This unit concerns the client’s immediate environment, which can positively or negatively impact their health and well-being. We can adapt the environment to promote health. Keeping the client’s unit or room clean and in order enhances their well-being. These housekeeping practices also protect clients from harmful microorganisms and other hazards. This unit also explores additional ways in which the client’s environment influences their health.

The environment is defined here as everything that can affect a person, that is, every aspect of their surroundings. This includes ventilation, temperature, and odours. All equipment and surroundings in a client’s environment must be constantly monitored, and any sources of danger must be removed. Good housekeeping practices at home and in the health care facility have an effect on the health of clients, and good practices concern every health care worker.

Ventilation

Ventilation is the movement of air in the room. Proper ventilation provides clean air with the proper amount of moisture, and at a comfortable temperature.

Figure 1.2.1 Ventilating with an open window

Temperature

Temperature affects our comfort and mood. The most comfortable temperature is between 20ºC–23ºC, with a slightly higher temperature for bathing. When the temperature is too high, we lose fluids through perspiration. Be sure to offer extra fluids in hotter temperatures. When the temperature is low, use extra blankets, shawls, or bed socks to prevent loss of body heat.

Humidity

Humidity is the percentage of moisture in the air. The body feels most comfortable when humidity is between 30% and 60%. If the humidity is lower, the nasal passages become dry and crack. Humidifiers or vaporizers can be used in environments with low humidity. Moist air, or high humidity air, will feel cooler if the air is moving. Fans can be used to circulate the air.

Figure 1.2.2 Room humidifier

Odours

Odours come from body discharge, perspiration, cooking, decaying food, and many other sources. Odours are most noticeable when they first strike the nose. Unpleasant odours take away the appetite. Sodium bicarbonate (baking soda) is useful for removing odours.

Light

Figure 1.2.3 Sunny living space

Colour

Figure 1.2.4 Colour palette

Noise

Noise is generally very disturbing. Noise may be generated by staff carelessly talking, laughing, or calling one another across a room. In fact, people are the source of most noise. Try to keep noise under control as much as possible.

Figure 1.2.5 Too noisy!

Neatness and Order

Some people thrive on neatness and others on clutter. A client’s unit or space should have enough order to be safe, but avoid rigid standards for clients who enjoy a bit of untidiness. It is important, however, to be sure to remove soiled linen and unused equipment promptly.

Figure 1.2.6 Untidy closet

Figure 1.2.7 Tidy closet

Privacy

Privacy is essential for the client’s well-being, and some clients are more private than others. Please be respectful of each client’s need for privacy.

Figure 1.2.8 Respecting privacy

Safety in the Environment

The Health Care Assistant needs to be constantly aware of the hazards in the environment. Use prevention as the best strategy to avoid accidents. Below are guidelines that will promote safety in the environment.

Figure 1.2.9 Safety tea cup

• Wipe up spills immediately.
• Remove items off the floor, which might be tripped over or bumped into.
• Keep beds in the lowest position, with brakes on and side rails up, if needed.
• Use handrails and grab bars in bathrooms and corridors.
• Test the temperature of baths and solutions, etc.
• Supervise smokers carefully and never allow smoking in bed.
• Leave furniture and equipment in its usual location, so that people won’t stumble over it.
• Use extra precautions when oxygen is in use.

Fire and Safety Rules and Precautions

It is important to know the fire and safety rules and precautions in every environment where you work and live. Know where the fire extinguishers are in the building!

Figure 1.2.10 Fire safety

Report and Record

Report and record all faulty furniture, equipment, and supplies, as these may create a hazard. Do not use equipment if it is faulty!

Figure 1.2.11 Report and record

Housekeeping procedures are part of the client’s care in an institution and a client’s care in the home. You are responsible for the client’s immediate surroundings.

Your responsibilities for cleaning will vary for each job assignment, but it is important to know what has to be done and whether you or someone else will be doing it.

Figure 1.2.12 Making a bed this way can stir up dust and bacteria

Pay attention to the following items in the client’s environment:

• The bedside table or dresser requires special attention. It can be a source of odour, unsightliness, and infection. All tissues and other disposables must be discarded. All surfaces, inside and out, should be wiped clean.
• Bedpans, commodes, and urinals require thorough cleaning after each use.
• Denture cups and water glasses used for mouth care must be kept clean. The toothbrush should stored so that it is not in contact with anything else.
• Washcloths and towels are replaced daily or more often, if necessary.
• A client’s personal belongings should be stored neatly in drawers or in the closet.
• Old newspapers and magazines should be recycled or discarded (with the client’s permission).
• Specific cleaning of some items must be done after each use:
  • Soap dish, basin, or denture cup.
  • Feces (bowel waste), blood, or vomit should be washed off first with cold water, or they will stick. Then, rewash thoroughly with soap and warm water.
  • Pure water will not dissolve fatty substances, such as Vaseline or mineral oil. Soaps and detergents must be mixed with warm water to dissolve such substances.
• In an institution, the cleaning and dietary staff will be responsible for cleanliness in the kitchen.

The Client’s Unit or Bedroom

• Bed is clean and neatly made.
• Bed is left in lowest position.
• Call bell is within reach of the client at all times while the client is in the room.
• Bedside table drawers containing personal articles (brush and comb, glasses, hearing aid) are within easy reach.
• Bedside table top and drawers are clean.
• Unit is sufficiently in order and safe according to the needs of the individual client.
• Side rails are up or down, as indicated in the care plan.

Figure 1.2.13 Creating a safe environment

Chapter 1 Attributions and References

Unit 1.2 Image Attributions

• Figure 1.2.1 View into a garden through an open ground floor window in Germany by Karl432, via Wikimedia Commons, is used under a CC BY-SA 4.0 license.
• Figure 1.2.2 Ultrasonic humidifier by MaxSem, via Wikimedia Commons, is in the public domain.
• Figure 1.2.3 Sunny living space by Jarek Ceborski/ Jarosław Ceborski on Unsplash, is used under the Unsplash License
• Figure 1.2.4 Colour Palette by Kiloueka, via Wikimedia Commons, is used under a CC BY-SA 4.0 license.
• Figure 1.2.5 Too noisy by Alpha, via Flickr, is used under a CC BY-NC-SA 2.0 license.
• Figure 1.2.6 Messy closet by Matthew Paul Argall, via Wikimedia Commons, was released into the public domain.
• Figure 1.2.7 A neat closet by Rachel, via Flickr, is used under a CC BY-NC 2.0 license.
• Figure 1.2.8 Please Knock & Ring Both Bells by Andrew Barclay, via Flickr, is used under a CC BY-NC-ND 2.0 license.
• Figure 1.2.9 Think Safety First by Jogi don, via Wikimedia Commons, is licensed under CC BY-SA 4.0 license.
• Figure 1.2.10 Fire extinguisher with sign by Mpelletier1, via Wikimedia Commons, is used under a CC BY-SA 3.0 license.
• Figure 1.2.11 Report and Record from OpenClipArtVectors is licensed under a CC0 1.0 Unversal Public Domain Dedication license.
• Figure 1.2.12 Making a bed by Harry Whittier Frees, via Wikimedia Commons, is in the public domain. [Original source: Frees, H. W. The Sandman: His Kittycat Stories. Boston: The Page Company. 1917]
• Figure 1.2.13 Creating a safe environment on Unsplash, is used under the Unsplash License.

Infections have become a major health and safety issue for health care workers and clients. People who are older or have chronic health issues are even more at risk for infections due to their altered and weakened immune systems. As members of the health care team, Health Care Assistants (HCAs) need to know the most current health and safety issues and know how to follow the guidelines and policies to prevent the transmission of these infectious agents. It is important for you, the HCA, to understand how infections are spread and why infection control guidelines and policies are in place — to protect your clients and you! Proper hand hygiene is the best way to prevent the spread of infection.

In health care, the use of effective and safe infection prevention and control practices is everyone’s responsibility. Infection prevention and control guidelines are mandated in all health care settings to protect patients and clients, health care personnel, and families from transmitting organisms that cause infections. This unit will review the principles of infection prevention and control practices, medical asepsis, and the use of additional precautions and personal protective equipment to control and prevent the spread of infection in health care settings.

What Is an Infection?

An infection is any illness caused by the growth of a pathogen on, or in, a person. These pathogens can be bacteria, viruses, or fungi. The common cold is caused by a virus, and so is influenza (the flu), and COVID-19.

Infections can range from fairly minor, like coughs and colds, to more serious ones, like septicemia (blood poisoning) and wound infections. Infections can spread quickly unless certain measures are taken.

Figure 2.2.1 Infections spread quickly!

When a pathogen is commonly found on our body without causing an illness, we call it colonization. People who are colonized will have no signs or symptoms; they feel fine. In certain circumstances, pathogens may go further to cause an infection. For example, Escherichia coli (E. coli) is a common species of bacteria found naturally in the intestine, where it helps produce vitamins K and B. While most strains of E. coli are harmless to humans, they can cause gastrointestinal problems like diarrhea, and in more severe cases, bacterial meningitis or pneumonia.

Some people are more at risk for infection because their immune systems are weakened. Clients with certain health conditions — those with diabetes, heart and skin diseases, or those with a weaker immune system — are also more at risk for infections.

Figure 2.2.2 School sores, or impetigo, is highly contagious

Resident and Transient Flora 

Figure 2.2.3 Bacteria infection

Not all germs cause infections! Billions of bacteria live in or on our bodies. This is normal and healthy, as these germs are part of the body’s resident flora. The parts of the body they typically colonize include the surface of the skin, mucous membranes (eyes, nose, mouth), digestive tract (gut, bowel), and upper respiratory system (mouth, nose and throat). These pathogens do not cause harm.

Transient flora are just passing through. Although they may attempt to colonize the same areas of the body as the resident flora, transient germs cannot remain in the body for extended periods. 

This is due to: 

• Competition from resident flora
• Elimination by the body’s immune system
• Physical or chemical changes within the body that discourage the growth of transient germs

How Infections Occur

Under normal conditions, neither resident nor transient pathogens cause harm. However, if the opportunity arises, some of these pathogens are able to cause infections. This can happen due to various conditions, including:

• When the immune system isn’t working properly, normal flora can overpopulate or move into areas of the body where they do not normally live.
• When the balance of normal pathogens is disrupted — for example, when a person takes broad-spectrum antibiotics — transient pathogens that are usually crowded out by resident pathogens have an opportunity to take over. Tougher, or antibiotic-resistant bacteria, can get the upper hand.
• Disease can result when normal flora can enter an area of the body that they do not normally get into. Catheters or surgical wounds can allow pathogens into areas of the body that are normally sterile.

Figure 2.2.4 Antibiotics can disrupt the balance of normal pathogens

Chain of Infection

The chain of infection is a way of describing how an infection spreads from one person to another. Let’s say an infectious germ is living and multiplying in a person. The person coughs into their hand, then touches a door handle, leaving pathogens there. Another person touches the door handle, then touches their eyes, nose, or mouth. The pathogens have just found a way into the next person, completing the chain of infection.

Breaking the Chain of Infection

The development of an infection involves a set of complex interrelationships between the source of the microorganism, the susceptible host, and the environment. For infection to occur, it requires the transmission of microorganisms from the source to a susceptible host. One way to understand this complex connection is the chain of infection, which can have six links: the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry and susceptible host (see Figure 2.2.5). Breaking any one of the links in the chain of infection will prevent infection from occurring.

Figure 2.2.5a and 2.2.5b The chain of infection. (Image courtesy of Public Health Agency of Canada (2016]). [Long description]

Image descriptions

Figure 2.2.5a and 2.2.5b The chain of infection

Figure 2.2.5a shows the chain of infection, a framework for understanding the complex relationship between infection and host during transmission. The chain can have six links: the infection agent, reservoir, portal of exit, mode of transmission, portal of entry and susceptible host.

Figure 2.2.5b shows that breaking any of the links in the chain of infection, as shown in Figure 2.2.5a, will prevent an infection from occurring.

[Back to Figure 2.2.5]

Infection prevention and control (IPAC) practices are evidence-based procedures and practices that can prevent and reduce disease transmission, and eliminate sources of potential infections (PIDAC, 2012). When used consistently, IPAC practices will prevent the transfer of health care associated infections (HAIs) in all health care settings. HAIs, previously called nosocomial infections, are infections that occur in any health care setting as a result of contact with a pathogen that was not present at the time the person infected was admitted (World Health Organization, 2009a).

Two types of techniques are used to prevent infection in the hospital setting. The first, medical asepsis or clean technique, has been used in the past to describe measures for reducing and preventing the spread of organisms (Perry, Potter & Ostendorf, 2014). The second, sterilization, also known as sterile asepsis, is a strict technique to eliminate all microorganisms from an area (Perry et al., 2014). When a patient/client is suspected of having or is confirmed to have certain pathogens or clinical presentations, additional precautions are implemented by the health care worker in addition to routine practices (PIDAC, 2012). These additional precautions are based on how an infection is transmitted, such as by contact, droplet, or air.

Additional precautions use personal protective equipment (PPE), such as gowns, eyewear, face shields, and masks, along with environmental controls to prevent transmission of infection. To reduce and prevent the spread of HAIs, a system of recommended IPAC routine practices are to be used consistently with all patients/clients at all times in all health care settings (Public Health Agency of Canada, 2012b). The principles of routine practices are based on the premise that all patients/clients are potentially infectious, even when asymptomatic, and IPAC routine practices should be used to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or soiled items (PIDAC, 2012). 

Principles of Asepsis

When providing care and even cleaning, the Health Care Assistant should always work from clean to dirty to prevent the spread of microorganisms. For example, in bathrooms clean the toilet last. If the toilet is cleaned first, microorganisms will spread over everything else in the room that the cleaning cloth or hands touch. Cleaning should also progress from far to near and/or top to bottom to prevent the spread of microorganisms. These same principles apply to the personal care provided to clients. As an example, if you are washing a client’s face, start with the inner of the eye farthest away from you.

Hand Hygiene Best Practices

Hand hygiene is the most important part of practice for health care workers and is the single most effective way to stop the spread of infections; failure to properly perform hand hygiene is the leading cause of hospital associated infections and the spread of antibiotic resistant organisms (ARO) (BC Centre for Disease Control, 2014; WHO, 2009a). Hand hygiene is a general term used to describe any action of hand cleaning and refers to the removal or destruction of soil, oil, or organic material, as well as the removal of microbial contamination acquired by contact with clients or the environment. Hand hygiene may be performed using an alcohol-based hand rub (ABHR) or soap and water.

Hand Hygiene

Figure 2.4.1 Hands carry germs

Even if your hands appear clean, they may carry germs. Hands pick up microorganisms (germs) in several ways. When people who are sick sneeze or cough, the germs that are making them sick are expelled into the air in tiny droplets. If these droplets get onto your hands, and then you touch your mouth, eyes, or nose without washing away the germs, you can pick up the infection.

Washing your hands prevents you from getting sick and educes the risk of infecting others. If you don’t wash your hands properly before coming into contact with others, you can infect them with the germs on your hands. Other people can also get sick from the germs unwashed hands leave on shared objects like doorknobs, keyboards, and other equipment in the home or workplace.

Hand hygiene is all about keeping your hands clean and the skin healthy. This is done by:

• Washing your hands with soap and water, or cleaning with alcohol-based hand rub (ABHR).
• Using moisturizer to protect your skin — this prevents chapping and skin breakdown.
• Not wearing jewellery or artificial nails — these interfere with cleaning your hands properly, and can harbor germs.

Figure 2.4.2 Hand jewellery and false nails hide germs

Hand Jewellery and False Nails

Hand jewellery such as rings, bracelets, and watches interfere with proper hand cleaning and can hide germs. You should either not wear these to work or remove them when cleaning your hands. Long nails, false nails, chipped nail polish, and nail jewellery can also harbour germs, which is why most health care facilities have policies against health care providers wearing them.

Figure 2.4.3 Change bandages regularly

Hand Care

It’s important that you keep the skin of your hands in good health, so that it doesn’t become dry or chapped and prone to breakdown. You should use hand lotion to prevent your skin from becoming dry. If you suffer from frequent skin breakdown (dermatitis), you should consult your workplace health provider or doctor.

If you have a cut on your hand, it’s important to cover it with a bandage so that no germs get into it. Be sure to change the bandage regularly, as you can’t properly clean a bandage, and you don’t want a dirty bandage to become a way for germs to spread.

Proper Methods of Handwashing

Although handwashing might seem like a simple task, you should follow these steps to thoroughly rid your hands of germs.

What Kind of Soap to Use?

• Use plain soap that does not contain antibacterial agents. Plain soap will remove the dirt and grease that attract bad bacteria.
• Plain soap will not kill the good bacteria that live on the hands.
• Using antibacterial products unnecessarily increases the concentration of antibiotics in the water supply and in the environment and increases the risk of antibiotic resistant organisms.
• Liquid soaps are better than bar soaps, because germs can live on bar soaps.

Figure 2.4.4 Liquid soap dispenser

Steps When Using Soap

1. Remove any hand or arm jewellery you may be wearing.
2. Wet your hands with warm water.
3. Apply plain soap to your hands and rub together for 20 seconds (the length of time it takes to sing “Twinkle, Twinkle Little Star” or “Happy Birthday”).
4. Wash the front and back of your hands, as well as between your fingers and under your nails.
5. Rinse your hands well for 10 seconds under warm running water, using a rubbing motion.
6. Wipe and dry your hands gently with a paper towel or a clean towel. Drying them vigorously can damage the skin.
7. Turn off the tap using the paper towel so that you do not re-contaminate your hands. When using a public bathroom, use the same paper towel to open the door when you leave.
8. If skin dryness is a problem, use a moisturizing lotion.

Figure 2.4.5 Wash your hands thoroughly

 Steps When Using Alcohol-Based Hand Rub

1. Alcohol-based hand rubs or ABHRs are quick to use. They are especially convenient when soap and water are not available.
2. Make sure your hands are dry, as wet hands will dilute the alcohol-based hand product.
3. Use enough of the product to cover all the surfaces of your hands and fingers.
4. Rub your hands together until the product has evaporated.
5. If dry skin is a problem, use a moisturizing lotion.
6. Alcohol-based hand rubs don’t work if your hands are greasy or visibly dirty. These products don’t clean your hands and are not a substitute for handwashing. If your hands are visibly soiled, it is best to use soap and water.
7. If it’s not possible to wash with soap and water, use towelettes to remove the soil, then use an alcohol-based hand rub.

Figure 2.4.6 Alcohol-based hand rub dispenser

 Soap and Water, or ABHR?

Figure 2.4.7 Soap or ABHR?

ABHR contains 60% to 90% alcohol concentration and is recommended for hand hygiene in health care settings (CDC, 2012). ABHRs:

• Kill the majority of germs (including viruses) from hands
• Are easy to use and have high levels of availability at the point of care
• Require less time to use than soap and water (20 to 30 seconds)
• Provide better skin tolerability

ABHR doesn’t remove dirt. If you have handled something that has left your hands soiled (e.g., raw chicken, a soiled diaper), then soap and water need to be used to remove the soil. Regardless of which method you use, make sure you clean all areas of your hands – palms, backs, fingers, nails — and don’t forget your thumbs.

