure what it is,” said Shantay Carter , registered nurse and co-founder of Women of Integrity . “When you notice the change, you have to use your critical thinking skills to decide what’s the next step. Critical thinking allows you to provide the best and safest care possible.”

Example #2: First Line of Defense

Often, nurses are the first line of defense for patients.

“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads . “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”

Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “ failure to rescue ,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.

Example #3: Patient Interactions

Nurses are the ones taking initial reports or discussing care with patients.

“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts . “So, when there is a concern, we are the first name that comes to mind (and get the call).”

“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child’s behavior (and) fluid intake, there were several recommendations I could make.”

Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.

Example #4: Using Detective Skills

Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.

“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”

Pompilio asked the parent to keep a medication diary.

“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.

Example #5: Prioritizing

“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”

A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.

Example #6: Medication & Care Coordination

Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.

“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.

Nurses applying critical skills can also help ease treatment concerns for patients.

“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.

Example #7: Critical Decisions

During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.

“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”

Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.

“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient’s surgery.”

“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There’s lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”

Example #8: Fast & Flexible Decisions

Allen said she thinks electronics are great, but she can remember a time when technology failed her.

“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”

In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.

Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.

“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”

Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.

“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.

Image courtesy of iStock.com/ davidf

Last updated on Jul 24, 2024. Originally published on Aug 25, 2021.

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