7.2 Urinary Elimination

Normal Urinary Elimination

The kidneys filter the blood to remove waste products and also assist in maintaining fluid balance in the body. The result is the production of urine.  Healthy adults produce between 1–2 litres of urine per day. Urine production is affected by a variety of factors such as disease process, age, medications, diet, and exercise. It is important for the HCA to monitor the client’s urinary output, colour, clarity, odour, frequency, and any complaints of pain or discomfort when voiding.  Any abnormalities or changes should be documented and reported, as these can indicate health related changes.  Therefore, it is important to know what the range of normal is for each observation.

Characteristics of Urine

Table 7.2.1 Characteristics of Normal Urine
Characteristic What is Normal?
Colour Can range from pale/light yellow to straw- colored (see Figure 7.2.1: Urine Hydration Chart)
Clarity Clear; no visible particles
Odour Faint, mild odor
Frequency
  • Average is 6–7 times in 24 hours.
  • Dependent upon amount of fluid intake, type of fluid, activity, and medications.
Urgency
  • A fuller bladder will cause increased urgency.
  • Pregnancy can cause pressure on the bladder resulting in a feeling of urgency.
Pain or discomfort Normally, there should be no pain or discomfort with urination.
From the lightest colour to the darkest, urine hydration level is hydrated, mildly hydrated, dehydrated and extremely dehydrated.
Figure 7.2.1 Urine Hydration Chart
Table 7.2.2 Abnormal Characteristics of Urine
Characteristic Abnormal Characteristics Possible Causes
Colour Amber, orange, brown, or red
  • Some foods cause color change in urine (beets, rhubarb, blueberries)
  • Vitamins and some medications can cause a bright yellow or orange hue
  • Dehydration causes urine to be more concentrated and thus darker
  • Blood in the urine may cause a red tinge
Clarity Cloudy, shreds of mucous, blood clots Could indicate a UTI or other kidney disorder
Odour Strong, foul
  • Concentrated urine from dehydration can have a stronger odour
  • Foul odour can indicate a UTI or other infection
  • Some foods such as asparagus can cause urine odour to change
Frequency/urgency Increased frequency (more than 7 times in 24 hrs) and feeling a constant need to void Can indicate a UTI or other medical condition such as diabetes or prostate problems in men
Pain or discomfort Burning, stinging sensation on voiding Can indicate a UTI or other infection .

Explore More

The following video provide you with more information about urine and urinary infections.

Videos: Characteristics of Urine and Urinary Tract Infections

Watch What Your Urine Color Says About Your Health | Urinary System Breakdown | #DeepDives by Health (2021) on YouTube.

Next, watch the video, Urinary Tract Infections, Animation by Alila Medical Media (2016) on YouTube.

Assisting with Urinary Elimination

The Health Care Assistant plays an important role in assisting clients to maintain normal elimination patterns. By following the guidelines below, you can support independence and possibly prevent urinary elimination problems. Always ensure to check the care plan.

HCA Guidelines for Urinary Elimination

  • Follow Routine Practices when assisting with elimination.
  • Encourage fluids as per the care plan.
  • Provide assistance promptly.
  • Encourage clients to call when feeling the need to void.
  • Provide comfort and privacy to the client as necessary.
  • Utilize adaptive devices as per the care plan (e.g., raised toilet seat, mechanical lifts, commode, and urinal).
  • Ensure the safety of the client (provide call bell, stand by if client is unsteady).
  • Provide peri-care after if the client is unable to do it themselves.
  • Ensure to wash the client’s hands afterwards, as well as your own.
  • Note characteristics of urine and report anything abnormal to supervisor.

Urinary Elimination – Using Equipment and Devices

Clients may need to use a variety of different devices and equipment to assist them with their urinary elimination needs. Clients who are unable to get out of bed due to mobility issues or injury may benefit from using a bedpan. Male clients may benefit from using a urinal at the bedside to prevent having to walk to the bathroom. Some male clients have condom catheters, which are external urinary drainage systems where a condom is applied to the penis and attached to a urinary drainage bag. Other clients may have indwelling catheters in which the catheter is inserted into their bladder. The catheter is attached to an external urinary drainage bag.