As illustrated in Figure 2.4.8, there are five key moments at which to perform hand hygiene to break the chain of infection when you are working in health care.

Figure 2.4.8 Five moments of hand hygiene [Click to view image full size]

Non-Sterile (Clean) Gloves

Both hand hygiene and clean glove use are strategies to prevent transmission of infections through hand contact. In the context of patient/client care, it makes sense to think of glove use and hand hygiene as complementary strategies to prevent transmission of pathogens. Gloves are critical to prevent the transmission of organisms when hand hygiene alone is not enough in an outbreak such as Clostridium difficile or the norovirus, or when a patient/client has a suspected or known pathogen. Studies have shown that gloves reduce transmission of microbes from the hands of health care workers (PIDAC, 2012). Checklist 2.4.1 provides the correct steps for applying and removing non-sterile gloves.

Non-sterile gloves are single use and should be applied:

• Before an aseptic procedure
• When anticipating contact with blood or body fluid, non-intact skin, secretions, excretions, mucous membranes, or equipment or environmental surfaces contaminated with the above blood or body fluids
• When in contact with a patient/client, their equipment or environment during additional precautions

Non-sterile gloves should be removed:

• If gloves are damaged and integrity is compromised
• When contact with blood, body fluid, non-intact skin, or mucous membranes has ended
• When contact with a single patient/client and their surroundings has ended (or when contact with a contaminated body site on a patient/client has ended)
• When there is an indication for hand hygiene

Checklist 2.4.1: Applying and Removing Non-Sterile Gloves

How to Don (Apply) Non-Sterile Gloves

STEP	ACTION	ADDITIONAL INFORMATION
1.	Perform hand hygiene.	Figure 2.4.9 Hand hygiene with ABHR
2.	Select the appropriate size of non-sterile gloves. Remove gloves one at a time out of the box, touching only the top of the cuff.	Figure 2.4.10 Remove gloves from box
3.	Put hand through opening and pull up to the wrist.	Figure 2.4.11 Apply first glove
4.	Repeat procedure with the second hand.	Figure 2.4.12 Apply second glove
5.	Adjust gloves to cover wrists or gown as required.	Prevents the contamination of the wrists.
6.	Complete care as required.	Figure 2.4.13 Non-sterile gloved hands

How to Doff (Remove) Gloves

STEPS	ACTION	Additional Information
1.	Grasp glove on the outside about 1.25 cm below the cuff (edge of the glove opening). Do not touch the wrist with the other hand.	Figure 2.4.14 Grasp glove on the outside 1.25 cm below the cuff
2.	Pull down glove, turning it inside out. Hold the inside-out glove in the gloved hand.	Figure 2.4.15 Pull glove off Figure 2.4.16 Inside out
3.	Gather the inside-out glove in the gloved hand.	Figure 2.4.17 Gather inside-out glove in remaining gloved hand
4.	Insert finger of the bare hand under the cuff of the gloved hand.	Figure 2.4.18 Insert finger under cuff of gloved hand
5.	Pull down the glove until it is inside out, drawing it over the first glove.	Figure 2.4.19 Remove second glove
6.	Discard gloves in a garbage container.	This step reduces the spread of microorganisms. Figure 2.4.20 Discard used non-sterile gloves
7.	Perform hand hygiene.	This step reduces the spread of microorganisms. Figure 2.4.21 Hand hygiene with ABHR

Routine Practices

Routine practices are the infection prevention and control (IPC) practices to use in the routine care of all clients at all times in all health care settings and are determined by the circumstances of the client, the environment, and the care activity to be performed. This is often referred to medical asepsis or clean technique, used to describe measures for reducing and preventing the spread of organisms (Perry, Potter & Ostendorf, 2014).

Routine practices include:

• Point-of-care-risk assessment
• Hand hygiene program (including point-of-care ABHR)
• Source control (triage, early diagnosis and treatment, respiratory hygiene, spatial separation)
• Client placement, accommodation, and flow
• Aseptic technique
• Use of personal protective equipment (PPE)
• Sharps safety and prevention of bloodborne pathogen transmission
• Management of the client care environment:
  • Cleaning of the client care environment
  • Cleaning and disinfection of non-critical client care equipment
  • Handling of waste and linen

The routine precautions taken to prevent transmission of infectious microorganisms are used in the care of all persons.

Routine practices apply to all clients. They prevent the spread of infection from:

• Blood
• All body fluids, secretions and excretions (except sweat)
• Non-intact skin (skin with open breaks)
• Mucous membranes

Personal Protective Equipment (PPE)

Figure 2.5.1 personal protective equipment (PPE)

Following routine practices and additional precautions involves the use of PPE personal protective equipment and requires health care providers to wear gloves, gowns, and eye protection. Each agency/facility will have a policy and procedures for when and what types of PPE the health care staff should use. Donning (putting on) and doffing (taking off) requires the provider to follow the proper order of putting on and taking of the PPE to ensure infection control. Figures 2.5.2 and 2.5.3 offer you the correct procedures for donning and doffing PPE.

Figure 2.5.2 Putting on (Donning) Personal Protective Equipment (PPE). [Image description]

Figure 2.5.3 Taking off (Doffing) Personal Protective Equipment (PPE).[Image description]

Image descriptions

Figure 2.5.2 Putting on (Donning) Personal Protective Equipment (PPE)

An infographic by Alberta Health Services describing 5 steps of putting on or donning personal protective equipment:

1. Hand Hygiene
   1. Using an alcohol-based hand rub is the preferred way to clean your hands.
   2. If your hands look or feel dirty, soap and water must be used to wash your hands.
2. Gown
   1. Make sure the gown covers from neck to knees to wrist.
   2. Tie at the back of neck and waist.
3. Procedure/Surgical mask and N95 respirator
   1. Procedure/Surgical mask
      • Secure the ties or elastic around your head so the mask stays in place.
      • Fit the moldable band to the nose bridge. Fit snugly to your face and below chin.
   2. N95 respirator. There are different styles of N95 respirators. They include: molded cup, flat-fold, and v-fold.
      1. Hold the N95 respirator in your hand.
      2. Position the N95 respirator under your chin with the nose piece up. Secure both of the elastic bands around your head so the N95 respirator stays in place.
      3. Use both hands to mold the metal band of the N95 respirator around the bridge of your nose.
      4. Seal check: Place both hands completely over the respirator, being careful not to disturb the position, and exhale sharply.
4. Eye protection or face shields
   1. Place over the eyes (or face).
   2. Adjust to fit.
5. Gloves
   • Pull the cuffs of the gloves over the cuffs of the gown.

[Back to Figure 2.5.2]

Figure 2.5.3 Taking off (Doffing) Personal Protective Equipment (PPE)

An infographic by Alberta Health Services describing 7 steps of taking off or doffing personal protective equipment:

1. Remove Gloves
   1. Grasp the outside edge of the glove near the wrist and peel away from the hand, turning the glove inside-out.
      • Hold the glove in the opposite gloved hand.
   2. Slide an ungloved finger or thumb under the wrist of the remaining glove.
   3. Peel the glove off and over the first glove, making a bag for both gloves.
   4. Put the gloves in the garbage.
2. Hand hygiene
   1. Using an alcohol-based hand rub is the preferred way to clean your hands.
   2. If your hands look or feel dirty, soap and water must be used to wash your hands.
3. Gown
   1. Carefully unfasten ties.
   2. Grasp the outside of the gown at the back of the shoulders and pull the gown down over the arms.
   3. Turn the gown inside out during removal.
   4. Put in hamper or, if disposable, put in garbage.
4. Hand hygiene
   1. Clean your hands. (See No. 2)
   2. Exit the patient room, close the door and clean your hands again.
5. Eye protection or face shield
   1. Handle only by headband or ear pieces.
   2. Carefully pull away from face.
   3. Put reusable items in appropriate area
      for cleaning.
   4. Put disposable items into garbage
6. Mask or N95 Respirator. There are different styles of N95 respirators but all styles have the same basic steps for doffing.
   1. Bend forward slightly and carefully remove the mask from your face by touching only the ties or elastic bands.
   2. Start with the bottom tie, then remove the top tie.
   3. Throw the mask in the garbage
7. Hand hygiene.
   • Clean your hands. (See No. 2)

[Back to Figure 2.5.3]

Point-of-care risk assessment (PCRA) is performed by all health care workers to determine the appropriate infection prevention and control measures for safe client care and to protect the worker from exposure to microorganisms. Remember how infections are spread, as this can help you perform a better PCRA and break the chain of infection.

Prior to every client interaction, you, as an HCA, have a responsibility to evaluate the infectious risk posed to yourself and other clients, visitors and workers by a client, situation, or procedure. The PCRA is an evaluation of the risk factors related to the interaction between you, the client, and the client’s environment to evaluate their potential for exposure to infectious agents and identify risks for transmission.

PCRA is when you evaluate the risk involved in providing care to a client who appears sick, or letting them interact with other clients. It may sound complicated, but in reality, health care workers conduct point-of-care risk assessments and observations of the client’s health status many times a day, often without thinking about it. For example, when you approach a client, you automatically note their mental status, ease of breathing, skin colour, etc. An infection control PCRA is simply an extension of this. The following section offers some questions to consider and Figure 2.6.1 shows the steps for deciding on the precautions you would take.

 PCRA Questions to Ask Yourself

Ask yourself the following questions before and during a PCRA:

• What contact will I have with the client? (direct hands-on care vs. no hands-on care; contact with mucus membranes or non-intact skin)
• What care activities am I going to perform? Is there a risk of splashes/sprays? Likely to stimulate a cough? Or gagging?
• If the client has diarrhea, are they continent? If incontinent, can stool be contained in an adult incontinence product?
• Is the client able and willing to perform hand hygiene? Or respiratory hygiene (covering their cough/sneeze)?
• Is the client able to follow instructions?
• Is the client in a shared room? Is there a better room/space that I should use to provide this care?
• Is there personal protective equipment that I should put on prior to this care activity?

Figure 2.6.1 PCRA decision algorithm [Image description]

Who Should Do PCRAs?

Everyone that interacts with clients should be doing PCRAs. It can be as simple as noting if they’re coughing today when they weren’t yesterday. Health care workers should routinely perform PCRAs throughout the day to apply control measures for their safety and the safety of clients and others in the health care environment.

For example, a PCRA is performed when a health care worker evaluates a client’s situation to:

• Determine the priority for single rooms, or for roommate selection, if rooms are to be shared by clients.
• Determine the possibility of exposure to blood, body fluids, secretions and excretions and non-intact skin, and select appropriate control measures (e.g., PPE) to prevent exposure.
• Determine the need for additional precautions when routine practices are inadequate to prevent exposure.

Have a look at Table 2.6.1 that uses Clostridium difficile (C. difficile) as an example of infection with contact spread to better understand the PCRA you might use in your work. It provides you with greater understanding of what would be higher risk, and helps you make better choices for the need of additional precautions to go along with your routine practices.

Additional Precautions Practices

Another practice used in health care is the use of additional precautions. Additional precautions are usually determined by the infection control team (Perry et al., 2014). When a client is suspected of having or is confirmed to have certain pathogens or clinical presentations, additional precautions are implemented by the health care worker in addition to routine practices (PIDAC, 2012).

The type of additional precautions to use along with the routine precautions will depend on how the particular pathogen is spread and this will determine the type of additional precautions to be used. There are generally three types of infection spread that require consideration for additional precautions: Contact, Droplet, and airborne. For example, Methicillin resistant Staphylococcus aureus (MRSA) requires contact precautions as the bacteria is spread by both direct and indirect contact. The infection control team will advise which additional precautions staff will use. Table 2.6.2 provides you with some examples you will likely see in your practice and to understand when additional precautions are used.

Some infections may need a combination of additional precautions (contact, droplet, airborne) since some microorganisms can be transferred by more than one route. Regardless of the additional precautions, you still need to use the routine practices even with the additional precautions.

Image descriptions

Figure 2.6.1 PCRA Decision Algorithm

The following is a flowchart PiCNET (2014, p. 15) describes the decision-making process around PCRA:

1. Notice the Symptoms
   • Cough
   • Diarrhea
   • Vomiting
   • Rash
2. Do they also have a fever?
3. If yes, are the symptoms new?
4. If yes:
   1. Is there something I should do? E.g., personal protective equipment.
   2. Is there something I should advise the client to do? E.g. respiratory etiquette, or mask.
   3. Who should I tell? E.g., physician or charge nurse.
   4. Have I seen more than one person with these symptoms today?
      • Could this be an outbreak?
      • Implement outbreak control strategies and contact Public Health

[Back to Figure 2.6.1]

Chapter 2 Attributions and References

Unit 2.2 Image Attributions

• Figure 2.2.1 Infections Spread Quickly! from PxHere, is used under a CC0 Public Domain licence.
• Figure 2.2.2 School Sores, or Impetigo, is Highly Contagious from PxHere, is used under a CC0 Public Domain licence.
• Figure 2.2.3 Bacteria Infection from PxHere, is used under a CC0 Public Domain licence.
• Figure 2.2.4 Antibiotics Can Disrupt the Balance of Normal Pathogens from PxHere, is used under a CC0 Public Domain licence.
• Figure 2.2.5 The Chain of Infection by the Public Health Agency of Canada (2016), for non-commercial reproduction. Original created by Dr. Donna Moralejo, Associate Professor, Memorial University.

Unit 2.4 Image Attributions

• Figure 2.4.1 Left 4 Germs : One about scrubbing your hands… by tbSMITH, via Flickr, is used under a CC BY-NC-ND 2.0 licence.
• Figure 2.4.2 Female hands with lunar black manicure by FineShine, via depositphotos.com , is used under an Attributed Free License.
• Figure 2.4.3 My boo-boo 3 by Thom Watson, via Flickr, is used under a CC BY-NC-SA 2.0 license.
• Figure 2.4.4 Person Washing Hands by Anna Shvets, via Pexels, is used under the Pexels license.
• Figure 2.4.5 Wash Your Hands Thoroughly from PxHere, is used under a CC0 Public Domain licence.
• Figure 2.4.6 Dispenser Photo by Amanda Mills, USCDCP, via Pixnio, is used under a CC0 Public Domain licence.
• Figure 2.4.7 Question Mark Question Answer Search Engine Icon by Peggy_Marco, via Pixabay, is used under the Pixabay License.
• Figure 2.4.8 Five Moments of Hand Hygiene from WHO IPC Training tools, is used under a CC BY-NC-SA 3.0 IGO license.
• Figure 2.4.9 Hand hygiene with ABHR by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.10 Remove gloves from box by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.11 Apply first glove by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.12 Apply second glove by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.13 Non-sterile gloved hands by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.14 Grasp glove on the outside 1/2 inch below the cuff by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.15 Pull glove off … by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.16 … inside out by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.17 Gather inside-out glove in remaining gloved hand by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.18 Insert finger under cuff of gloved hand by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.19 Remove second glove by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.20 Discard used non-sterile gloves by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 2.4.21 Hand hygiene with ABHR by Doyle & McCutcheon (2015), via BCcampus, is used under a CC BY 4.0 licence.

Unit 2.5 Image Attributions

• Figure 2.5.1 personal protective equipment (PPE) from PxHere, is used under a CC0 Public Domain licence.
• Figure 2.5.2 Putting on (Donning) Personal Protective Equipment (PPE) by Alberta Health Services is licensed under a CC BY-NC-SA license.
• Figure 2.5.3 Taking off (Doffing) Personal Protective Equipment (PPE) by Alberta Health Services is licensed under a CC BY-NC-SA license.

Unit 2.6 Image Attributions

• Figure 2.6.1 PCRA Decision Algorithm from the Provincial Infection Control Network of BC (PICNet, 2014, p. 15), is used under a CC BY-NC-ND 4.0 licence.
• Table 2.6.1 PCRA Example Using C. Difficile is from Table 2 in the Public Health Agency of Canada (2016), via Government of Canada website, for non-commercial reproduction.
• Table 2.6.2 Additional Precautions PPE from the Provincial Infection Control Network of BC (PICNet, 2014, p. 18), is used under a CC BY-NC-ND 4.0 licence.

Videos

• Soap and Water by LearningHub (2022) is licensed under a Standard YouTube License.
• Alcohol Based Hand Rub by LearningHub (2022) is licensed under a Standard YouTube License.
• PPE Donning for Medical Mask by LearningHub (2022) is licensed under a Standard YouTube License.
• PPE Doffing for Medical Mask by LearningHub (2022) is licensed under a Standard YouTube License.

References

BC Centre for Disease Control (BCCDC). (2014). Hand hygiene. Retrieved from http://www.bccdc.ca/prevention/HandHygiene/default.htm.

Braswell, M. L., & Spruce, L. (2012). Implementing AORN recommended practices for surgical attire. AORN Journal, 95(1), 122-140. doi: 10.1016/j.aorn.2011.10.017.

Centers for Disease Control and Prevention (CDC). (2007). Part III: Precautions to prevent the transmission of infectious agents. Retrieved from http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html.

Centers for Disease Control (CDC). (2012). Frequently asked questions about Clostridium difficile for health care providers. https://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html

Doyle, G. R., & McCutcheon, J. A. (2015, November 23 ). Clinical procedures for safer patient care. British Columbia Institute of Technology (BCIT)/ BCcampus. https://opentextbc.ca/clinicalskills/

LearningHub. (2022, February 28). Alcohol based hand rub [Video]. YouTube. https://www.youtube.com/watch?v=_WCzsSC18Io

LearningHub. (2022, February 28). PPE doffing for medical mask [Video]. YouTube. https://www.youtube.com/watch?v=pL8blsiZfF8

LearningHub. (2022, February 28). PPE donning for medical mask [Video]. YouTube. https://www.youtube.com/watch?v=FcCbvnxT0vI

LearningHub. (2022, February 28). Soap and water [Video]. YouTube. https://www.youtube.com/watch?v=19Rpe5wmqYE

Longtin, Y., Sax, H., Allegranzi, B., Schneider, F., & Pittet, D. (2011). Hand hygiene. New England Journal of Medicine, 34(13) 24–28. http://www.nejm.org/doi/pdf/10.1056/NEJMvcm0903599.

Patrick, M., & Van Wicklin, S. A. (2012). Implementing AORN recommended practices for hand hygiene. AORN Journal, 9(4), 492–507. https://doi.org/10.1016/j.aorn.2012.01.019

Poutanen, S. M., Vearncombe, M., McGeer, A. J., Gardam, M., Large, G., & Simor, A. E. (2005). Nosocomial acquisition of methicillin-resistant Staphylococcus aureus during an outbreak of severe acute respiratory syndrome. Infection control and hospital epidemiology, 26(2), 134–137. https://doi.org/10.1086/502516

Provincial Infection Control Network of British Columbia [PICNet]. (n.d.). Guidelines & toolkits. Provincial Health Services Authority (PHSA). https://www.picnet.ca/practice-guidelines

Provincial Infection Control Network of British Columbia [PICNet]. (2014). Infection control quick-reference guide for residential care facilities (Volume 2) [PDF]. PHSA. https://www.picnet.ca/resources/rescarebooklet/ www.picnet.ca/practice-guidelines

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques (8th ed.). Elsevier-Mosby.

Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Routine practices and additional precautions in all health care settings (3rd ed.). Public Health Ontario.  http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf.

Public Health Agency of Canada (PHAC). (2012a). Hand hygiene practices in health care settings. Government of Canada. http://publications.gc.ca/site/eng/430135/publication.html.

Public Health Agency of Canada (PHAC). (2012b). Routine practices and additional precautions for preventing the transmission of infection in health care settings. Government of Canada. http://www.phac-aspc.gc.ca/nois-sinp/guide/ summary-sommaire/tihs-tims-eng.php

Public Health Agency of Canada. (2012). Routine practices and additional precautions assessment and educational tools: Protecting Canadians from illness [PDF]. File HP40-65-2012). Government of Canada.  https://publications.gc.ca/collections/collection_2013/aspc-phac/HP40-65-2012-eng.pdf

Public Health Agency of Canada. (2016). Routine practices and additional precautions for preventing the transmission of infection in health care settings. Government of Canada. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-health care-associated-infections/part-a.html [Date modified: 2017-09-05]

Public Health Agency of Canada. (2016). Appendix X: Technique for putting on and taking off personal protective equipment [images]. In Routine practices and additional precautions for preventing the transmission of infection in health care settings. Government of Canada. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-health care-associated-infections/part-a.html [Date modified: 2017-09-05] [Images Reproduced with permission from the Ontario Ministry of Health and Long-Term Care.]

Rees, J. (2017, October 2). Putting on sterile gloves VIMEO (2017 remake) [Video]. The University of Edinburgh. Media Hopper Create. https://media.ed.ac.uk/media/Putting+on+sterile+gloves+VIMEO+%282017+remake%29/1_wjlyrirj

Sorrentino, S., Remmert, L., & Wilks, M. (2019).  Mosby’s Canadian textbook for the support worker (4th ed.). Elsevier Canada.

World Health Organization (WHO). (2009a). WHO guidelines for hand hygiene in health care: First global patient safety challenge. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf?ua=1.

World Health Organization (WHO). (2009b, May 5). Figure 2. My five moments for hand hygiene [Image]. In Hand hygiene technical reference manual: to be used by health-care workers, trainers and observers of hand hygiene practices [PDF]. https://www.who.int/publications/i/item/9789241598606

Body mechanics is defined as “the efficient and careful use of the body in moving and lifting.” The goals of body mechanics are to conserve energy and to prevent injury. A thorough knowledge of body mechanics is essential if you are to safely carry out your role as a Health Care Assistant. Body mechanics, however, is not just confined to your working hours. All areas of your life demand a conscious awareness of the need to practice safe body mechanics.

When working as an HCA, you cannot avoid lifting, whether it is assisting a client or lifting a load of laundry. However, you can control how you are lifting. Back, wrist, and shoulder injuries are all too common among health care workers. Many of these injuries could be prevented if workers used correct body mechanics and kept themselves physically fit.

Body mechanics involve the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during moving, transferring, and positioning clients. Proper body mechanics allow individuals to carry out activities without an excessive use of energy, and it helps prevent injuries for clients and health care providers (Perry, Potter & Ostendorf, 2018).

Elements of Body Mechanics

Body movement requires coordinated muscle activity and neurological integration. It involves the basic elements of body alignment (posture), balance, and coordinated movement. Body alignment and posture bring body parts into position to promote optimal balance and body function. When the body is well aligned, whether standing, sitting, or lying, the strain on the joints, muscles, tendons, and ligaments is minimized (WorkSafeBC, 2013).

Body alignment is achieved by placing one body part in line with another body part in a vertical or horizontal line. Correct alignment contributes to body balance and decreases strain on musculoskeletal structures. Without this balance, the risk of falls and injuries increases. In the language of body mechanics, the centre of gravity is the centre of the weight of an object or person. A lower centre of gravity increases stability. This can be achieved by bending the knees and bringing the centre of gravity closer to the base of support, keeping the back straight. A wide base of support is the foundation for stability, and is achieved by placing feet a comfortable, shoulder-width distance apart. When a vertical line falls from the centre of gravity through the wide base of support, body balance is achieved. If the vertical line moves outside the base of support, the body will lose balance.

The diagram in Figure 3.2.1 demonstrates: (A) a well-aligned person whose balance is maintained and whose line of gravity falls within the base of support; (B) balance is not maintained when the line of gravity falls outside the base of support; and (C) balance is regained when the line of gravity falls within the base of support.

Figure 3.2.1 Centre of gravity

Principles of Body Mechanics

Table 3.2.1 describes the principles of body mechanics that should be applied during all client-handling activities.

Table 3.2.1 Principles of Body Mechanics

Action	Principle
Evaluate the environment.	Evaluate the weight of the load before lifting, and determine if assistance is required.
Plan the move.	Plan the move: gather all supplies and clear the area of obstacles.
Avoid stretching and twisting.	Avoid stretching, reaching, and twisting, which may place the line of gravity outside the base of support.
Ensure proper body stance.	Keep stance (feet) shoulder-width apart. Tighten abdominal, gluteal, and leg muscles in anticipation of the move. Stand up straight to protect the back and provide balance.
Stand close to the person or object being moved.	Place the weight of the object being moved close to your centre of gravity for balance. Hold objects close to your centre of gravity. When you are about to transfer, remain as close as possible to the object or person you are assisting. Use the long and strong muscles of arms and legs, not the back muscles. Figure 3.2.2 Hold objects close to your centre of gravity Figure 3.2.3 Note the caregiver’s centre of gravity and proximity to the client
Face direction of the movement.	Facing the direction of the movement prevents abnormal twisting of the spine.
Avoid lifting.	Turning, rolling, pivoting, and leverage require less work than lifting. Do not lift if possible; use mechanical lifts as required. Encourage the client to help as much as possible. Note: Many agencies have “no lift” policies.
Work at waist level.	Keep all work at waist level to avoid stooping. Raise the height of the bed or object if possible. Do not bend at the waist.
Reduce friction between surfaces.	Reduce friction between surfaces so that less force is required to move the client. Special sliding sheets can be used to ease client transfers or positioning.
Bend the knees.	Bending the knees maintains your centre of gravity and lets the strong muscles of your legs do the lifting.
Push the object rather than pull it, and maintain continuous movement.	It is easier to push an object than to pull it. Less energy is required to keep an object moving than to stop and start it.
Use assistive devices.	Use assistive devices (gait belt, slider boards, mechanical lifts) as required to position clients and transfer them from one surface to another.
Work with others.	The person with the heaviest load should coordinate all the effort of the others involved in the handling technique.

Maintaining Proper Body Mechanics

• When standing, keep your feet about hip width apart (about 30 cm [12 inches]). This provides a strong base of support and balance for you to work.
• Always bend at your hips and knees when lifting or stooping instead of bending at the waist and overextending your back.
• Use the larger and stronger muscles of your thighs, hips, shoulders, and upper arms while bending or lifting objects. This protects your back and smaller muscles from injury.
• Hold heavy objects close to your body when lifting or carrying them.
• Turn your entire body, including your head and legs, toward the care activity you are doing, rather than twisting.
• Remember good posture. Keep your back and trunk straight and aligned with your hips and your head facing forward toward the direction you are working. This prevents twisting, which increases your risk of injury.
• Always raise the bed to waist height when working with a client who is in bed, or when making a bed. This prevents unnecessary bending of your back.
• When pushing, place one leg forward. When pulling, move one leg back. This provides you with a stronger and more stable base of support than if both legs were next to each other.
• Whenever possible, have another person help you with lifting, rolling, or moving clients.
• Have others help you with lifting or moving heavy objects.
• Do not perform care activities that will be physically dangerous to you, or for which you may not physically be capable.
• Keep in mind that when moving a client, the path or direction in which you are moving must be clear of objects that could get in the way and cause potential injury.
• Always lock the brakes on the bed and wheelchair before transferring a client. This prevents the bed or wheelchair from moving and causing potential injury to you or the client.

Client Handling Injury Prevention

Health care providers experience musculoskeletal injuries (MSI) when the physical demands of the care activity exceed the physical capabilities of the worker, resulting in strain or sprain-type injuries. Understanding the risk factors, the early signs, and symptoms of injury, and the work procedures that control or minimize the risks will help keep you, the HCA, safer at work.

The role of an HCA is hard work. You may know many caregivers who were injured during work; some never returning to the job they love and are well-trained to perform. Some of the care activities required to care for clients can be physically demanding. This can make it difficult to provide care while being careful with your body. However, it is important for you to remain healthy and safe at work.

Moving and assisting clients is not like moving boxes — which have convenient handles and behave predictably. When assisting a client during care routines, HCAs develop a relationship with that person, which can interfere with the ability to be objective about the risks involved. Being able to quickly and accurately observe and evaluate the client’s ability to participate, being mindful of the risk factors, knowing the available transfer options and equipment, and being aware of your own abilities helps to reduce the likelihood and consequences of injury. The prevention of MSIs often requires changing work practices and redesigning job duties.

Being a health care provider puts you at high risk of injury. As a result, employers place a high priority on maintaining a safe work environment for employees while providing quality client care. For example, employers may implement “no manual lifting” policies and programs to keep everyone safe. The no-lift model of care approach seeks to reduce unnecessary risk and introduces and promotes safer ways of moving and assisting clients while providing high-quality care. A program for the prevention of client-handling injuries should have management commitment and support, proper and safe client-handling equipment, equipment maintenance, employee training, advanced training for resource staff, and offer a shared ownership approach to safe client handling (Interior Health, 2011; Workers Compensation BC, 2008).

Musculoskeletal Injury (MSI)

Figure 3.2.4 A type of MSI is a torn rotator cuff.

MSI has been defined as an injury or disorder of the muscles, tendons, ligaments, joints, nerves, blood vessels or related soft tissue, including a sprain, strain, and inflammation that may be caused or aggravated by work (Workers’ Compensation Board of British Columbia, 2009).

Workers may notice pain, numbness, tingling, or weakness while on the job.

Sometimes pain is just a part of a person’s everyday life, and can be ignored. Other times, it can be a result of an injury or disease. To decrease the chances of injury or disease, it may be necessary to reduce exposures to physical movements at work that have the potential to place you, the HCA, at risk of injury (like strain) or disease (like tendinitis or carpal tunnel syndrome). It is important to note that each individual’s response to a physical exposure is different. The human body was designed to be active, so eliminating all physical activity is also unhealthy (Workers’ Compensation Board of British Columbia, 2009).

It is important for you and your employer to recognize the signs and symptoms that could indicate an MSI. Signs that can be observed include swelling, redness, and/or difficulty moving a particular body part. Symptoms that can be felt but not observed include numbness, tingling, and/or pain. Signs and symptoms of MSI may appear suddenly — from a single incident, for example — or appear gradually over a longer period, from repetitive movements. If you are experiencing signs or symptoms of MSI, inform your supervisor and report to the first aid attendant (if there is one) or see a health care provider. An MSI may be treated more effectively if it is discovered and reported early (Workers’ Compensation Board of British Columbia, 2009).

Potential Health Effects

An MSI can affect your ability to perform duties and activities at work and at home. Early signs or symptoms of MSIs can progress into conditions such as the following, which can have long-term effects:

• Muscle strains to the neck, back, shoulders, or legs

• Tendinitis (swelling of a tendon, which is a band of tissue that attaches muscle to bone)

• Carpal tunnel syndrome (pressure on a nerve in the wrist, resulting in numbness, tingling, pain, or weakness in the hand, wrist, or forearm)

Such effects generally occur due to the physical demands of some care activities. These care activities include force (lifting, pulling, or gripping an object); repetition (lack of rest or variation in muscle use, or when learning a new care activity); work posture (awkward position, reaching overhead, or twisting); and local contact stress (tools or edges digging into the hand or wrist). The amount of risk from these effects depends on how long and often you do the care activity in a given day over time.

Example:

An HCA repeatedly bends over low-positioned beds to give care.

Figure 3.2.5 Poor body mechanics

Table 3.2.2 lists risk factors that contribute to MSI.

MSI Prevention

As the saying goes, “Prevention is the best medicine.” As a health care worker, you are in the best position to understand the demands of the job, recognize the risks, and prevent MSI. If you experience or see unsafe working conditions or equipment, you should report them immediately to your supervisor, so changes can be made to eliminate or minimize risk.

MSI Treatment

If you experience any strain or other injury, report it as soon as you are able. Treatment will vary according to the type of MSI. Treatment can include the application of cold or heat, medication, physical therapy, and even surgery. An MSI may be treated more effectively if it is discovered and reported early. (Workers’ Compensation Board of British Columbia, 2009)

Figure 3.3.1 Back Pain

There are many resources available to help you stay safe at work. Back Talk: An Owner’s Manual for Backs from WorkSafeBC (2014) is an especially useful resource for Health Care Assistants. It provides information about the care and maintenance of your back.

Chapter 3 Attributions and References

Image Attributions

• Figure 3.2.1 Centre of Gravity by Doyle and McCutcheon (2015), via Wikimedia Commons, is used under a CC BY 4.0 licence.
• Figure 3.2.2 Equilibrium Principle image on Table 3.2 Principles of Body Mechanics from Doyle and McCutcheon (2015) is used under a CC BY 4.0 licence.
• Figure 3.2.3 Home Care Transfer Pivot by BruceBlaus, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.
• Figure 3.2.4 Torn Rotator Cuff by Nucleus Communications, via Wikimedia Commons, is used under a CC BY SA-4.0 licence.
• Figure 3.2.5 Poor body mechanics by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• Figure 3.3.1 Back pain by David Cross, via Flickr, is used under a CC-BY-NC-SA 2.0 licence.

Video

• The benefits of good posture – Murat Dalkilinç, by TED-Ed (2015) is licensed under a Standard YouTube License.

References

Berman, A., & Snyder, S. J. (2016). Skills in clinical nursing (8th ed.). Pearson.

Interior Health Authority (2011). Safe patient handling. Patient handling injury prevention program. http://www.interiorhealth.ca/information.aspx?id=12726&terms=injury+prevention

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing skills and techniques (9th ed.). Elsevier-Mosby.

Registered Nursing. (n.d.). Ergonomic principles: NCLEX-RN. https://www.registerednursing.org/nclex/ergonomic-principles/

TED-Ed. (2015, July 30). The benefits of good posture – Murat Dalkilinç (Video). YouTube. https://www.youtube.com/watch?v=OyK0oE5rwFY

Thomas, D., McMahon, A., & Thomas, Y. L. (2012). Figure 4.1 [image]. In Moving and handling guidelines 2012 (p. 88). Accident Compensation Corporation/ACC New Zealand. http://www.acc.co.nz/assets/provider/acc6075-moving-and-handling-people-guidelines.pdf

Workers’ Compensation Board of British Columbia (2009). Understanding the risks of musculoskeletal injury (MSI); An educational guide for workers on sprains, strains and other MSI’s. (pp. 1–3). Workers’ Compensation Board of B.C. https://www.worksafebc.com/en/resources/health-safety/books-guides/understanding-the-risks-of-musculoskeletal-injury-msi-an-educational-guide-for-workers-on-sprains-strains-and-other-msis?lang=en

WorkSafeBC. (2008). Understanding the risks of musculoskeletal injury (MSI): An educational guide for workers on sprains, strains, and other MSIs. http://www.worksafebc.com/publications/Health_and_Safety/by_topic/assets/pdf/msi_workers.pdf.

WorkSafeBC. (2013). Preventing musculoskeletal injury (MSI). http://www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/msi_employers.pdf.

WorkSafeBC. (2014, December). Back talk: An owner’s manual for backs [PDF]. https://www.worksafebc.com/en/resources/health-safety/books-guides/back-talk-an-owners-manual-for-backs?lang=en

Daily Personal Care

When you work as a Health Care Assistant, much of the time is spent assisting clients with personal care activities that they are no longer able to do on their own. Most people are used to taking care of their personal needs and privacy, so the loss of this independence is often difficult for clients to accept. When you are caring for clients, allow them to do as much of their own care as they are able, respect their sense of modesty, and try to avoid any embarrassment to them. When you give personal care, give it in a pleasant, efficient way and don’t physically expose the client any more than is absolutely necessary. Some clients need only a minimal amount of help; others are totally dependent on you.

People may require personal care for a variety of reasons. Assistance with personal care may be temporary while a person recovers from an injury or illness, or it may be permanent and required for the remainder of their lives.

Types of Patients/Clients Who May Need Personal Care

HCAs provide personal care to a range of patients/clients, including:

• Patients/clients recovering from an illness or accident
• Patients/clients with a long-term chronic condition (e.g., heart failure, diabetes, HIV/AIDS)
• Frail patients/clients or those of advanced age
• Patients/clients who are permanently disabled
• Patient/clients who are dying

Providing personal care is a priority for the HCA. It is the most important care activity they do. Personal care provision demonstrates to the client that you are concerned about their physical health and general well-being.

Care activities are divided into two types:

• Tasks: care activities that HCAs are educated and trained to perform as part of their assigned HCA role.
• Restricted activities: higher-risk care activities outlined in health professional regulations that an HCA cannot perform without authorization (delegation) by a regulated health professional, such as a registered nurse. Restricted activities are not considered HCA tasks.

This unit explores the importance of providing personal care, and provides instruction for performing tasks related to personal care. The importance of infection control and how HCAs can work to break the chain of infection to keep clients healthy is discussed. Bathing, oral care, dressing/grooming, and toileting are topics reviewed in this unit, with an explanation of how HCAs can help with these types of tasks.

An essential, but often overlooked part of daily personal care is oral hygiene. It involves cleaning of the client’s mouth, and teeth or dentures. Oral hygiene removes debris (which can harbour microorganisms), stimulates circulation, reduces unpleasant odours, and improves the tastes of foods.

Depending upon your client, you may only need to assist them with oral hygiene, or you may need to provide total oral hygiene care. Performing or assisting with oral hygiene is an important task of the HCA. Oral hygiene should be performed at least twice per day, with morning and evening care. Oral hygiene may also be performed after eating meals and any time the client requests. Regular, daily flossing helps remove plaque and food debris, which promotes bacteria, from the client’s mouth. Unclean mouths harbour bacteria, which can cause additional health problems for the client. Having a clean mouth promotes a sense of comfort and self-esteem for the client, and improves the overall taste of food.

Providing oral care also gives HCAs an opportunity to observe the health of the client’s teeth, gums, and tongue. HCAs should encourage their clients to independently perform as much of their oral care as possible. For clients who are unable to grasp the handle of a toothbrush, special toothbrushes may be available for them. A split rubber ball or tape can be used to build up the handle of the toothbrush to make it easier for the client to hold. An electric toothbrush may also be used. Avoid using hydrogen peroxide or alcohol-based products, because they promote mouth irritation and mucosal membrane breakdown. For some clients, using a toothbrush may be unsafe, such as those who are unable to spit or who are unconscious. For these patients, special mouth swabs are available for use. Oral care should be provided every 2 hours for clients who are unconscious or unable to drink. Apply a moisturizing ointment, such as a lip balm, to the client’s lips to prevent skin breakdown, chapping, and drying of the lips.