The Health Care Assistant has an important role in providing assistance with elimination and cleansing the genital area after elimination. This section discusses how to offer a client a bedpan or urinal, how to apply a condom catheter, and how to cleanse the genital area and catheter tubing. Instruction is provided about how to empty urinary drainage bags that are attached to condom catheters and indwelling catheters, and how to properly measure urine output.

Figure 7.2.2 Urinary and Bowel Assistive Equipment

Clients who are unable to get out of bed due to mobility issues or surgery may need to use a bedpan when urinating or for bowel movements. The standard bedpan looks like a toilet seat and has a wide, high rim. These types of bedpans are placed under the patient with the widest end under their buttocks. The fracture pan has a lower, thinner rim. The smaller, flatter end is placed under the buttocks. The higher end with the handle is placed facing the clients feet. The fracture pan should be used for clients who are unable to lift their hips for bedpan placement after back or spinal injuries or surgeries.

Using a Bedpan

Table 7.2.3 Procedure: Use of a Bedpan
STEP ACTIONS REASON
1. Check the client’s care plan. Ensures you have information specific to this client’s care
2. Perform hand hygiene before preparing supplies. Follows Routine Practices to prevent the spread of pathogens
3. Assemble equipment and supplies:

  • non-sterile gloves
  • bedpan
  • incontinent pad or waterproof pad
  • toilet paper
 Gloves are needed for contact with blood/body fluids

Incontinent pad or waterproof pad protects bed linens
4. Provide privacy for the patient by closing doors and/or curtains. Maintains the privacy and dignity of the client
5. Explain the procedure to the patient. Clients have a right to information about their care
6. Raise the bed to working height. Positioning helps prevent injury to the HCA
7. Fold down the top linens just enough to slide the bedpan under the client. Maintains privacy and dignity of the client
8. Place an incontinent pad or waterproof pad under the client as needed. Protects bed linens from urine or feces in case of accidental spilling of bedpan contents
9. Assist the client with removing their pants and undergarments if they are unable to do so.
10. Place a bedpan near the client’s hips.

Position a standard bedpan with the wider edge aligned with the buttocks.

Position a fracture pan with the flatter end under the patient’s buttocks and the handle toward the foot of the bed.
11.
  • If the client is able, they can bend their knees and lift their hips as you slide the bedpan under their buttocks.
  • You can provide assistance for the patient as they raise their hips by placing one hand at the small of their back to help raise their buttocks.
12.
  • If the client is unable to lift their hips, roll them to the side facing opposite you.
  • Position the waterproof pad under the client’s.
  • Then, position the bedpan under their buttocks, pressing firmly but gently downward on the bedpan, against their buttocks.
  • Hold the bedpan securely against the patient as you roll the client back toward you.
  • Check to ensure the bedpan is adequately underneath the client’s buttocks.
 Correct positioning ensures client comfort and prevents spillage of bedpan contents
13.
  • Clean the patient’s perineum.
  • For female patients, wipe the buttocks from front to back, away from the vaginal area.
 Ensures bacteria from the anal area and from feces do not enter the vaginal area and cause a possible infection
14.
  • Lower the bed to its lowest setting.
  • Reposition the patient for comfort.
  • If required by the client’s care plan, ensure the bed side rails are raised.
 Provides safety and comfort
15.
  • Dispose the contents of the bedpan into the toilet.
  • Clean the bedpan according to your facility policy.
  • Dry and put the bedpan away.
  Decreases odours and ensures cleanliness of client’s environment
16.
  • Measure urine as required.
  • Document output of urine or feces as appropriate.
 Ensures communication of client’s health status to other team members
17. Dispose of your gloves, and wash and dry your hands. Follows Routine Practices to prevent the spread of pathogens
18. Document the procedure and any observations or changes you noticed in the client’s condition or behavior. Ensures communication of the client’s health status to other team members

Watch the video:

How to use a Bed Pan – Tips for Caregivers by CareChannel (2019) by CareChannel. CareChannel is developed by the Saint Elizabeth Foundation, presented by Elizz, and funded by The Ontario Ministry Of Health Long Term Care.

Using a Urinal

The use of a urinal helps the male client privately and safely urinate, without having to ambulate to the bathroom or commode. Many male clients find it easier to urinate in a high sitting or standing position. Assist the client into the position they are most comfortable with, and which they can safely assume during urination. Health Care Assistants may need to assist some clients with positioning and holding the urinal while they urinate.