Assisting Clients with Oral Hygiene

Table 4.2.1 Procedure: Patients Who Can Brush Their Own Teeth or Need Some Assistance

STEP	ACTION	REASON/CONSIDERATIONS
1.	Explain the procedure to the client. Provide privacy.
2.	Wash and dry hands. Always wear gloves when providing oral care.
3.	Assemble equipment. You will need: emesis basin water cup toothbrush toothpaste mouthwash a towel	Figure 4.2.1 Dental supplies
4.	Ensure the client is in an upright position for safety. If the client is able to brush their own teeth, provide equipment and assist as needed.	A high sitting position prevents choking or aspiration.
5.	Wet the toothbrush and apply a small amount of toothpaste to the bristles on the brush.
6.	Hold the toothbrush at a 45-degree angle to the gum line. Brush one tooth at a time in an up-and-down motion. Start from the top of the gum line and work down the tooth.
7.	Start at the upper teeth and then complete the lower teeth.
8.	To clean biting surfaces of teeth and the tongue, use a back-and-forth motion.
9.	Be sure to brush all surfaces of the teeth, gums, tongue, and mouth.
10	Ensure the client adequately rinses their mouth with clean water and dries their lips and face.
11.	Offer lip and/or mouth moisturizer as needed, and according to the client’s preferences.

Patients Who Are Unable to Perform Mouth Hygiene Independently

Table 4.2.2 Procedure: Patients Who Are Unable to Perform Mouth Hygiene Independently, Such as an Unconscious Client

STEP	ACTION	REASON/CONSIDERATIONS
1.	Explain the procedure to the client. Provide privacy.
2.	Complete hand hygiene and assemble needed equipment. Always wear gloves when providing oral care.
3.	Assemble equipment. You will need: emesis basin water cup two toothbrushes, to help hold the mouth open and the other to brush mouth swab wooden tongue blade gauze toothpaste mouthwash moisturizer towel lip and mouth moisturizer
4.	Put the client in a side-lying position. Turn their head to the side.	To prevent possible choking or aspiration.
5.	Place a towel or waterproof pad under their cheek and chin to prevent the client or bed linens from getting wet.
6.	Place an emesis or kidney basin against the side of their mouth and cheek.	To catch liquid and secretions.
7.	Open the client’s mouth by placing gentle pressure on their chin and upper mouth. Use a second toothbrush, such as the type in Figure 4.2.1, or place a padded tongue depressor to help keep the client’s mouth open and prevent them from biting down. To make a padded tongue blade, place two wooden tongue blades together. Wrap gauze over the top half and tape it into place.	Never put your fingers inside a client’s mouth because the client may bite down, even if they do not mean to. Figure 4.2.2 “Open wide!” Two toothbrush techniques
8.	Brush teeth gently, using a dry toothbrush or a mouth swab. Dip the swab in water and squeeze the excess solution from the swab. Swab all surfaces of their teeth, gums, inside their cheeks, the roof of their mouth, and their tongue. Use clean swabs as necessary.	Suction excess secretions as directed in the care plan.
9.	Rinse the client’s entire mouth with a clean swab. Ensure there are no pooled secretions.
10.	Ensure the client’s mouth, face, and neck are dry.
11.	Apply moisturizer to lips and/or mouth.
12.	Return the client to a comfortable position. Lower the bed to its lowest height and raise the side rails.
13.	Put away your equipment and supplies.
14.	Remove your gloves and wash and dry your hands.
15.	Document the completion of the task and record any changes in condition or behaviour. Report any tooth or mouth conditions observed, such as sores, open areas, or bleeding from gums, tongue, or broken teeth.

Denture Care

Table 4.2.3 Procedure: Dental Care

STEP	ACTION	REASON/CONSIDERATIONS
1.	Explain the procedure to the client. Provide privacy.
2.	Complete hand hygiene. Always wear gloves when providing oral care.
3.	Assemble needed equipment: gauze pad or washcloth water denture cup denture cleaning produce toothbrush toothpaste mouth swab mouthwash denture cream or adhesive lip and mouth moisturizer	Figure 4.2.3 Types of partial dentures
4.	Assist the client to remove dentures, if needed, by placing a tissue, gauze pad, or washcloth underneath the client’s denture line and gently pulling forward to break the suction. You may need to gently rock the dentures from side to side or forward to break the suction.
5.	Carefully place dentures in a water filled cup or container.	Figure 4.2.4 Denture container (be sure to wear gloves)
6.	Carry the dentures to the sink using a denture cup to prevent accidental breakage.
7.	Place a towel in the sink while you are washing them. Hold them firmly.	This will prevent you from accidentally breaking dentures on the hard surface of the sink.
8.	Clean dentures as you would teeth. Use denture cleaning products. Use warm, but not hot, water. Rinse dentures completely.	Hot water can cause dentures to warp and no longer fit the client correctly. Figure 4.2.5 Denture care
9.	Provide or assist with mouth care prior to replacing dentures. Assist the client to brush their gums and tongue with toothpaste and a toothbrush. Ensure they rinse their mouth completely. Offer alcohol-free mouthwash.
10.	If returning dentures to the client’s mouth, apply denture cream or adhesive, as needed.
11.	Assist the client to place the dentures back in their mouth. To reinsert dentures, insert at an angle, pressing firmly onto the gum line.
12.	If storing dentures, store them in clean, cool water in a container with a closed top.	To prevent accidental breaking or misplacement. If in a facility, ensure the client’s name is on the denture cup to prevent loss or confusion.
13.	Remove your gloves. Wash and dry your hands.
14.	Document the completion of the task and record any changes in the client’s condition or behaviour. Report any tooth or mouth conditions you’ve observed, or if dentures are broken or missing.

 Flossing Your Client’s Teeth

Table 4.2.4 Procedure: Flossing

STEP	ACTION	REASON/CONSIDERATIONS
1.	Explain the procedure to the client. Provide privacy.
2.	Complete hand hygiene. Always wear gloves when providing oral care.
3.	Assemble needed equipment. If assisting with flossing, break off about 45 cm (18 inches) of floss. Wind ends of floss around your pointer or middle finger. Wrap the other end of the floss around the same finger on the opposite hand. Or use a dental flosser (see Figure 4.2.6), as this may be easier to use.	Figure 4.2.6 Dental flossers
4.	Hold the floss tightly between your thumb and forefingers. Starting at the top and back of the mouth, guide the floss between two teeth. Use a gentle rubbing motion to guide the floss between the teeth.	Do not quickly snap the floss between the teeth, or you can cause pain or injury.
5.	Once you reach the gum line, curve the floss into a C shape against one tooth. For upper teeth, move the floss away from the gum line with a gentle downward motion against the tooth. For lower teeth, use an upward motion against the tooth, away from the gum line.
6.	Repeat for each tooth, using a clean section of floss for every one to two teeth.
7.	Allow the client to rinse and dry their mouth. Dispose of floss. Do not reuse floss.
8.	Remove your gloves. Wash and dry your hands.

Personal hygiene care is provided in both supportive care facilities and in a client’s home. Personal hygiene care includes the basic personal hygiene that is done either by the client or by the HCA every morning and evening.

The skills outlined below describe personal hygiene in a supportive care facility. It can, of course, be adapted to provide care in the home. When doing personal hygiene care (often referred to as morning or A.M. care, and bedtime or P.M. care) you usually do not give the client a full bath. The areas that are washed, rinsed, and dried are:

• Face including eyes, neck, and behind the ears
• Axilla (underarm area) and under breasts
• Hands
• Back from neck to lower back
• Perineal (genital) area

Bathing

Assisting a client with regular bathing is important for their health and for promoting self-esteem and healing. Clients who are recovering from an injury or illness, who have a chronic condition, who are permanently disabled, who are dying, or who are frail, may require assistance for performing this essential task (Sorrentino, et al., 2019; Taylor, et al., 2001). This is an important part of the job of an HCA. The care plan will direct the HCA as to the frequency and type of bath that should be performed. At minimum, a client should have their face, underarms, under breasts or folds, hands, and genital areas cleansed daily in the morning and evening.

Providing personal care gives HCAs an opportunity to observe and communicate with clients (Sorrentino, et al., 2019). Covering the areas to be washed with the bath blanket or towel maintains warmth and dignity. Providing personal hygiene care gives the HCA the opportunity to observe the client’s skin condition by uncovering and observing each area as you wash. The HCA should observe the client’s skin for changes in colour, temperature, swelling, new bruises, open areas, red areas, or sores. These should be documented and the supervisor informed.

Health Care Assistants should always encourage the client to perform any personal hygiene task they are able to, and help as needed. Some clients are able to bathe or shower independently, or with minimal assistance. Some clients will require total care, meaning the HCA will have to provide their personal hygiene care completely (McLain, et al., 2018). If a client is immobile, weak, or frail, bed baths should be provided instead of risking a fall in a bathtub. Never allow a weak or frail client to stand in a shower alone. In these types of situations, a tub or bed bath may be more appropriate. The HCA can also shampoo the client’s hair in bed by using a shampoo tray or a no-rinse shampoo cap.

Clients have a right to refuse any treatment, including bathing. The HCA should educate the client about the importance of bathing and try to find out why the client does not want a bath. Sometimes, they may not want a bath at a particular time, but would be willing to have one at a later time. Document the reason for refusal and inform the supervisor (Sorrentino, et al., 2019; Taylor, et al., 2001).

When providing or assisting with a bath, the water temperature should be checked. The temperature should be no greater than 40°C. Allow clients to test the water temperature to determine whether it is comfortable for them. It is important, when providing or assisting with a bath, that the client is provided privacy (Sorrentino, et al., 2019; McLain, et al., 2018). This includes closing doors, drawing curtains, and limiting access to the area for others while the client is bathing. Towels, gowns, or bath blankets can be used to cover the client’s body, exposing only the body part being washed during bed baths. Sometimes allowing the client to get into the bath with their gown or shirt on will not only make the client feel comfortable, but will also make the bathing experience go more smoothly.

Providing a back rub after a bath, before bed, or anytime a client needs to relax is an important skill for the Health Care Assistant, but is often overlooked. This is an excellent way to teach a client how to relax, observe their skin, and promote good circulation. Giving a proper back rub is discussed later in this unit.

Instructions for providing a tub or shower bath, assisting with a transfer into and out of a tub, providing a bed bath, and providing a shampoo in bed are also discussed later in the unit.

Tub or Shower Bath

Table 4.3.1 Procedure: Tub or Shower Bath

STEP	ACTION	REASON
1.	Read the client’s care plan.
2.	Wash and dry hands according to proper handwashing guidelines.
3.	Assemble equipment needed: soap shampoo/conditioner washcloths towels personal items clean clothing	Good organization is time efficient.
4.	Ensure the bathroom is warm and comfortable. Take care that it is not too cold or too hot.	Client comfort.
5.	Remove any fall risk hazards, such as loose rugs, from the floor.	Safety.
6.	Place any safety devices in the tub or shower as needed (e.g., shower chair, rubber mats).	Figure 4.3.1 Shower chair
7.	Ensure safety items such as handrails and grab bars are in good working order. Immediately inform a supervisor if they are not.
8.	Turn on the water and test the water temperature using a bath thermometer. Water temperature should be no higher than 40°C. If providing a tub bath, fill the bath and test the temperature before putting the client in the tub.	To prevent scalding injury
9.	Allow the client to test the water temperature for their comfort. Adjust as needed.
10.	Assist the client to the bathroom. If the client is ambulatory, assist as needed to undress just before transferring them into the tub or shower. This prevents them from chilling.
11.	If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items, such as shower chairs and grab bars.	Tub baths, or very warm showers, can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of client discomfort, weakness, or complaints of feeling faint.
12.	If the client is standing to shower, stay in the bathroom and monitor the client’s need for assistance. If they are weak, always stay with them in the bathroom, providing privacy as possible.
13.	Never let a weak person stand to bathe or leave them alone in the bath. You can stay in the bathroom and draw the shower curtain to provide privacy. Communicate with the client frequently to let them know you are there to help.
14.	Water should be turned off, and the tub drained, before assisting the client to transfer out of the tub.

Partial Bed Bath

Health Care Assistants should always encourage the client to perform any personal hygiene task they are able to, and help as needed. Some clients will require personal hygiene care in bed because they are unable to move to the bath or shower. Providing a bed bath allows a client to receive personal hygiene care with minimal movement on their part. There are two types of bed baths: full and partial. A full or complete bed bath requires the care provider to clean the client’s entire body — head-to-toe. Whereas a partial bed bath is washing the important areas, such as the face, neck, axilla, hands, and peri-area. Perineal care (peri-care) involves cleaning the urethral meatus, vagina or penis, perineum (the area between the vagina or penis and the anus), and anal areas. Peri-care is critical as this area is prone to infection and must be cleaned daily, especially if the client is incontinent.

Table 4.3.2 Procedure: Personal Hygiene Care (Partial Bed Bath)

STEP	ACTION	REASON
1.	Read the client’s care plan.
2.	Call the client by their name. Introduce yourself and explain what you are going to do.	Minimizes embarrassment to the client by using clear and respectful communication.
3.	Wash your hands. Set up the environment and provide privacy. Make sure windows are closed and the room is warm enough. Assemble all supplies. For washing, you should have the following supplies ready: washbasin with warm water soap or peri-wash 2 large towels 2 washcloths clean gown 2 pairs of gloves, lotion	Good organization saves time.
4.	Raise the bed to working height.	Allows the use of correct body mechanics and protects you from back injury.
5.	Lower the bed rails nearest to you. Place the towel across the client’s chest.	Safety and client’s comfort.
6.	Make a bath mitt with the washcloth by folding it over your hand. Wet the bath mitt and squeeze out excess water. Keep access to the water basin close to prevent dripping water over the client.	Provides a thick, soft surface to wash with. Bath mitt Figure 4.3.2 Mitt technique
7.	Eyes Do not use soap. Wash from the inner eye by the nose outwards. Do this as often as necessary to cleanse the eye. Use a different part of the face cloth with each wipe. Rinse the cloth before proceeding to wash the second eye. Note: Many clients will have mucous crusting caked along the eyelashes. To remove this crusting, fold a warm wet washcloth and place it over the eyes for a few minutes. Remove the cloth and gently wash away the crusting using the procedure for washing the eyes.	Figure 4.3.3 Technique for washing the eyes
8.	Face, Head, Neck, and Ears Start with face, then wash forehead, neck, and ears (outer ear and behind ear). Wash, rinse and dry. Ask the client if they want to use soap on their face.	This follows the principles of asepsis (working from clean to dirty) to prevent the transfer of microorganisms. Many clients have dry skin and do not need soap on their faces. Soap will dry the skin more.
9.	Axilla and Breasts Remove gown. Cover chest with a towel. If there is no other cover, use gown to cover the client’s chest. Expose only areas to be washed. Observe skin for redness, rash, scratches, broken skin, Lift breasts to observe and wash. Wash, rinse and dry axilla and under breasts. Then wash under each arm.	Privacy, self-esteem. Always encourage independence and range of motion for joints.
10.	Hands Wash the client’s hands with a washcloth and dry thoroughly. If possible, it is desirable to soak the hands in a basin of water for comfort and thoroughness of cleansing. This can be done in bed with the basin placed on a towel, or with the client sitting up and the basin on the overbed table.	Putting the client’s hand in a basin of water is a more thorough way of washing the hand than just wiping it with a washcloth. It is also comforting and relaxing.
11.	Assist client to put on clean gown. Apply deodorant as desired by the client.	Self-esteem and comfort, as well as client comfort and privacy.
12.	Perineal Area See Perineal Care (4.4) for detailed information on perineal care.
13.	After completing perineal care, raise side rail. Empty and rinse wash basin and fill with clean water. Return to bedside and lower side rail. Turn the client on their side away from you.	For safety and medical asepsis.
14.	Back Place the towel along back on the bed. Wash, rinse, and dry from the nape of neck to lower back.	To prevent water dripping on bed linens to maintain medical asepsis.
15.	Back Massage Gently massage and check the entire back. Gently massage all bony prominences and pressure areas with non-prescription moisturizing lotion. Do not rub any reddened areas.	To promote self-esteem and comfort. Do not massage or rub hot reddened areas, as these may be the start of a pressure sore.
16.	Assist the client onto their back. Lower bed to lowest setting, return call bell. Open curtains.
17.	Clean area by placing dirty linen in hamper. Rinse the wash basin and return it and other items to the nightstand.	To maintain a tidy environment.
18.	Wash hands.	To maintain medical asepsis to prevent cross-contamination.
19.	Report and record observations to supervisor.

The perineum is the tiny patch of sensitive skin between the genitals (vaginal opening or scrotum) and anus, and it’s also the bottom region of the pelvic cavity. The perineum may refer to just the part of your body you can see (the skin in between your genitals and your anus). Some might refer the perineum as the perineal area, genital area, or the triangle area between the legs.

Perineal care (peri-care) is bathing the genitalia and surrounding area. Some clients may be embarrassed, but this is part of client care. It is important to maintain a professional, matter-of-fact attitude. As with all good caregiving efforts, remember to allow the client to do as much as they can on their own. You can start by providing the client with a wet washcloth, soap, and a towel and then instructing them to wash the perineal area. You may need to say it in simpler terms so they understand, such as, “I’ll give you a washcloth so you can wash between your legs or your private area.” Remind clients with uncircumcised penises to retract the foreskin to cleanse the penis.

Cleanliness of the genital area is an important part of everyone’s care, particularly if the client is having difficulty controlling bowel and bladder function. This procedure is part of personal hygiene care and must be done whenever the client is soiled or wet.

Perineal Care for a Client with a Vulva

This procedure should always be a part of A.M. care.

Table 4.4.1 Procedure: Perineal Care for a Client with a Vulva

STEP	ACTION	REASON
1.	With the client lying on their back, uncover the perineal area only.	Provides privacy and warmth.
2.	Put on gloves.	Medical asepsis to avoid contact with mucous membranes.
3.	Separate the labia and use a clean part of the washcloth for each stroke. Wash from urinary meatus down to perineum (from front to back) as many times as needed. Use a clean part of the washcloth for each stroke.	Figure 4.4.1 Perineal care on a client with a vulva Asepsis: Wash from top to bottom and clean to dirty to prevent cross-contamination.
4.	Wash down the labia minora and majora. Far then near, top to bottom. Rinse all areas well, using a clean part of the cloth for each stroke.
5.	Wash across supra-pubic area (far to near). Wash groin, starting on the farthest side, including the upper and inner thigh (top to bottom). Rinse and dry all areas well.
6.	Turn the client on their side facing away from you.
7.	Wash and rinse buttocks.
8.	Wash anus using a “J stroke” action. Then rinse using a corner of the towel or a fresh washcloth.	Asepsis. Do not rinse or place the washcloth in the basin after washing the anal area.
9.	Dry buttocks then dry anus.
10.	Remove gloves.
11.	Wash hands or use hand sanitizer.

Perineal Care for a Client with a Penis

This procedure should always be a part of A.M. care.

Table 4.4.2 Procedure: Perineal Care for a Client with a Penis

STEP	ACTION	REASON
1.	With the client lying on their back, uncover the perineal area only.	Provides privacy and warmth
2.	Put on gloves.	Medical asepsis to avoid contact with mucous membranes.
3.	Draw back foreskin, if uncircumcised. Wash the head of the penis from the urinary meatus outward in a circular motion, using a clean part of the cloth for each stroke. Rinse well using the same method. Return the foreskin.	Figure 4.4.2 Perineal care for a client with a penis Principles of asepsis: wash from near to far and top to bottom to prevent cross-contamination.
4.	Wash shaft of penis from head of penis toward the body, using a clean part of the cloth for each stroke.	To prevent cross-contamination.
5.	Wash down the upper surface of the scrotum.
6.	Wash across supra-pubic area. Wash groin starting on farthest side, including upper and inner thigh. Rinse and dry all areas well.	Principles of asepsis: wash from near to far and top to bottom to prevent cross-contamination.
7.	Turn the client on their side facing away from you.
8.	Wash and rinse the buttocks.
9.	Wash the anus using a “J stroke” action. Then rinse using a corner of the towel or a fresh washcloth.	Asepsis. Do not rinse or place the washcloth in the basin after washing the anal area.
10.	Dry buttocks, then dry the anus.
11.	Remove gloves.
12.	Wash hands/use hand sanitizer.

Additional Notes and Adaptations for Perineal Care

If the client is very difficult to turn or finds it painful to turn, you can use an adaptation to personal hygiene care and perineal care.

After washing the face, axilla, and hands, you may then wash the perineal area. You then remove your gloves, change the wash water, and obtain a new washcloth and towel. Then position the client on their side (Sim’s position), wash their back, and then put on new gloves and wash the anal area. By doing hygiene care in this sequence, you reduce the number of times you must turn the client, but you are still following all the principles of asepsis.

If the client wears an incontinent brief, you can then put that on while the client is on their side. Fanfold one side of the brief and tuck it under the client. Check for correct placement of the brief. It should cover their buttocks and groin area. The top part of the brief will be about 2.5–7.5 cm (1–3 inches) above their buttocks. Roll the client to the other side. Let them know they will feel a “bump” from the brief as they roll over it. Ensure the bed rails are up. Move to the other side of the bed. Pull the other half of the brief from under the client. Assist the client back to the supine position (client is lying on their back). Pull the brief up between their legs. Peel tape from tabs and fold each side inward toward the front. Secure tape to the front of the brief.

Back rubs can conveniently be given after baths, before bedtime, or after repositioning. Back rubs help boost relaxation, stimulate circulation, and promote sleep. Back rubs do not need to be long, and typically take about 5 minutes of your time. Always ensure it is okay to provide a back rub. Health Care Assistants must check with their supervisor and check the care plan. Again, giving a back rub gives the HCA the opportunity to observe skin condition for rashes, bruises, red, white, or open areas, and other signs of skin breakdown. Always report and record observations of any changes in skin condition.

Purpose for Giving a Back Rub

• To give comfort
• To stimulate blood circulation
• To promote rest and sleep
• To prevent pressure sores
• To observe the skin condition
• To relax and relieve tension in tissues and muscles
• To refresh the client and relieve fatigue

General Instructions for Giving a Back Rub

• Back care is given as a part of A.M. care and P.M. care.
• When giving a back rub, use more pressure (gentle) on the upward strokes towards the head and less pressure on the downward strokes.
• Back rubs may be contraindicated in clients susceptible to clotting disorders — check with the supervisor.
• Do not take your hands off of the client’s back until the end of the procedure.
• Stop the back rub if, at any time, the client reports discomfort or no longer wishes you to continue.

Table 4.5.1 Procedure: Back Rub

STEP	ACTION	REASON
1.	Explain the procedure and position to the client.
2.	Perform hand hygiene and gather all supplies.	Good organization is time efficient.
3.	Adjust bed to a comfortable height.	Prevent back strain and injury.
4.	Provide privacy and adjust the light, temperature, and sound in the room.	Client comfort.
5.	Lower the side rails and help the client assume a prone or side-lying position (Sim’s position).
6.	Expose the client’s back, shoulders, upper arms, and buttocks, and cover the remainder of the body.
7.	Use lotion that has been warmed in a basin of warm water, or by running the bottle under warm water for a few minutes.	Do not heat lotion in the microwave. Rationale: It may explode or be too hot and burn the skin.
8.	Place a small amount of lotion in your hand, and rub your palms together to warm the lotion and lubricate your hands. Caution the client that the lotion may still feel cool.	This lubricates your hands during the back rub, and helps warm the lotion so the client does not feel too cold.
9.	Apply both hands to the sacral area (the lower back), applying gentle pressure moving upward along each side of the spine. Massage in a circular motion, strokes moving upwards from buttocks to shoulders, and then back down the outer part of the back (see Figure 4.5.1).	Use gloves only if you or the client have any open cuts, wounds, or sores to prevent infection.
10.	Continue this massage pattern for about 2–3 minutes.
11.	You may change the pattern to small circular motions, either making a circular movement moving upward along the spine and outward from the spine, and laterally alongside the back, down to the iliac crest (hip) or downward and inward toward the spine (see Figure 4.5.1)
12.	Continue this massage pattern for about 2–3 minutes.	Figure 4.5.1 Back rub motions
13.	When you are almost done with the back rub, let the client know so they are prepared for the ending of their back rub.
14.	Wipe away any excess lotion. Assist the client with dressing. Position the client for comfort.
15.	Lower the bed to its lowest setting. Ensure the side rails are up.
16.	Put away equipment and supplies. Dispose of any dirty linens.
17.	Wash and dry your hands.
18.	Document the client’s response and record any changes in condition or behaviour.

Shaving facial hair may help a client feel good about themselves and helps them to maintain their appearance in the way it was prior to becoming unable to provide their own care. It also helps the client to appear familiar and well-cared to their family and friends, which can be comforting during periods of illness. What is not often highlighted is that some women may also need shaving. As women age, excess hair may appear on their upper lip and chin, and they or their family may wish to have these areas shaved.

Remember to always allow the person to do the shaving if they are able to. The HCA can help by preparing the items they will use for shaving. You can also hold up the hand mirror or provide extra light so they can see better. However, before shaving a client, HCAs should obtain their consent. Inquire about their preferences as they will have a certain way based on years of shaving routine (starting on the neck vs. starting with the sideburns), and ask what types of products they like. Always wear gloves during shaving due to the risk of bleeding. While consideration is given for the type of razor a client prefers, electric razors are most often used in care facilities due to the risk of injury from manual razors and the fact that some clients are on medication or have conditions that put them at a higher risk of bleeding. So it is always important to check the care plan to ensure that the client can be shaved with a razor that has a blade. Shaving cream should always be used with safety razor blades. Shaving cream is not to be used when using an electric razor. Never share or use someone else’s razor on a client, as blood-borne diseases can be spread this way due to the possibility of blood on the client’s razor.

Table 4.6.1 Procedure: Shaving the Client

STEP	ACTION	REASON
1.	Explain the procedure to the client.
2.	Wash and dry your hands. Always wear gloves when shaving.
3.	Assemble equipment, for example: safety razor/electric razor shaving cream washcloths towels, basin with water lotion aftershave
4.	Provide privacy and comfort to the client. If the client is in a bed, adjust the bed to a safe working height. Lock the brakes. If the client is sitting in a wheelchair, ensure the brakes are on.
5.	Place a towel under client’s chin, covering their shoulders and the front of their chest.
6.	If the client is able to shave independently, place all equipment and supplies within reach and help as needed. Ensure safety razor blades are sharp.	A dull blade can irritate the skin and increase the risk of cuts and bleeding.
7.	Wash the client’s face with warm water, leaving the area to be shaved wet. You can leave a warm towel on the client’s face and neck for several minutes to help soften their hair. If using an electric shaver, dry the client’s face after washing it.	This helps avoid cuts and makes for a smoother shave.
8.	Rub shaving cream into client’s beard and mustache if using a razor.	Figure 4.6.1 Using shaving cream or wet shaving provides a smoother shave. The shaving cream helps soften the skin and hair, and provides a smoother shave.
9.	Pull skin taut in the area to be shaved. Shave one area at a time.
10.	Shave using gentle, short strokes in the same direction. Shave in the direction of hair growth.	Figure 4.6.2 Man getting his beard shaved.
11.	Rinse the safety razor often. Apply shaving cream as needed. Ensure the water temperature does not get too cool while shaving. If using an electric razor, pull skin taut. If using a foil shaver (a single-head shaver, which is usually rectangular shaped), shave with smooth and even movements in an up-and-down direction along the line of hair growth. If using a three-head shaver (a shaver with three round heads set inside a triangle), shave in a circular motion. Make sure to shave the client’s chin and neck.
12.	Once shaving is complete, rinse and pat dry the client’s face. Offer a mirror so they can inspect the shave. Touch up any areas the client requests.
13.	If the client has cuts from shaving, blot the area with a gauze pad until it stops bleeding.
14.	Apply moisturizer and/or aftershave, per the client’s request and preferences. Avoid applying lotion or aftershave to irritated or cut skin.
15.	Ensure the bed is at its lowest height, and side rails are up.	Ensure safety.
16.	Remove your gloves. Wash and dry your hands.
17.	Document and report any cuts the client received during shaving and/or any skin conditions observed, such as red, irritated skin, broken skin, or pimples, boils, or cuts.

Shaving Underarms and Legs

To assist with shaving underarms and legs, follow the same procedures and guidelines as above. Shave leg hair from ankle to knee, using short, smooth strokes upward. Some clients also like to shave their knee to thigh area. Ask the client what their preference is. Apply shaving cream to legs or underarms prior to shaving. Ensure the razor used is sharp, not dull. Shave underarm hair in short, smooth strokes. Underarm hair can grow in all directions. Always shave in the direction of hair growth.

Providing hand, foot, and nail care for a client offers an opportunity for HCAs to observe the health of their client’s skin, nails, and the strength of their hands and feet. It also provides a sense of comfort and promotes self-esteem for the client.

While many clients may enjoy having their hands and feet cared for, take special care with clients who do not find it pleasurable. Additionally, some clients have sensitive feet and may be ticklish. You should always tell a client when you are going to touch their feet and inform them of what you are doing so that the client expects the touch.

HCAs may assist with hand and foot care tasks that are listed below. However, a regulated health professional, such as a registered nurse, must first assess the client before the HCA can be assigned to the following tasks:

• Observing for any changes and reporting to the supervisor
• Nail clipping for clients without chronic diseases or conditions like diabetes, swollen feet, compromised skin, or compromised nail integrity.
• Soaking, massaging, and applying lotion to hands and feet as per the care plan.

Clients with chronic diseases or compromised skin/nail integrity require special care from a podiatrist or specially trained nurse. While it is acceptable for HCAs to wash and inspect these clients’ hands and feet, they should never clip their fingernails or toenails (Sorrentino, et al., 2019; McLain, et al., 2018). Nail care should not be provided by HCAs for clients with the following chronic diseases and conditions:

• Diabetes or circulation problems
• Swelling in hands or feet
• Medications that affect blood clotting
• Fingernails or toenails that are weak, brittle, thick, or ingrown
• Infections, rashes, or skin damage in hands, fingernails, feet, or toenails

Make sure to follow directions from a supervisor and those written in the care plan for any nail care that is performed.

Hand and Nail Care​

Foot and Nail Care

For people living with physical or cognitive impairments, dressing and grooming tasks are often difficult to manage alone, and they might get frustrated because they cannot do what they once were able to do — they may take their frustration out on the people around them. As an HCA, you can help and encourage your clients to feel supported and capable. All your clients’ daily living activities should include basic personal grooming habits that enhance their well-being and self-esteem. When assisting with grooming and dressing, the HCA needs to understand the client’s needs, preferences, and their ability to carry out those tasks. Client diversity and individuality should be respected.

Grooming and getting dressed involves several steps and the use of many different skills. Sometimes caregivers forget that older adults, and those with cognitive impairments, find it challenging to carry out these steps. If the client becomes confused or frustrated, they may become irritable, uncooperative, or upset. Below are some strategies that you can use to help clients manage their grooming and dressing:

• Keep the environment calm and pleasant. Turn down, or turn off, any TV or loud music.
• Provide frequent, gentle reminders. This will help your client feel supported and capable.
• Find appropriate preferences. Consider what your client finds important in their clothes. For example, let the client wear their favourite colour.
• Use friendly conversation. This is a helpful and positive distraction technique to keep the client’s anxieties lower.
• Space out grooming tasks. Get clients to complete one thing at a time (allow them to wash their face before asking them to brush their teeth, for example).
• Simplify clothing choices. Putting out an outfit for the care receiver to wear, or give an option of only two outfits.
• Be flexible. Wearing a bra or pantyhose may not be important to them, especially if it’s an added stressor.
• Give time. Allow the clients to do as much as they can for themselves. For example, let the client put the sweater on and help with the small buttons.
• Consider easy-to-use clothes. Adaptive clothing may include large front fasteners (zippers or Velcro), elastic waistbands, and slip-on shoes.
• Minimize stress. If the person has a weak side, for example, put the painful or weak arm into a shirt, pullover, or jacket before the strong arm. When taking them off, take out the strong arm first.

Some clients may be prescribed by their doctor special compression or anti-embolism stockings to wear on their legs. Anti-embolism stockings help force blood in superficial veins of the legs to deeper veins, prevent stagnation of blood in the veins of the legs, and promote venous return to the heart (Sorrentino, et al., 2019; Taylor, et al., 2001). A physician’s order is required for their use. These types of stockings are used for clients with poor circulation, who have limited activity, or are at risk for getting a blood clot. They are also used to help prevent or reduce swelling.

Several manufacturers produce men’s and women’s stockings that apply pressure to the legs from the foot to mid-thigh or higher. Some apply mild pressure; others apply pressure equivalent to that of an elastic bandage. Anti-embolism stockings are made of elastic material and available in either knee-high or thigh-high length. They are also available in a variety of colours. Many people who are on their feet or remain in one position a great deal, such as HCAs, nurses, salespeople, and businesspeople, find them useful. The stockings should be fitted correctly to the person’s measurements.

Stockings should be placed on the client’s legs prior to the client getting out of bed in the morning, to prevent blood pooling in the lower legs which causes swelling (Sorrentino, et al., 2019; Taylor, et al., 2001). Follow the instructions written in the care plan for guidelines for when to apply, how long the client should wear these stockings each day, and when to remove the stockings. Anti-embolism stockings should always be removed during morning care, the legs inspected, and the stockings reapplied before the client is out of bed.

General Guidelines

• Apply the stockings in the morning before the client is out of bed and while the client is supine position (where client lies flat on their back, facing upward). Some stockings fit only the left or right leg. If the client is sitting or has been up and about, have them lie down with their legs and feet well-elevated for at least 15 minutes before applying the stockings. After the leg vessels are congested with blood, the effectiveness of the stockings is defeated.
• Do not massage the legs. If a clot is present, it may break away from the vessel wall and circulate in the bloodstream.
• Check the legs regularly for redness, blistering, swelling, and pain. Some people recommend checking the legs at least once every 8 hours; others recommend twice a day.
• The stockings should be removed completely once a day.
• Launder the stockings as necessary, but at least every three days, as soiled stockings irritate the skin.
• Always ensure there are no wrinkles in the stockings, as these can cause pressure sores to develop.

Table 4.9 Anti-Embolism Stockings Procedure

STEP	ACTION	REASON
1.	Explain the procedure to the client. Ensure they understand the importance of wearing these elastic support stockings. Seek guidance from a supervisor as needed, and report refusal to wear stockings.	Figure 4.9.1 Styles of stockings
2.	Wash and dry your hands.
3.	Assemble equipment, for example: support stockings lotion shoes
4.	If the client has been moving around out of bed, have them lie down with their legs elevated for 15 minutes before applying the stockings.	To decrease any accumulated blood in the lower extremities.
5.	Make sure legs are clean and dry. Observe skin for condition and changes, such as sores, swelling, and changes in colour. Make note of any observed changes and any client complaints, such as numbness, pain, or tingling in the lower extremities.	Allows you to advise your supervisor right away, as the client may require medical care.
6.	You may use powder or lotion on the client’s legs before applying the stockings.	This provides comfort to the client, eases the application of stockings, and protects the client’s skin.
7.	Raise the bed to waist height. Position client in the supine position.
8.	Apply stockings according to the care plan and as a supervisor directs.
9.	Place your hand and arm inside one stocking and turn it inside out up to the heel of the stocking. Grasp the heel of the stocking with your fingers of the hand holding the stocking. If the stockings do not appear to fit well and appear to be digging into the top of the client’s leg, inform a supervisor right away.	If the stocking does not fit well, the client may need to be refitted for the appropriately sized stocking.
10.	Move the stocking down over your arm so that the length of the stocking is now bunched near your hand.
11.	Carefully take the client’s foot and position the opening of the stocking that is near your hand over the client’s toes.
12.	Place the foot of the stocking over the client’s toes, then over the foot, then over the heel. Pull the stocking up slowly as you move it upwards over the client’s leg.
13.	Gently pull the top of the stocking up over the entire calf, smoothing out all wrinkles.	This helps to prevent skin breakdown.
14.	Make sure the heel of the foot is in the heel pocket of the stocking.
15.	If there are no toe openings, gently pull on the tip of the stocking by the toes to relieve pressure. For stockings with toe openings, the client’s toes should be positioned appropriately in the toe area.	To allow circulation to be readily observed.
16.	Repeat with the other leg.
17.	Discard gloves if you are wearing them, and wash your hands.	To prevent spread of infection.
18.	Report and record any changes in skin colour, temperature, swelling, sores on legs, and client complaints.

Chapter 4 Attributions and References

Unit 4.2 Image Attributions

• Figure 4.2.1 Dental Supplies from PxHere, is used under a CC0 Public Domain licence.
• Figure 4.2.2 Oral Health and Aging: Information for Caregivers, by the National Institute of Dental and Craniofacial Research (2019), is used under a CC0 Public Domain licence.
• Figure 4.2.3 Types of Partial Dentures from Authority Dental, is used under a CC BY 2.0 licence.
• Figure 4.2.4 Denture Container by Authority Dental, via Flickr, is used under a CC BY 2.0 licence.
• Figure 4.2.5 Cleaning denture with denture brush technical picture by Authority Dental, via Flickr, is used under a CC BY 2.0 licence.
• Figure 4.2.6 Turquoise dental floss sticks by Marco Verch, via Flickr, is used under a CC BY 2.0 licence.

Unit 4.3 Image Attributions

• Figure 4.3.1 Transfer Bench by Roger Mommaerts via Wikimedia Commons, is used under a CC BY-SA 2.0 licence.
• Figure 4.3.2 Mitt Technique by HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 license.
• Figure 4.3.3 Cleaning Eyes by HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 license.

Unit 4.4 Image Attributions

• Figure 4.4.1 Female Perineal Care by HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 license.
• Figure 4.4.2 Male Perineal Care by HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 license.

Unit 4.5 Image Attributions

• Figure 4.5.1 Back Rub Motions by T. Christianson, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.

Unit 4.6 Image Attributions

• Figure 4.6.1 Wet Shave by Lbeaumont, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.
• Figure 4.6.2 Photo of a man getting his beard shaved, by RODNAE Productions, from Pexels.com, is used under the Pexels License.