Table 7.2.4 Procedure: Use of a Urinal
STEP ACTION REASON
1. Check the client’s care plan. Ensures you have information specific to this client’s care
2. Perform hand hygiene before preparing supplies. Follows Routine Practices to prevent the spread of pathogens
3. Assemble equipment and supplies:

  • non-sterile gloves
  • urinal
  • incontinent pad or waterproof pad
  • toilet paper
 Gloves are needed for contact with blood/body fluids

Incontinent pad or waterproof pad protects bed linens.
4. Provide privacy for the patient by closing doors and/or curtains. Maintains privacy and dignity of the client
5. Explain the procedure to the patient. Clients have a right to information about their care
6. Raise the bed to working height. Positioning helps prevent injury to the HCA
7.
  • Raise the head of the bed to put the client in a sitting position in bed or at the side of the bed.
  • Alternatively, assist the client to a standing position.
 Some men may find it easier to void when in a standing position.
8. Place an incontinent pad or waterproof pad under client’s hips as needed. Helps protect bed linens from urine in case of accidental spilling of urinal contents.
9. If the client is able, hand them the urinal. Promotes independence
10.
  • If the client requires assistance, place the urinal between the client’s legs.
  • Position the head of the penis into the urinal, ensuring it is completely inside the container.
11.
  • Be with the client while assisting with urination.
  • Allow for quiet during this time.
  • Provide privacy by covering the client with a blanket if they are in bed.
 Maintains the privacy and dignity of the client
12.
  • Provide privacy for the client to urinate if they do not require assistance by leaving the room.
  • Check on the client every five minutes, knocking before entering.
  • Provide toilet paper.
 Maintains the privacy and dignity of the client
13. Discard gloves and wash your hands. Follows Routine Practices to prevent the spread of pathogens
14. When the client has finished using the urinal, wash your hands and don clean gloves. Follows Routine Practices to prevent the spread of pathogens
15. Close the cap on the urinal. Prevents spillage of contents
16.
  • Lower the bed to the lowest height.
  • If required by the client’s care plan, ensure the bed rails are raised.
 Ensures client safety
17. Remove the urinal and supplies. Ensures cleanliness of the client’s environment
18. Measure urine and record output as required. Ensures communication of the client’s health status to other team members
19.
  • Dispose of urine into toilet.
  • Flush toilet.
  • Rinse and then store urinal.
  • Do not store a urinal on a bedside table.
  • Hang the urinal on a bed rail near the patient, so they can easily access it.
 Decreases odours and ensures cleanliness of the client’s environment
20. Dispose of gloves and wash your hands. Follows Routine Practices to prevent the spread of pathogens
21. Document the procedure and any observations or changes in the client’s condition or behavior that you’ve observed. Ensures communication of the client’s health status to other team members

Watch the video,

Assisting with a Urinal by Ashraf Z Qotmosh (2020).

Condom Catheter

Figure 7.2.3 Condom Catheter

Condom catheters are worn by some males to assist with urination. This urinary drainage system allows a client to engage in their normal activities, without being concerned about problems with urination, such as incontinence. It is a less invasive urinary drainage system than an indwelling catheter and has a low risk of infection. It is important for Health Care Assistants to ensure the tubing to this urinary drainage system is not kinked or twisted, and that the drainage collection bag is worn below the level of the bladder.

Figure 7.2.4 Urinary drainage bag
Table 7.2.5 Procedure: Assisting with the Use of a Condom Catheter
STEP ACTION REASON
1. Check the client’s care plan. Ensures you have information specific to this client’s care
2. Perform hand hygiene before preparing supplies. Follows Routine Practices to prevent the spread of pathogens
3. Assemble equipment and supplies:

  • soap or peri-wash
  • wash cloth
  • towel
  • condom catheter
  • drainage bag
 Gloves are needed for contact with blood/body fluids

 
4. Provide privacy for the patient by closing doors and/or curtains Maintains privacy and dignity of the client
5. Explain the procedure to the client. Clients have a right to information about their care
6. Raise bed to working height; place client in a supine position. Positioning helps prevent injury to the HCA
7. Only expose genital area. Maintains privacy and dignity of the client
8. Remove the old condom catheter if one is in place by detaching it from the drainage system tubing and rolling the condom down and off the penis, starting at the base of the penis and rolling towards the tip of the penis. Dispose of the old condom catheter. Ensures cleanliness of the client’s environment
9. Wash the penis carefully with soap and warm water (temperature no greater than 40 degrees Celsius). For uncircumcised males, push the foreskin down the shaft of the penis and clean the head (glans) of the penis. The glans of the penis should be washed using a circular motion from the opening of the urinary meatus outward. Wash the shaft of the penis using downward strokes. Remember to move the foreskin back up. If the foreskin is not reduced (put back into its original place), swelling will result due to circulation of blood to the penis being cut off. If the foreskin is not reduced (put back into its original place), swelling will result due to circulation of blood to the penis being cut off
10. Observe the penis for sores, open or red areas, and broken skin.
11. Attach the condom catheter to tubing of the collection system.
12. Push pubic hair away from the shaft of the penis. Prevents the pubic hair from sticking to the condom.
13.
  • Hold the base of the penis with your non-dominant hand.
  • With your dominant hand, roll the condom catheter onto the penis, starting at the tip of the penis and then over the shaft of the penis, toward the base.
  • Leave about one inch of space between the glans of the penis and the drainage tip to prevent irritation.
14. If tape is being used to secure the condom in place, apply it in a spiral manner, starting at the top of the penis, and working downward.
15. Ensure the tubing for the collection system is connected to the condom.
16.
  • A Velcro or stabilization device may be used to secure the tubing to the client’s thigh.
  • Use according to care plan or agency guidelines.
17.
  • Ensure the tip of the condom is not twisted.
  • Ensure the tubing to the collection system is not kinked or twisted.
  • The collection system tubing and drainage bag should always be kept below the level of the bladder.
 Ensures urine from the drainage bag does not move back up to the penis
18. Lower the bed to its lowest position.

If required by the client’s care plan, ensure the bed rails are raised. .

 Provides safety for the client
19. Discard used supplies. Ensures cleanliness of the client’s environment
20. Discard gloves and wash your hands. Follows Routine Practices to prevent the spread of pathogens
21. Document the application of the condom catheter and any skin conditions that you’ve observed on your client, such as sores, swelling, red, or raw areas. Ensures communication of the client’s health status to other team members

Watch the video:

How to apply a Condom Catheter, by University of Manitoba Nursing Skills (2018)

Cleaning the Skin and Indwelling Catheter Tubing

Providing personal hygiene care is an important part of the Health Care Assistant’s job.  Cleaning the catheter tubing should be completed daily, when providing bathing and perineal care for the client.

Procedure: Assisting with Cleaning the Skin and Indwelling Catheter Tubing
STEP ACTION REASON
1. Check the client’s care plan. Ensures you have information specific to this client’s care
2. Perform hand hygiene before preparing supplies. Follows Routine Practices to prevent the spread of pathogens.
3. Assemble equipment and supplies:

  • soap or peri-wash
  • wash cloth
  • towel
  • condom catheter
  • drainage bag
 Gloves are needed for contact with blood/body fluids
4. Provide privacy for the patient by closing doors and/or curtains. Maintains privacy and dignity of the client
5. Explain the procedure to the client. Clients have a right to information about their care
6.
  • Raise bed to working height.
  • Place the client in a supine position.
 Prevents injury to the HCA
7. Only expose genital area. Maintains privacy and dignity of the client
8. Position the client on their back to expose the perineal area and catheter tubing.
9. Place a towel or disposable protective pad under the client. Prevents bed linens from becoming soiled
10. Wash the client’s genital area gently with soap and warm water (no greater than 40 degrees Celsius).

Males

  • Start at the meatus (urinary opening) and clean outward in a circular motion.
  • Clean the shaft of the penis with downward strokes.
  • For uncircumcised males, gently push back on the foreskin to clean under this area.
  • You should use a clean area of the washcloth with each stroke.
  • Remember to replace the foreskin.