Unit 4.7 Image Attributions

• Figure 4.7.1 Person Getting a Nail File by RODNAE Productions, on Pexels.com, is used under the Pexels License.
• Figure 4.7.2 Pedicures by Amy the Nurse, via Flickr, is used under a CC BY-NC-ND 2.0 license.

Unit 4.9 Image Attributions

• Figure 4.9.1 Knee-high and thigh-high anti-embolism compression stockings by Lentpjuve, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.

Videos

• How to help with tooth brushing, by CareChannel (2019) [St. Elizabeth Foundation] is licensed under a Standard YouTube License.
• Denture Care (How to Care for Someone’s Dentures), by CareChannel (2019) [St. Elizabeth Foundation] is licensed under a Standard YouTube License.
• Chapter 1- Considerations for A.M. Care – BCcampus, written and produced by Chantal Lortie and Natasha Fontaine (2022), from Selkirk College and COTR, and licensed under a CC BY-NC 4.0 licence.
• Chapter 2- Before Beginning A.M. Care – BCcampus, also written and produced by Chantal Lortie and Natasha Fontaine (2022), from Selkirk College and COTR, and licensed under a CC BY-NC 4.0 licence.
• Personal Care – Health Care Playlist, watch the Personal Care (Chapters 3–10) videos, from BCcampus. These videos were written and produced by Chantal Lortie and Natasha Fontaine (2022), from Selkirk College and College of the Rockies (COTR), and licensed under a CC BY-NC 4.0 licence.
• Backrub Skills Demonstration by Frances Payne Bolton School of Nursing (2010) is licensed under a Standard YouTube License.
• Helping Someone Shave, presented by CareChannel (2019) [St. Elizabeth Foundation] is licensed under a Standard YouTube License.
• How to Care for Nails, presented by CareChannel (2019) [St. Elizabeth Foundation] is licensed under a Standard YouTube License.
• How to Help with Getting Dressed – Caregiver Tips, presented by the St. Elizabeth Foundation on YouTube CareChannel is licensed under a Standard YouTube License.
• How to Help with Compression Stockings – Tips for Caregivers by CareChannel (2019)is licensed under a Standard YouTube License.

References

McLain, K., Wade, A., & O’Hara-Leslie, E. (2018, April 27). Foundations for assisting in home care. SUNY Broome Community College. https://textbooks.opensuny.org/foundations-for-assisting-in-home-care/

National Institute of Dental and Craniofacial Research (2019, July). Oral health and aging: Information for caregivers [PDF]. National Institute of Health/ US Government. https://www.nidcr.nih.gov/sites/default/files/2019-09/oral-health-aging-brushing.pdf

Open Learning Media. (2012). HCA program [Digital images]. Thompson Rivers University.

Sorrentino, S., Remmert, L. N., & Wilk, M. J. (2017). Mosby’s Canadian textbook for the support worker. Elsevier (4th ed.) Elsevier Canada.

Taylor, C., Lillis, C. & LeMone, P. (2001). Fundamentals of nursing: The art and science of nursing care. Lippincott, Williams & Wilkins.

A well-made bed is an essential contribution to the client’s feeling of well-being. Comfort and appearance of the bed are important, and the Health Care Assistant must be able to make a bed that is neat and free of wrinkles. Most beds found in health care facilities can be adjusted to suit the client’s needs and comfort.

Hospital beds can be adjusted into various positions based on the client’s needs, diagnosis, or condition. It is important to know these common bed positions, so that you can effectively communicate with the health care team.

Fowler’s Position 

The standard client position is the Fowler's position, where the client is in a semi-upright seated position, at about a 45–60-degree angle, with the knees either bent or straight. This position is considered standard because it allows the client’s abdominal muscles to relax, making it easier to breathe and eat. It is frequently used for clients with oral or nasal gastric feeding tubes because it minimizes the risk of aspiration. In addition, peristalsis and swallowing are aided by the effect of gravitational pull. This is a common position to provide client comfort and care.

High Fowler’s position is used to describe a client’s position, where the upper body is positioned approximately 60–90 degrees in relation to the lower body. This position may be used while you assist a client to eat when they are at risk for choking and aspiration.

Figure 5.2.1 Fowler’s position

Semi-Fowler’s

The client sits at a 30–45-degree angle. Semi-Fowler's position is slightly lower than the Fowler’s position. It can also be used for clients with a feeding tube.

Figure 5.2.2 Semi-Fowler’s position

Trendelenberg

In the Trendelenberg position, the client lies flat on their back in the supine position, with their feet elevated higher than their head by about 15–30 degrees. This position is used in situations such as hypotension and medical emergencies as it helps promote venous return to major organs, such as the head and heart.

Figure 5.2.3 Trendelenburg position

Reverse Trendelenberg

With the reverse Trendelenburg position, the head is slightly higher than the feet at 15–30 degrees. This position may be used to promote gastric emptying.

Figure 5.2.4 Reverse Trendelenburg position

Making an Unoccupied Bed

While making a bed may seem like a simple task, in health care settings there specific steps and reasoning for doing so. In this unit you will review these steps for making both an unoccupied and occupied bed.

Table 5.3.1 Procedure: Making an Unoccupied Bed

STEP	ACTION	REASON/CONSIDERATIONS
1.	Wash and dry your hands. Apply gloves if linens are soiled with blood or body fluids.	Following routine practices prevents the spread of pathogens.
2.	Assemble equipment and supplies, such as clean linens and pillows. Check the care plan to see what the bed make-up requirements are for the client. Remember to carry linens away from your body.	Promotes organization and efficiency. Carrying linens away from yourself prevents the bacteria on your clothes from getting on the clean linens.
3.	Assemble supplies in the order they will be used: bottom or fitted sheet, slider sheets, soaker pad, top or flat sheet, blanket, bedspread, and pillowcases. Turn the pile of linens upside down and place on a clean surface within your reach.	Promotes organization and efficiency.
4.	Raise the bed to waist level. Work on one side of the bed at a time. Lower the bed rails on the side you are working. Move to the other side of the bed as needed.	Follows principles of body mechanics and reduces the risk of musculoskeletal injury. Completing one side of the bed first promotes efficiency.
5.	Remove and fold any bedding to be reused (such as blankets, comforters, or quilts) and place them on a clean surface.
6.	Remove soiled linens and place in the appropriate receptacle (e.g., hamper). Roll soiled linens away from you inside out. Discard in the appropriate container.	Decreases spread of pathogens. Do not shake linens, as this will release microorganisms into the air.
7.	Discard gloves and wash your hands.	Follows routine practices.
8.	Place the bottom or fitted sheet in the middle of the bed lengthwise. The fold/crease should be in the centre of the bed.	Ensures even placement of bottom sheet.
9.	Unfold half of the sheet on the side you are working, and tuck the corners under the mattress.	Completing one side of the bed first promotes efficiency.
10.	Fanfold (accordion style) the other half of the sheet and leave in the centre of the bed.	Figure 5.3.1 Fanfolded sheets (bottom sheet, slider sheet, and soaker pad)
11.	Place the slider sheet across the bed. Fanfold it to the other side of the bed. The top edge will lay just below the pillow.
12.	Place the soaker pad in the centre of the bed. Open it on the side you are working. Fanfold it to the other side of the bed.
13.	Place top sheet in centre of the bed lengthwise. Fanfold it to the other side of the bed.
14.	Go to the opposite side of the bed.	Completing one side of the bed first promotes efficiency.
15.	Repeat steps 8–11, opening the fitted sheet and tucking it under the edges of the bed. Unfold the remaining half of the top sheet and bed pad.
16.	Add blankets and bedspreads.
17.	Mitre corners of the bedding (See Table 5.3.2 procedure: How to Mitre a Corner, below.)
18.	Bring the top sheet and blankets down over the bedspread, forming a cuff. Smooth out any wrinkles.
19.	Remove the soiled pillowcase by turning it down and placing it inside out.	This step reduces spread of pathogens
20.	Putting a Pillowcase on a Pillow Method 1: Grasp the pillow in one hand and fold it in half so that it makes a V shape. Guide the pillow into the open end of the pillowcase, which is in your other hand. Smooth out the pillow inside the case. Method 2: Grasp the end of a pillowcase at the centre of bottom seams. With your other hand, gather up the pillowcase so it is covering your hand. Grasp the pillow with the hand that is covered by the pillowcase. Pull the pillowcase down and over the pillow.
21.	Lower the bed to its lowest height. Follow the care plan for bed rails.	Reduces risk of injury to the client.
22.	Remove and dispose of your gloves if used. Wash and dry your hands.	Following routine practices reduces spread of pathogens.
23.	Document completion of task if required.

Mitre the Corners

Table 5.3.2 Procedure: How to Mitre a Corner

STEP	ACTION	EXAMPLE
1.	Begin with the bedspread and sheet tucked at the end of the bed, and the remainder hanging over the side of the bed.	Figure 5.3.2 Step 1
2.	Grasp the edge of the bedding about 45 cm (18 inches) away from the end of the bed.	Figure 5.3.3 Step 2
3.	Bring it up to the top of the bed. Hold it taut (tight) at about a 45-degree angle. It will have a triangular shape.	Figure 5.3.4 Step 3
4.	Lay the triangular shape against the side of the mattress.	Figure 5.3.5 Step 4
5.	Tuck the bedspread and sheet under the mattress. You should end up with a visible diagonal fold in the bedspread.	Figure 5.3.6 Step 5

Making an Occupied Bed

Table 5.3.3 Procedure: Making an Occupied Bed 

STEP	ACTION	REASON/CONSIDERATIONS
1.	Identify your client and explain the procedure.	Promotes safety. Communicating with the client promotes co-operation.
2.	Wash and dry your hands. Don gloves if linens are soiled with blood or body fluids.	Following routine practices prevents the spread of pathogens.
3.	Assemble equipment and supplies, such as clean linens and pillows. Assemble supplies in the order they will be used: bottom or fitted sheet, slider sheets, soaker pad, top or flat sheet, then blanket, bedspread, and pillowcases. Turn the pile of linens upside down and place on a clean surface within your reach. Remember to carry linens away from your body.	Promotes organization and efficiency. Carrying linens away from your body prevents the bacteria on your clothes from getting on the clean linens.
4.	Raise the bed to waist level. Remember to use good body mechanics and never lean over the bed. Work on one side of the bed at a time. Move to the other side of the bed as needed. Lower the bed rails on the side you are working.	Follows principles of body mechanics and reduces the risk of musculoskeletal injuries. Completing one side of the bed first promotes efficiency.
5.	Remove and fold any bedding to be reused (such as blankets, comforters or quilts) and place them on a clean surface.	Do not shake linens as this will release microorganisms the air.
6.	Loosen bedding on the side you are working. Loosen top sheet at foot and bottom or flat sheet at the foot and top of the bed. Leave top sheet or a bath blanket on the client.	Leaving the client covered provides warmth and privacy.
7.	Raise the bed to waist level. Never lean over the bed. Work on one side of the bed at a time. Move to the other side of the bed as needed. Lower the bed rails on the side you are working.	Follows principles of body mechanics and reduces risk of musculoskeletal injuries.
8.	Leave the pillow under client’s head for comfort.
9.	Turn the client to the opposite side from which you are working. Ensure the bed rail on the opposite side is raised. Position for safety and comfort.
10.	Roll the soiled bottom sheet and bed pad toward the client. The soiled sheet and mattress pad should be rolled inward, so the soiled part does not touch the client.	Figure 5.3.7 Roll soiled sheets toward the client Prevents spread of pathogens.
11.	Gently tuck the soiled sheets under the client.
12.	Position the clean bottom or fitted sheet lengthwise along the length of the client. Tuck the clean bottom sheet next to and under the soiled sheets underneath the client. Be sure the clean sheet is underneath the soiled sheet. Tuck the bottom sheet in at the head and foot, under the mattress and smooth out any wrinkles.	This will ensure the new sheet stays clean, and that it will be easy to move to the other side after you turn the client onto their opposite side. Smoothing out wrinkles reduces skin irritation.
13.	Open half the slider sheet on your side. Fanfold (fold it up accordion style) the remaining half. Tuck this under the client, over the clean sheet but under the soiled sheet.	Figure 5.3.8 Fanfolded clean sheets
14.	Turn the client to the clean side of the bed. Let them know that they will feel a “bump” as they roll over the linens underneath them. Position the client for safety and comfort. If the bed has rails, ensure the bed rails are positioned up before you move to the opposite side of the bed.	Promotes safety and comfort.
15.	Go to the opposite side of the bed.
16.	Loosen the bottom sheet at the head and foot of the bed. Roll the soiled bottom sheet and bed pad into a ball so that the soiled part of the linen is inside, and away from clean areas. Place soiled linen in the appropriate receptacle.	Reduces the spread of pathogens.
17.	Remove your gloves and wash your hands. If you move away from the bed, ensure the bed rails are up.	Following routine practices reduces spread of pathogens. A raised bed rail promotes safety.
18.	Roll the clean bottom sheet, slider sheet, and soaker pad out from under the client. Tuck in corners and smooth out wrinkles.	Smoothing out wrinkles reduces skin irritation.
19.	Re-position the client back to the centre of the bed.
20.	Remove the soiled top sheet and replace with the clean top sheet. Replace blankets and top bedding over the client.
21.	Bring the top sheet and blanket down over the top bedding to form a cuff.
22.	Remove soiled pillowcases and replace with clean pillowcases, as outlined in the Making an Unoccupied Bed procedure (Table 5.3.1).
23.	At the foot of the bed, make a toe pleat by lifting all linens with pinched fingers.	This allows the client to have room to move their feet and prevents deformities of the feet from pressure made by tight linens.
24.	Position the client for comfort.
25.	Lower the bed to its lowest setting. Ensure side rails are positioned according to care plan.	Ensures safety of client.
26.	Remove gloves, and wash and dry your hands.	Following routine practices reduces spread of pathogens.
27.	Observe, record, and report any changes in condition or behaviour.	Communication with the health care team is an important aspect of the HCA role.

Chapter 5 Attributions and References

Unit 5.2 Image Attributions

• 5.2.1 Fowler’s Position by Doyle and McCutcheon (2015), via Wikimedia Commons, is used under a CC BY SA-4.0 licence.
• 5.2.2 Semi-Fowler’s Position by Doyle and McCutcheon (2015), via Wikimedia Commons, is used under a CC BY SA-4.0 licence.
• 5.2.3 Trendelenberg Position by Doyle and McCutcheon (2015), via BCcampus, is used under a CC BY SA-4.0 licence.
• 5.2.3 Reverse Trendelenberg by Saltanat ebli, via Wikimedia Commons, is used under a CC0 1.0 Public Domain licence.

Unit 5.3 Image Attributions

• 5.3.1 Fanfolded sheets by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• 5.3.2 Step 1 by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• 5.3.3 Step 2 by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• 5.3.4 Step 3 by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• 5.3.5 Step 4 by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• 5.3.6 Step 5 by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.
• 5.3.7 Roll soiled sheets toward the client by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY licence.
• 5.3.8 Fanfolded clean sheets by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence.

Videos

• B 301 Unoccupied Bed by Skills Lab (2017) is licensed under a Standard YouTube License.
• B 302 Occupied Care video by Skills Lab (2017) is licensed under a Standard YouTube License.

References

Doyle, G. R. & McCutcheon, J. A. (2015, November 23). 3.5 Positioning patients in bed [Digital Images]. In Clinical procedures for safer patient care. British Columbia Institute of Technology (BCIT)/ BCcampus. https://opentextbc.ca/clinicalskills/chapter/3-4-positioning-a-patient-in-bed/

Many of the clients you will be caring for will need some help with meals. They may be unable to feed themselves because of weakness or disability. Be aware of their feelings of loss regarding this skill when you assist them to eat. It is important to determine how much the clients can do themselves and encourage independence, but it is also important to know when to assist clients when they need support to eat. In some circumstances, for example, during illness, it may be necessary to record a client’s food or fluid intake and compare this to total output. In this unit, we explore how HCAs can support clients who either cannot feed themselves or are at risk for choking.

Swallowing

Before discussing how to support clients with their dietary needs, let us review the mechanism of swallowing. Swallowing is the transport of a substance from the mouth to the stomach. It is an important part of eating and drinking. The chewed food or drink that is moved in one swallow is called a bolus. The most common complications with swallowing are choking and dysphagia (Girdi-Papp, 2022).

Figure 6.2.1 Regions of the human respiratory tract.

The entire swallowing process takes about 4–8 seconds for solid food, and about one second for very soft food and liquids. Although this sounds quick and effortless, swallowing is a complex process that involves both the muscles of the tongue and the muscles of the pharynx and esophagus. It is aided by the presence of mucus and saliva. Swallowing consists of three phases — oral, pharyngeal, and esophageal — and involves many smooth muscles of the pharynx and esophagus. The oral phase is voluntary and controlled by the cerebral cortex, whereas the pharyngeal and esophageal phases are non-voluntary processes (Girdi-Papp, 2022).

ƒFigure 6.2.2 Swallowing movements during juice drinking filmed in MRI. Click to watch.

Dysphagia

Dysphagia is difficulty in swallowing. It can have various causes and involve different parts of the swallowing mechanism or anatomy. Dysphagia frequently produces coughing, choking, or pulmonary aspiration and subsequent aspiration pneumonia. Dysphagia can also lead to dehydration and weight loss (Girdi-Papp, 2022). There are two types of dysphagia: oropharyngeal and esophageal.

Oropharyngeal dysphagia includes difficulty controlling the position of food in the mouth, difficulty initiating a swallow, nasal regurgitation, and a gurgling voice after swallowing. Clients identify the mouth or neck as the site of the problem. These problems are common among older individuals, and clients who have had strokes, head and neck cancer, and progressive neurologic diseases like Parkinson’s disease, Alzheimer’s disease, or multiple sclerosis (Girdi-Papp, 2022).

In esophageal dysphagia, clients indicate an inability to swallow solid food, saying that it is held up or stuck before it reaches the stomach or is regurgitated. Various diseases in or adjacent to the esophagus can result in dysphagia, and the treatment depends on the cause (Girdi-Papp, 2022). There are several triggers that can cause a client to have difficulty swallowing, so it is important to know what the signs of dysphagia are and ask yourself:

• Is the diet the right texture?
• Is the fluid the right consistency?
• Is the client positioned correctly?
• Are the bites and drink the right size?
• Is the client eating too fast?
• Does the client need adaptive utensils?

If the answer is “yes” to any of the above questions, either intervene and self-correct where appropriate, and consult with the care team to discuss the need for a reassessment of the client’s care plan.

Many treatments are used in dysphagia because it is not a disease, but a symptom or condition associated with a wide variety of diseases. Treatments can include swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery.

Choking

Choking is a life-threatening medical emergency that occurs when the air passage into the lungs is blocked by food or another object. This obstruction can be partial or complete. The disruption of normal breathing by choking hinders oxygen delivery to the body, resulting in asphyxia. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, choking is potentially fatal. It is a major cause of unintentional injury-related death (Girdi-Papp, 2022).