Females

  • Separate the labia and use a clean part of the washcloth to wipe from front to back on each side — use a clean part of the washcloth for each stroke.
  • Wipe from top to bottom down the middle to the opening of the vagina.
  • Clean the area between the vagina and anus last, washing from front to back.
  • Never move from back to front.
11.
  • The catheter tip is inside the bladder.
  • Pulling on the tubing could cause injury to the bladder.
 Take care to avoid pulling on the catheter at any time, as this could cause injury to the client
12. Hold the tubing with one hand close to the meatus, while gently cleansing the length of the tubing — starting from the point of entry (urinary opening) and moving down the tubing. Prevents the pubic hair from sticking to the condom
13.
  • A warm soapy washcloth can be used, unless otherwise directed in the Care Plan.
  • Replace with clean washcloths as needed.
  • When done washing the tubing, use a clean, wet washcloth to rinse the tubing.
  • Always move from the urinary opening downward.
 Never clean the bottom part of the tubing and move toward the urinary opening. This could introduce bacteria into the urinary system.
14.
  • Observe the genital area around the catheter for sores, swelling, crusting, leakage, or bleeding.
  • Document and report these observations.
 Ensures communication of the client’s health status to other team members
15. Ensure the catheter tubing is taped or that a catheter securement device is in place, according to the Care Plan. Prevents kinking of the tubing
16.
  • Position the client so that the catheter tubing does not kink or pull.
  • The urinary drainage bag should be below the level of the client’s bladder.
17.
  • Dispose of dirty linens and water.
  • Remove the bed protector or towel from under the client.
 Ensures cleanliness of the client’s environment
18. Lower the bed to its lowest setting, and if required by care plan, ensure side rails are raised. Provides safety for the client
19. Discard gloves and wash your hands. Follows Routine Practices to prevent the spread of pathogens
A20. Record the time of procedure and any observations or changes observed in the client’s behaviour or condition. Ensures communication of the client’s health status to other team members

Watch the video:

How to Perform Perineal Care with an Indwelling Catheter, by University of Manitoba Nursing Skills (2018).

Emptying the Urinary Drainage Bag

Drainage bags on urinary collection systems, such as those from indwelling catheters or condom catheters need to be emptied regularly. Health Care Assistants should frequently check that the tubing on the catheter system is not twisted or kinked, and ensure that drainage bags are below bladder level. Never hang them from the client’s bed rails, as the bag will move when the bed rails are raised or lowered.

Figure 7.2.5 Drainage Bag Position
Figure 7.2.6 Empty the Drainage Bag
Table 7.2.7 Procedure: Assisting with Emptying the Urinary Drainage Bag
STEP ACTION REASON
1. Check the client’s care plan. Ensures you have information specific to this client’s care
2. Perform hand hygiene and don gloves. Follows Routine Practices to prevent the spread of pathogens

Gloves are needed for contact with blood/body fluids
3. Assemble equipment and supplies:

  • measuring pitcher or graduate cylinder
  • paper towel
  

 
4. Provide privacy for the patient by closing doors and/or curtains. Maintains the privacy and dignity of the client
5. Explain the procedure to the client. Clients have a right to information about their care
6. Place the measuring pitcher or graduate cylinder below the drainage bag on a paper towel. Protects floor from contamination
7. Release the drain from the holder.
8. Open the clamp on the drainage bag without allowing the drain to touch the measuring cylinder. Prevents transfer of bacteria from cylinder to drain
9. Allow contents to pour into a measuring container.
10. Take care to prevent urine from splashing onto your face or clothing.
11. Clamp the drainage bag and clean the end of the drain with an alcohol wipe. Prevents transfer of bacteria to drainage bag
12. Position the clamp back into its holder.
13.
  • Measure the amount of urine at eye level while it is sitting on a flat surface.
  • Record this as output.
 Measuring at eye level ensures greater accuracy of measurement
14.
  • Dispose of urine in the toilet.
  • Flush the toilet.
  • Clean the measuring container and store.
 Decreases odours and ensures cleanliness of the client’s environment
15. Discard gloves and wash your hands. Follows Routine Practices to prevent the spread of pathogens
16.
  • Document procedure, output, and any observed changes in behavior or condition.
  • Report observations about changes in urine color, odor, amount, or characteristics, such as cloudiness, mucus or blood present.
  • Note the condition of the drainage bag and catheter tubing.
  • Report concerns or the need to replace catheter tubing or the drainage bag to a supervisor.
 Ensures communication of the client’s health status to other team members

Measuring Urinary Output

Fluid taken into the body must be eliminated from the body. The urine that is excreted from the body is called output. It is important for Health Care Assistants to measure the output of their clients to ensure optimal health. A client may have a condition in which the healthcare provider wants to ensure that their intake equals their output. This helps to maintain adequate fluid balance. Fluids are usually measured using milliliters (ml). The agency will specify the unit of measurement for Health Care Assistants.