Deaths from choking most often occur in the very young (< 1 year old) and in older adults (> 75 years). The obstruction of the airway most commonly occurs at the pharynx or trachea. Foods that can adapt their shape to that of the pharynx, such as bananas, marshmallows, or gelatinous candies, are particularly dangerous. Choking is frequently caused by tumours, swelling of the airway tissues due to infections, and neurological disorders (Girdi-Papp, 2022). Complications of choking include:

• Brain damage, which typically occurs if the body is deprived of air for 3 minutes.
• Death, which will usually occur if breathing is not restored in 6–8 minutes.

Causes

Children younger than age three are especially at risk of choking because they explore the environment by putting objects in their mouth. Their airway is smaller in diameter than an adult’s airway, and their coughing may not be as effective as that of an adult in clearing an airway obstruction. However, choking in adults is most often caused by food. Risk factors include:

• Medical conditions that affect the coordination of swallowing, such as:
  • Strokes
  • Parkinson’s disease
  • Alzheimer’s disease
• Using alcohol or sedatives
• Undergoing a procedure involving the oral cavity or pharynx

In the prevention of choking in clients with dysphagia, the appropriate selection of food items with smaller particle sizes, smoother texture, and fluidity can reduce the risk.

An important part of the Health Care Assistant’s job is to assist clients with eating. This may include planning and preparing meals, shopping for ingredients, serving food, and assisting with eating. Eating habits and nutrition can be affected by a number of diversity factors, such as culture, personal choices, religions, allergies, finances, aging, and illness.

Supporting older adults to meet their dietary needs requires you to understand the effects that aging has on clients’ appetites. Physical changes, vision, hearing, and poor-fitting dentures can all affect their ability to eat. Other factors from chronic illnesses, such as arthritis or cognitive impairments, can impact their control of eating and mealtime.

Considerations

HCAs can provide a pleasant atmosphere during mealtime by ensuring there are no unpleasant odours. Empty trash cans and remove urinals or bedpans from sight. Offer to assist the client to the bathroom and perform oral care prior to eating to make mealtime more comfortable. Ensure clients who wear dentures have them in their mouths prior to eating. This allows the client to better chew and digest their food.

Clients should always be in an upright position during mealtimes. This helps to prevent choking. For clients with swallowing or choking difficulties, they should be kept in an upright position for 30–60 minutes after their meal is complete.

Some clients may only need assistance with preparing food as they are able to eat independently. Many types of adaptive equipment, such as special plates, cups, and eating utensils, are available to help people be as independent as possible while eating. Other clients require complete support during eating, and the HCA will need to assist the client to eat. You should sit next to clients while assisting with eating and offer to keep those who are independent company. Mealtime is a good time to get to know clients. Clients who prefer to pray or have religious or spiritual practices before meals should be allowed to practice these rituals. Give privacy as appropriate and requested (McLain, et al., 2018; Sorrentino, et al., 2019).

HCAs should offer foods that are appealing to their clients, and allow them to choose the foods they would like to eat, as appropriate. Follow care plan guidelines when preparing special diets.

Assisting with Eating

Assisting a Client with Dysphagia

There are times when physicians order special diets for their clients for different reasons, such as disease, weight control, or physical or neurological changes that put clients at risk of choking. But just like any meal planning, the client’s preferences, culture, religion, allergies, and intolerances are taken into consideration.

In care facilities, when a client does not have any dietary restrictions, their diet would be called either a regular or general diet. However, there are many types of special diets that you may see in your practice. For example, there are restricted diets, such as the diabetic diet, sodium-controlled diet, or a gluten-free diet. There are also diets that have modified texture due to illness, disease, or neurological and physical disabilities. A clear-liquid diet would be for acute illness or for post-operative patients, or the mechanical soft diet may be used for gastrointestinal disorder, or moving from a liquid diet. Whatever diet is ordered for the client, it is chosen based on a thorough assessment of the client’s history, health status, and ability to swallow, and it will be outlined in their care plan.

Considerations

Below are important considerations for clients who require special diets:

• If the client has facial weakness, arm/hand weakness, or paralysis, assist with eating from the client’s strong side and place eating utensils on their stronger side.
• If the client has a swallowing problem, allow longer periods between bites for adequate chewing and swallowing. Encourage the client to tuck their chin down and bend their body forward while swallowing. This encourages the food to move down the esophagus.
• Limit the amount of conversation while the client is chewing and swallowing.
• Ensure that food is cut into bite-sized pieces and that food is the appropriate consistency (pureed), according to the client’s prescribed diet.

Types of Modified Texture Diets

Figure 6.4.1 Texture-Modified Diets (Infographic courtesy IDDSI, 2022). [Image description]

Adaptive eating devices are modified utensils, dishes, and cups that make it easier for people with different types of physical difficulties to eat, including clients who may be weak or have difficulty grasping utensils. These devices can enhance mealtime and client independence, as well. While there are many such devices on the market, they can easily be made by simply building up the hand of eating utensils with gauze and tape.

Figure 6.4.2 Adaptive utensils

Special Diets: Enteral Nutrition

Some clients, because of illness, injury, or surgery, have extreme difficulty chewing or swallowing and as a result have additional dietary considerations. For such clients, it is unsafe to eat or drink by mouth, therefore a physician will order all foods, fluids, and medications to be given through a tube. Only licensed health care workers can administer the foods, fluids, and medications through the tube, but as an HCA you will care for clients who have had these procedures, so it is important for you to understand.

Enteral nutrition is provided to people who cannot chew or swallow foods or fluids past their esophagus into their stomachs. Enteral nutrition is a liquid nutritional formula delivered into the gastrointestinal tract through a gavage tube. The need for enteral nutrition may occur due to trauma or cancers to the face, mouth, esophagus, or neck. Also, people with advanced dementia who no longer know how to eat may have an enteral nutritional feeding tube. Many people refer to these tubes to as G-tubes, and there are many types of G-tubes depending on where they are surgically placed (Sorrentino, et al., 2019).

How often a client receives enteral nutrition depends on how the physician or dietician orders them, as well as the type of tube in place. There could be scheduled feedings given four times per day or these could be continuous over the day. Naso-intestinal and jejunostomy tube feedings are always continuous.

What Is the HCA Role in Enteral Nutrition?

As an HCA, your role with enteral nutrition and feeding tubes will mostly be observation, unless this task has been delegated to you by a regulated health professional, such as a registered nurse. Clients with enteral feeding tubes are at risk for aspiration. These tubes can move from the stomach or intestine and into the esophagus or airway because clients move, or they or their caregivers may accidentally pull on the tube. Also, with such tubes regurgitation may occur due to delayed stomach emptying and over-feeding. To prevent regurgitation and aspiration, have the client in a semi-Fowler’s or sitting position during feeding and for at least one hour after eating to promote digestion. Also, avoid putting the client in a left-lying side position as this prevents stomach emptying.

Observations and Comfort Measures

As the HCA caring for clients with enteral feeding tubes, it is essential you use your skills to make observations and provide comfort because aspiration is not the only risk with this type of feeding. Delayed stomach emptying, diarrhea, and constipation can also occur, so observe and report any of the following immediately to your supervisor:

• Coughing or gurgling voice
• Nausea, vomiting
• Diarrhea
• Discomfort during the tube feeding
• Stomach distention (enlarged or swollen)
• Elevated temperature and/or pulse rate
• Redness, swelling, drainage, odour, pain at ostomy site

Because most people with enteral feeding tubes do not take anything by mouth NPO, mouth care is extremely important. Dry mouth and lips and sore throat can cause discomfort; therefore, good oral hygiene will be required. Brush teeth, moisturize lips and mouth, and if allowed, offer ice chips or hard candy to suck on. If the tube is placed into the nose, the tubes can put pressure on the nose and it becomes irritated and red. Try to reposition the tube slightly away from the nostril; tape or tube holders can be used to help with this and be sure to clean the nose at least every 4 hours. To prevent the tube from being pulled out of place, pin or secure the tubing to the client’s gown with a rubber band and safety pin or secure-strip with enough slack to allow movement.

Measuring Intake

To maintain adequate health, individuals need to take in a certain amount of fluid per day. Depending on a client’s condition, they may either be encouraged to drink fluids or limit their fluid intake. Fluid that is taken in is called intake. Fluids are usually measured using millilitres (ml). One cup of liquid is 8 ounces or 250 ml.

The amount of food that is eaten can also be measured. This can be done by weighing the food prior to serving and subtracting the amount left to get the total food intake. Food intake can also be measured by determining the total percentage eaten. If all the meal is consumed, the intake is 100%. If none of the meal is consumed, the intake is 0%. A quarter of the meal consumed would be 25% and half the meal consumed would be 50% (McLain, et al., 2018; Sorrentino, et al., 2019). The facility policy will specify the unit of measurement to be used.

• Explain to the client the importance of recording their intake. Throughout your shift, monitor or ask the client what and how much they have had to eat or drink.
• During food preparation, measure the amount of food or liquid that is served. Use standard measuring cups and spoons to properly measure intake. Record this in the appropriate place.
• Once the client has finished eating or drinking, subtract the amount they have consumed from the amount you served. Record this number as their input. Input for fluid should be recorded as millitres (ml).
• Record the weight or percentage of food consumed in the appropriate place.
• Document all food and drink intake. The agency may provide a specific intake and output (I & O) sheet. Health care staff including HCAs should report any observations or changes in condition or behaviour.

Image Descriptions

Figure 6.4.1 Texture-Modified Diets (Infographic courtesy IDDSI, 2022).

Texture modified diets.

“Dysphasia is when an individual has difficulty swallowing making it hard for them to eat and drink. Their food and drink may need to be modified to make it safer and minimising the risk of choking and aspiration.”

The Modified Food Groups

• Level 3 – Liquidised
  • All food items should be prepared separately.
  • It should be completely smooth, passed through a sieve and lump free with a moderately thick liquid consistency. No thin liquid should separate.
• Level 4 – Pureed
  • Food should be smooth, without lumps or separated liquid. It should hold its shape on a spoon and be a mousse like consistency.
  • Extra gravy or sauce should not be added.
• Level 5 – Minced and Moist
  • Food particles should be no bigger than 4 mm. Tender and moist with a fine minced consistency with no separated liquid.
  • Extra gravy or sauce should not be added.
• Level 6 – Soft and -Sized
  • Food particles should be no bigger than 15 mm × 15 mm and soft enough to press down with a fork without regaining shape.
  • Gravy or sauce should be bound within the dish and not served separately.
• EC 7 -Easy to Chew
  • Age appropriate foods that are a soft/tender texture that can be cut with a fork or spoon. No hard, tough, stringy textures with pips, seeds, bones or gristle.
• Level 7 – Regular
  • Everyday foods of different textures, Chewing required, includes mixed consistencies e.g., cereal with milk, soup with vegetables & sandwiches.

Ingredients to avoid in Levels 3-7 Easy to Chew: Foods with husks, seeds, pips, or fibrous textures. No hard, crunchy or sticky textures. If in doubt pass ingredients through a fine sieve and thicken to correct consistency.

[Back to Figure 6.4.1]

Chapter 6 Attributions and References

Unit 6.2 Image Attributions

• Figure 6.2.1 Illu conducting passages [adapted], by Jmarchn, via Wikimedia Commons, is in the public domain. [Vectorized version of File:Illu conducting passages.jpg, which was a work of the US Government. Originally from SEER Training, U.S. National Cancer Institute.]
• Figure 6.2.2. Real-time MRI – Swallowing (Pineapple Juice) (https://commons.wikimedia.org/wiki/File:Real-time_MRI_-_Swallowing_(Pineapple_Juice).ogv) by Biomedizinische NMR Forschungs GmbH (https://www.mpinat.mpg.de/en/frahm/), via Wikimedia Commons is used under a CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/deed.en) licence.

Unit 6.4 Image Attributions

• Figure 6.4.1 Textures-Modified Diets © The International Dysphagia Diet Standardisation Initiative 2019. This infographic is used under a CC BY SA 4.0. Derivative works extending beyond language translation are NOT PERMITTED.
  
• Figure 6.4.2 Adaptive Utensils by AMorice CC0
• Figure 6.4.3 Diagram showing the position of a nasogastric tube CRUK 340 by Cancer Research UK, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.
• Figure 6.4.4 [adapted] Diagram showing the position of a nasogastric tube CRUK 340 by Cancer Research UK, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.
• Figure 6.4.5 Diagram showing the position of a percutaneous endoscopic gastrostomy (PEG) feeding tube CRUK 341 by Cancer Research UK, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.
• Figure 6.4.6 Diagram showing the position of a percutaneous jejunostomy feeding tube CRUK 342 by Cancer Research UK, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.
• Figure 6.4.7 Diagram showing the position of a percutaneous endoscopic gastrostomy (PEG) feeding tube CRUK 341.svg by Cancer Research UK, via Wikimedia Commons, is used under a CC BY-SA 4.0 licence.

Videos

• Feed a Resident in a Chair CNA Skill NEW! by 4yourCNA (2016) is licensed under a Standard YouTube License.
• PEARSON VUE/CREDENTIA 2022 – FEEDS CLIENT WHO CANNOT FEED SELF by Nurse Jar (2019) is licensed under a Standard YouTube License.
• Understanding Dysphagia by Nestlé Health Science Canada (2011) is licensed under a Standard YouTube License.

References

Girdi-Papp, M. (2022). Comparative oral+ENT biology. (pp. 438–450). OpenStax CNX. 

Hughes, M., Kenmir, A., Romaniuk, D., & Vander Meeren, P. (n.d.). Meal assistance virtual gaming simulation – Simple book publishing. ECampus Ontario. https://ecampusontario.pressbooks.pub/mavgs/

International Dysphagia Diet Standardisation Initiative (IDDSI). (2019, July). Complete IDDSI framework
detailed definitions 2.0. https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf.

International Dysphagia Diet Standardisation Initiative (IDDSI). (2022, September). Textured modified diets [Infographic/PDF]. UK IDDSI Reference Group (UKIRG). https://iddsi.org/IDDSI/media/images/CountrySpecific/UnitedKingdom/Texture-Modified-Diets-(UK-IDDSI-Festival).png.

McLain, K., O’Hara-Leslie, E., & Wade, A. (n.d.). Foundations for assisting in home care. Milne Publishing/SUNY Geneseo. https://milnepublishing.geneseo.edu/home-health-aide/

Nurse Jar. (2019, April 13). PEARSON VUE/CREDENTIA 2022 – FEEDS CLIENT WHO CANNOT FEED SELF (Video). YouTube. https://www.youtube.com/watch?v=faw_mOmoDxk

Sorrentino, S., Remmert, L., & Wilks, M. (2019). Mosby’s Canadian textbook for the support worker (4th ed.). Elsevier Canada.

Biomedizinische NMR Forschungs GmbH. (2011, September 16). Real-time magnetic resonance imaging at a resolution of 20 ms [GIF]. Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Real-time_MRI_-_Swallowing_(Pineapple_Juice).ogv

The elimination of waste products from the body is a basic need. It is also a natural process, and most healthy people have regular fecal and urinary elimination habits. When people become dependent on others for care, elimination habits are often disrupted, and control can be lost. As HCA students, you will become familiar with alternative ways of assisting clients with their elimination needs.

When assisting clients with urinary and bowel elimination, it is important to understand what type of care activity is required to help the client meet their needs. There are two types of care activities:

• Tasks: care activities that HCAs are educated and trained to perform as part of their assigned HCA role (for example, assisting a client to use the toilet).
• Restricted activities: higher-risk care activities outlined in health professional regulations that an HCA cannot perform without authorization (delegation) by a regulated health professional, such as a registered nurse (for example, giving a rectal suppository or enema). Restricted activities are not considered HCA tasks.

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

Figure 7.2.1 Urine hydration chart

Explore More

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

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 check the care plan.

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. Clients with a penis may benefit from using a urinal at the bedside to prevent having to walk to the bathroom. Some clients need a urinary catheter. Clients with a penis may require 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

Using a Bedpan

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 client 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 client’s 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 Urinal

The use of a urinal helps a clients with penises privately and safely urinate, without having to ambulate to the bathroom or commode. Many clients with a penis 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.

Condom Catheter

Figure 7.2.3 Condom catheter

Condom catheters are worn by some clients with penises 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

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. Providing perineal care and cleaning the catheter tubing are both tasks. However, some elements of catheter care involve restricted activities. HCAs must have client-specific delegation from a regulated health professional to perform any restricted activities.

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

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 health care provider wants to ensure that their intake equals their output. This helps to maintain adequate fluid balance. Fluids are usually measured using millilitres (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.

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 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 and something 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 clients 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. Clients with dementia also have an increased risk for functional incontinence.

Normal Bowel Elimination

The stomach breaks down ingested food by means of stomach acid and enzymes. This product is called chyme. Chyme is passed into the small intestine through peristalsis. Chemical digestion and absorption of nutrients is the main function of the small intestine. The large intestine continues to absorb nutrients and fluid. The resulting waste is called feces and is stored in the colon and rectum until the urge to defecate is felt. The HCA should monitor the client’s bowel movements and note the frequency, consistency, colour, odour and any pain or discomfort experienced during bowel movements. This will assist the nurse in adjusting the client’s diet or medications.

Characteristics of Normal Bowel Movements

There is a range of normal when considering the frequency of bowel movements. It is important to know what is normal for your client. Some people have bowel movements daily, for others normal is every 2–3 days. The frequency of a person’s bowel movements can be affected by many factors, such as activity, age, medications, diet, fluid intake, and elimination habits. The Bristol Stool Chart (Figure 7.3.1) can assist you in identifying the consistency of the bowel movement.

Figure 7.3.1 Bristol Stool Chart [Image description]

Abnormal Bowel Elimination

Assisting with Bowel 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 prevent constipation. Always ensure to check the care plan.

Problems with Bowel Elimination

Constipation

Constipation is a common problem experienced in older adults. Many factors contribute to constipation: age, medications, lack of adequate fluids or fibre, lack of exercise, delaying urge to defecate, lack of privacy. Frequent or constant constipation can lead to a variety of other health issues such as hemorrhoids, fecal impaction, and bowel obstruction. HCAs play an important role in preventing constipation in clients. Although prevention is key, HCAs may be involved in assisting with or caring for clients who have required other measures to address the constipation such as rectal suppositories, enemas or disimpaction.