Urinals and catheter drainage systems have measuring lines on the system. The amount of urine at the number indicates the amount of output. For clients who use a toilet, commode, or bedpan, urine contents can be emptied into a graduated or other measuring pitcher to provide an accurate measurement of output. Contents can be disposed of down the toilet once the urine has been measured.

Table 7.2.8 Procedure: Measuring Urinary Output
STEP ACTION REASON
1. Explain to the client the importance of measuring urinary output. Clients have a right to information about their care
2. Always wash hands and don gloves when measuring urinary output. Following Routine Practices prevents the spread of pathogens. Gloves are needed for contact with blood/body fluids
3. Pour urine from a bedpan, commode, urinal, or urinary drainage bag into a measuring pitcher or cylinder.
4. Place the measuring pitcher on a paper towel on a flat surface. Measuring on a flat surface ensures accuracy
5. Note the amount of urine at eye level. Record amount. Amount of urine should be documented in milliliters (ml). Measuring at eye level ensures greater accuracy of measurement
6. Discard urine into the toilet, unless the urine is needed for a specimen.
7. If you notice anything unusual about the urine, save the urine to be inspected by a supervisor. Ensures communication of the client’s health status to other team members
8. Flush the toilet. Decreases odours
9. Rinse bedpans, commodes, urinals, and measuring pitchers that were used. Decreases odours
10. Store equipment in the appropriate place. Ensures cleanliness of the client’s environment
11. Discard gloves and wash your hands. Following Routine Practices prevents the spread of pathogens
12.
  • Document all output.
  • Report any observations or changes in condition or behavior.
 Ensures communication of the client’s health status to other team members
13. Record and report changes in the characteristics of the client’s urine, including color, amount, odor, blood or mucus in the urine, or if the client has difficulty or pain while urinating. Ensures communication of the client’s health status to other team members

Watch the video:

Empty Urinary Drainage Bag CNA Skill NEW, by 4yourCNA (2016)

Urinary Incontinence

Urinary incontinence is the involuntary loss of urine. Although abnormal, it is a common symptom that can seriously affect the physical, psychological, and social well-being of affected individuals of all ages. It has been estimated that one in five (1 in 5) women develop urinary incontinence, but many are too embarrassed to discuss the condition with their health care providers. Some believe it’s a normal part of aging that they have to live with. The result can be isolation and depression when they limit their activities and social interactions because of embarrassment due to incontinence. Health care assistants can decrease incontinence by providing regular toileting opportunities to the client. This will greatly impact the client’s dignity and self-esteem. There are a variety of incontinence products available. They can provide the client with a sense of continence, and help to keep clothing and bed linens dry.  Changing the incontinence products when wet and providing thorough and frequent skin care will prevent odour, discomfort, and skin breakdown.

Figure 7.2.7 Incontinence Product

Types of Urinary Incontinence

Continence is achieved through an interplay of the physiology of the bladder, urethra, sphincter, pelvic floor, and the nervous system coordinating these organs. A disruption in any of these areas can cause several types of urinary incontinence.

  • Stress urinary incontinence is the involuntary loss of urine with intra-abdominal pressure (e.g., laughing and coughing) or physical exertion (e.g., jumping). It is caused by weak pelvic floor muscles that are often the result of pregnancy and vaginal delivery, menopause, and vaginal hysterectomy.
  • Urge urinary incontinence (also referred to as “overactive bladder”) is urine leakage caused by the sensation of a strong desire to void (urgency). It can be caused by increased sensitivity to stimulation by the detrusor muscle in the bladder or decreased inhibitory control of the central nervous system.
  • Mixed urinary incontinence is a mix of urinary frequency, urgency, and stress incontinence.
  • Overflow incontinence occurs when small amounts of urine leak from a bladder that is always full. This condition tends to occur in males with enlarged prostates that prevent the complete emptying of the bladder.
  • Functional incontinence occurs in older adults who have normal bladder control, but have a problem getting to the toilet because of arthritis or other disorders that make it hard to move quickly or manipulate zippers or buttons. Patients with dementia also have an increased risk for functional incontinence.
definition

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Personal Care Skills for Health Care Assistants Copyright © 2023 by Tracy Christianson and Kimberly Morris, Thompson Rivers University. is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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