Table 7.3.3 Procedure: Administering a Rectal Suppository or Enema

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.	Following routine practices prevents the spread of pathogens.
3.	Assemble equipment and supplies: non-sterile gloves water-soluble lubricant incontinent pad or waterproof pad	Gloves are needed for contact with blood/body fluids. Lubricant reduces friction as the suppository enters rectal canal. Incontinent pad or waterproof pad protects bed linens.
4.	Explain the procedure to the client. If client prefers to self-administer the suppository/enema, give specific instructions to client on correct procedure.	Clients have a right to information about their care. Client may feel more comfortable self-administering suppository. If so provide glove, lubricant, and instructions.
5.	Raise bed to working height. Position client on left side with upper leg flexed over lower leg toward the waist (Sim’s position). Provide privacy and drape the client with only the buttocks and anal area exposed. Place an incontinent pad or waterproof pad underneath the client’s buttocks.	Positioning helps prevent injury to the HCA administering the suppository. This protects client’s privacy and facilitates relaxation. Some literature suggests that left side-lying Sim’s position lessens the likelihood of the suppository being expelled. Incontinent or waterproof pad protects linens from potential fecal drainage.
6.	Apply clean, non-sterile gloves.	Figure 7.3.2 Gloves Gloves protect the HCA from contact with mucous membranes and body fluids.
7.	Remove wrapper from suppository/tip of enema and lubricate rounded tip of suppository and index finger of dominant hand with lubricant. Lubricate rounded tip of suppository or tip of enema.	Figure 7.3.3 Disposable enema Figure 7.3.4 Lubricant Lubricant reduces friction as suppository/enema enters rectal canal. Inserting the rounded top promotes client comfort.
8.	Separate buttocks with non-dominant hand and, using gloved index finger of dominant hand, insert suppository (rounded tip toward client) into rectum toward umbilicus while having client take a deep breath, exhale through the mouth, and relax anal sphincter. If enema: Expel air from enema and then insert tip of enema into rectum toward umbilicus while having client take a deep breath, exhale through the mouth, and relax anal sphincter.	Ensure the suppository is removed from the package. Upon insertion, you should feel the anal sphincter close around your finger. Forcing the suppository/enema through a clenched sphincter will cause pain.
9.	With your gloved finger, insert suppository along wall of rectum about 5 cm beyond anal sphincter. Do not insert the suppository into feces. If enema: Roll plastic bottle from bottom to tip until all solution has entered rectum and colon.	Suppository should be against rectal mucosa for absorption and therapeutic action. Inserting suppository into feces will decrease its effectiveness. If the client experiences cramping during enema administration, stop. Ask the client to take a deep breath. Resume administration when cramps subside. Hold buttock cheeks together if client feels immediate need for a bowel movement.
10.	Remove finger and wipe client’s anal area.	Wiping removes excess lubricant and provides comfort to the client.
11.	Ask the client to remain on side for 5–10 minutes.	This position helps prevent the expulsion of suppository.
12.	Discard gloves by turning them inside out and disposing of them and any used supplies as per agency policy. Perform hand hygiene.	Using gloves reduces transfer of microorganisms. Figure 7.3.5 Dispose of gloves Figure 7.3.6 Using an ABHR
13.	Ensure call bell is nearby and bedpan or commode is available and close by. Client may need assistance; refer to care plan.	If suppository is a laxative or stool softener, client will require a bedpan/commode or close proximity to toilet. Figure 7.3.7 Ensure call bell is available to client
14.	Document procedure as per agency policy and include client’s tolerance of administration.	Timely and accurate documentation promotes client safety.

Image Descriptions

Figure 7.3.1 Bristol Stool Chart

• Type 1 – separate hard lumps, like nuts (hard to pass)
• Type 2 – sausage-shape but lumpy
• Type 3 – like a sausage but with cracks on its surface
• Type 4 – like a sausage or snakes, smooth and soft
• Type 5 – soft blobs with clear-cut edges (passed easily)
• Type 6 – fluffy pieces with ragged edges, a mushy stool
• Type 7 – watery, no solid pieces, entirely liquid

[Back to Figure 7.3.1]

Obtaining Urine Specimen for Culture

As an HCA you may be asked to collect a urine specimen for testing. There are a variety of tests that can be completed on urine, and the type of test will determine how the urine is collected. Below are several types of urine tests and the accompanying procedures.

Routine Urine Specimen

This common urine specimen tests for blood, sugar, ketones, white blood cells and other substances in the urine. Adults with cognitive impairments may not be able to understand the need for peri-care prior to collection, which is needed for a mid-stream collection.

See Table 7.4.1 to learn the correct procedure for collecting a routine urine specimen.

Table 7.4.1 Procedure: Collecting a Routine Urine Specimen

STEP	ACTION	REASON
1.	Check the client’s care plan.	Ensures you have information specific to this client’s care.
2.	Perform hand hygiene.	Follows routine practices to prevent the spread of pathogens.
3.	Assemble equipment and supplies: bedpan, urinal or other specimen collection container label specimen container with lid supplies for peri-care if needed (washcloth, soap or peri-wash)	Figure 7.4.1 Urine Specimen
4.	Provide privacy for the client 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.	Label the specimen container.	Ensures the correct test is performed on the correct client.
7.	Put on gloves.	Gloves are needed for contact with blood/body fluids.
8.	Assist client to void into urinal, bedpan, or specimen collection container. Do not put toilet paper into the container.	Avoids contamination of specimen (toilet paper will contaminate the specimen).
9.	Assist client as needed. Pour urine from bedpan, urinal or collection container into specimen container. Fill at least halfway (approximately 120 ml). Dispose of excess urine into toilet.
10.	Ensure lid is securely on container and container is labelled correctly. Store according to facility policy.	The urine specimen needs to be refrigerated if there is not a laboratory on site.
11.	Clean up supplies, remove gloves and perform hand hygiene.

Mid-Stream Urine Specimen

This type of specimen requires peri-care to be done prior to collecting the sample. The client is also instructed to void a small amount, then void again into the specimen collection container. This ensures that microorganisms from outside the body are not contaminating the specimen. This may be more difficult to obtain from clients who have cognitive impairment.

24-Hour Urine Specimen

A 24-hour urine specimen includes all urine voided over a 24-hour period. This may be ordered for measuring kidney function. A large container will be used to collect the urine over the time period.

An ostomy is a surgical procedure that creates an opening (stoma) from an area inside the body to the outside of the body. In ostomies related to elimination, a stoma is an opening on the abdomen that is connected to the gastrointestinal or urinary system to allow waste (urine or feces) to be collected in a pouch. See Figure 7.5.1 for an image of a stoma. A stoma can be permanent, such as when an organ is removed, or temporary, such as when an organ requires time to heal. Ostomies are created for clients with conditions such as cancer of the bowel or bladder, inflammatory bowel diseases, or perforation of the colon.

Figure 7.5.1 Stoma

There are several different kinds of ostomies related to elimination. Common types of ostomies include the following:

• Ileostomy: The lower end of the small intestine (ileum) is attached to a stoma to bypass the colon, rectum, and anus.
• Colostomy: The colon is attached to a stoma to bypass the rectum and the anus.
• Urostomy: The ureters (tubes that carry urine from the kidney to the bladder) are attached to a stoma to bypass the bladder.

Figures 7.5.2 and 7.5.3 show the anatomical locations of ileostomies and various sites of colostomies. It is important to understand the site of a client’s colostomy because the site impacts the characteristics of the waste. For example, due to the natural digestive process of the colon and absorption of water, waste from an ileostomy or a colostomy placed in the anterior ascending colon will be watery compared to waste from an ostomy placed in the descending colon.

Figure 7.5.2 Location of an ileostomy compared to colostomies

Figure 7.5.3 Colostomy types

The tissue of a stoma is very delicate. Immediately after surgery, a stoma is swollen, but it will shrink in size over several weeks. A healthy, healed stoma appears moist and dark red or pink in colour. Stomas that are swollen; dry; have malodorous discharge; or are bluish, purple, black, or pale should be reported to the provider. The skin surrounding a stoma can easily become irritated from the pouch adhesive or leakage of fluid from the stoma, so the nurse must perform interventions to prevent skin breakdown. Any identified signs of skin breakdown should be reported to the provider.

Stoma appliances are supplied as a one- or two-piece set. A two-piece set consists of an ostomy barrier (also called a wafer) and a pouch. The ostomy barrier is the part of the appliance that sticks to the skin with a hole that is fitted around the stoma. The pouch collects the waste and must be emptied regularly. It attaches to the ostomy barrier in a clicking motion to secure the two parts, similar to how a plastic storage container cover snaps to a container to create a seal. The pouching system must be completely sealed to prevent the leaking of the waste and to protect the surrounding peristomal skin. The pouch has an end with an opening where the waste is drained and is closed using a plastic clip or Velcro strip.

In a one-piece stoma appliance set, the ostomy barrier and the pouch are one piece. See Figure 7.5.4 for an image of a stoma with an ostomy barrier in place. See Figure 7.5.5 for an image of a client with an ileostomy appliance with a pouch attached. The flange is the adhesive part of the ostomy pouching system that secures it to the body.

Figure 7.5.4 Ostomy barrier

Figure 7.5.5 Ostomy pouch

Individuals with colostomies, ileostomies, and urostomies have no sensation and no control over the output of the stoma. Depending on the type of system, the ostomy appliance can last from four to seven days, but the pouch must be changed if there is leaking, odour, excessive skin exposure, or itching or burning under the skin barrier. Clients with pouches can swim and take showers with the pouching system on.

Changing an Ostomy Appliance (Flange and Pouch)

Safety Considerations

• Pouching system should be changed every 4 to 7 days, depending on the client and type of pouch. Notify supervisor if there is skin breakdown, if there are challenges with flange adhesion, or if there are other concerns related to the pouching system.
• Clients should participate in the care of their ostomy, if able, and health care providers should promote client and family involvement.
• Encourage the client to empty the pouch when it is one-third to one-half full of urine, flatus, or feces as they become heavy and have increased risk of spillage.
• Ostomy product choices may be limited in acute care settings. Other choices are available in community retail settings. Encourage the client/family to explore other options.
• Observe the centre of the flange for evidence of leaking. Waste on the peristomal skin can cause skin breakdown. Leaking flanges must be changed immediately.
• An ostomy belt may be used to help hold the ostomy pouch in place.
• Factors that affect the pouching system include sweating, high heat, moist or oily skin, and physical exercise.
• Always report minor skin irritations immediately. Skin that is sore, wet, or red is difficult to seal with a flange.
• Change ileostomy appliances prior to eating to decrease the likelihood that a bowel movement will occur during appliance change.

Table 7.5.1 Procedure: Changing an Ostomy Appliance

STEP	ACTION	ADDITIONAL INFORMATION
1.	Perform hand hygiene.	This prevents the spread of microorganisms. Figure 7.5.6 Hand hygiene
2.	Gather supplies, including: flange ostomy bag and clip scissors, stoma measuring guide waterproof pad pen adhesive remover for old flange stomahesive paste or powder warm wet cloth(s) and dry cloth non-sterile gloves	Figure 7.5.7 Ostomy Supplies
3.	Identify the client and review the procedure. Encourage the client to participate as much as possible, or observe and assist client as they complete the procedure.	Proper identification complies with agency policy. Encouraging clients to participate helps them adjust to having an ostomy.
4.	Create privacy. Place waterproof pad under pouch.	The pad prevents the spilling of effluent on client and bed sheets.
5.	Apply gloves. Remove the ostomy bag, and measure and empty contents. Place the old pouching system in a garbage bag.	Figure 7.5.8 Removing an ostomy bag
6.	Remove the flange by gently pulling it toward the stoma. Support the skin with your other hand. An adhesive remover may be used.	Gentle removal helps prevent skin tears. An adhesive remover may be used to decrease skin and hair stripping. Figure 7.5.9 Removing a flange
7.	Clean the stoma gently by wiping with warm water. Do not use soap.	Aggressive cleaning can cause bleeding. If removing the stomahesive paste from the skin, use a dry cloth first. Clean the stoma and peristomal skin. Figure 7.5.10 Cleaning a stoma
8.	Observe the stoma and peristomal skin.	A stoma should be pink to red in colour, preferrably moist and raised above skin level. Figure 7.5.11 Healthy stoma Observe stoma Skin surrounding the stoma should be intact and free from wounds, rashes, or skin breakdown. Notify your supervisor if you are concerned about the condition of the peristomal skin.
9.	Measure the stoma diameter using the measuring guide (tracing template) and cut out stoma hole. Trace diameter of the measuring guide onto the flange, and cut on the outside of the pen marking.	The opening should be 2 mm larger than the stoma size. Keep the measurement guide with the client’s supplies for future use. Trace template. Figure 7.5.12 Measuring stoma size Once the size is traced onto back of flange, cut out the size to fit the stoma. Figure 7.5.13 Cutting flange to size Check the flange to ensure a proper fit to the stoma. Figure 7.5.14 Fitting flange to stoma
10.	Prepare skin and apply accessory products as required or according to agency policy.	Peristomal skin prep. Accessory products may include stomahesive paste, stomahesive powder, or products used to create a skin sealant to adhere pouching system to skin to prevent leaking. Wet skin will prevent the flange from adhering to the skin. Figure 7.5.15 Prepping peristomal skin Apply stomahesive paste. Figure 7.5.16 Applying stomahesive paste
11.	Remove the inner backing on the flange and apply flange over stoma. Leave the border tape on. Apply pressure. Hold in place for 1 minute to warm the flange to meld to the client’s body. Then remove outer border backing and press gently to create seal.	The warmth of the hand can help the appliance adhere to the skin and prevent leakage. Remove backing from flange. Figure 7.5.17 Preparing flange Apply flange around stoma. Figure 7.5.18 Applying flange Press gently to create seal. Figure 7.5.19 Sealing flange
12.	Apply the ostomy bag. Attach the clip to the bottom of the bag.	Apply ostomy pouch. This step prevents the effluent from soiling the client or bed. Figure 7.5.20 Applying ostomy pouch Attach clip to bottom of bag. Figure 7.5.21 Closing ostomy pouch
13.	Hold palm of hand over ostomy pouch for 2 minutes to assist with appliance adhering to skin.	Some flanges are heat activated and adhere better when warmth is applied.
14.	Clean up supplies, and place the client in a comfortable position. Remove garbage from the client’s room.	Removing garbage helps decrease odour.
15.	Perform hand hygiene.	This minimizes the transmission of microorganisms.
16.	Document procedure.	Follow agency policy for documentation. Document the appearance of the stoma and peristomal skin, products used, and the client’s ability to tolerate procedure and assistance with procedure.

Procedure Video

The following video provides the best demonstration of the skills for how to empty and change an ostomy flange and bag.

Stool Specimen Collection

Stool samples are collected from clients to test for cancer, parasites, or occult blood (i.e., hidden blood). Follow specific instructions from the facility/agency where you are working for collecting the sample.

To collect a sample, perform the following steps:

• Explain the procedure to the client. Instruct them to flush the toilet before defecating to remove any potential chemicals and to not place toilet paper in the toilet after defecating. Request they notify you when they have had a bowel movement.
• Review the manufacturer’s instructions because different test kits may have different instructions.
• Contact the laboratory with any questions.
• Label the card with the patient’s name and medical information as per agency policy. Open the flap of the guaiac test card.
• Apply non-sterile 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 labelled test card in a transport bag and send it to the laboratory for analysis.
• If you are working in an agency where nurses apply the guaiac developer solution to the card, allow the specimen to dry for 3–5 minutes. Open the reverse side of the card and apply two drops of guaiac developer solution to each square. A blue reaction will occur within 60 seconds if the test is positive. The absence of a blue colour after 60 seconds is considered a negative test.
• Document the date and time of the test and any unusual characteristics of the stool sample.

Chapter 7 Attributions and References

Unit 7.2 Image Attributions

• Figure 7.2.1 Urine Hydration Chart by Aishik Rehman, via Wikimedia Commons, is licensed under a CC BY-SA 4.0 licence.
• Figure 7.2.2 Home Care Bedpans & Urinals by BruceBlaus, via Wikimedia Commons, is licensed under a CC BY-SA 4.0 licence.
• Figure 7.2.3 Condom Catheter by BruceBlaus, via Wikimedia Commons, is licensed under a CC BY-SA 4.0 licence.
• Figure 7.2.4 Urinary Drainage Bag by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence. 
• Figure 7.2.5 Drainage Bag Position by BruceBlaus, via Wikimedia Commons, is licensed under a CC BY-SA 4.0 licence.
• Figure 7.2.6 Empty the Drainage Bag by BruceBlaus, via Wikimedia Commons, is licensed under a CC BY-SA 4.0 licence.
• Figure 7.2.7 Incontinence product by Hadifn, via Wikimedia Commons, is licensed under a CC BY-SA 4.0 licence.

Unit 7.3 Image Attributions

• Figure 7.3.1 Bristol Stool Chart by John C Bullas, via Flickr, is licsensed under a CC BY-NC-ND 2.0 licence.
• Figure 7.3.2 Gloves by CDC, via Wikimedia Commons, is in the public domain.
• Figure 7.3.3 Disposable Enema by Helena4780, via Wikimedia Commons, is licensed under a CC BY-SA-4.0 licence.
• Figure 7.3.4 Lubricate tip of suppository or enema from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.3.5 Dispose of gloves from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.3.6 Using an ABHR by Kelly Sikkema on Unsplash, is used under the Unsplash License.
• Figure 7.3.7 Ensure call bell is available to client by Kim Morris, HCA Program/ Thompson Rivers University, is used under a CC BY 2.0 licence. 

Unit 7.4 Image Attributions

• Figure 7.4.1 Urine Specimen by Turbotorque, via Wikimedia Commons, is in the public domain.

Unit 7.5 Image Attributions

• Figure 7.5.1 Stoma by Salicyna, via Wikimedia Commons, is licensed under a CC BY-SA-4.0 licence.
• Figure 7.5.2 Location of Ileostomy by BruceBlaus, via Wikimedia Commons, is licensed under a CC BY-SA-4.0 licence.
• Figure 7.5.3 Colostomy Types by BruceBlaus, via Wikimedia Commons, is used under a CC BY 3.0 licence.
• Figure 7.5.4 Ostomy Barrier by Eric Polsinelli, via Wikimedia Commons, is licensed under a CC BY-SA-4.0 licence.
• Figure 7.5.5 Ostomy Pouch by Salicyna, via Wikimedia Commons, is licensed under a CC BY-SA-4.0 licence.
• Figure 7.5.6 Hand Hygiene by Arlington County, via Flickr, is licensed under CC BY-SA 2.0 licence.
• Figure 7.5.7 Ostomy Supplies from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.8 Removing an Ostomy Bag, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.9 Removing a Flange, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.10 Cleaning a Stoma, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.11 Healthy Stoma, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.12 Measuring Stoma Size, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.13 Cutting Flange to Size, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.14 Fitting Flange to Stoma, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.15 Prepping Peristomal Skin, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.16 Applying Stomahesive Paste, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.17 Preparing Flange, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.18 Applying Flange, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.19 Applying Ostomy Pouch, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.20 Applying Ostomy Pouch, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.
• Figure 7.5.21 Closing Ostomy Pouch, from Anderson, Doyle & McCutcheon (2018), via BCcampus, is used under a CC BY 4.0 licence.

Videos

• What Your Urine Colour Says About Your Health | Urinary System Breakdown | #DeepDives by Health (2021) is licensed under a Standard YouTube License.
• Urinary Tract Infections, Animation by Alila Medical Media (2016) is licensed under a Standard YouTube License.
• How to use a Bedpan – Tips for Caregivers by CareChannel (2019) is licensed under a Standard YouTube License.
• Assisting with a Urinal by Ashraf Z Qotmosh (2020) is licensed under a Standard YouTube License.
• How to Apply a Condom Catheter, by University of Manitoba Nursing Skills (2018) is licensed under a Standard YouTube License.
• How to Perform Perineal Care with an Indwelling Catheter, by University of Manitoba Nursing Skills (2018) is licensed under a Standard YouTube License.
• Empty Urinary Drainage Bag CNA Skill NEW, by 4yourCNA (2016) is licensed under a Standard YouTube License.

References

Anderson, R., Doyle, G. R., & McCutcheon, J. A. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Thompson Rivers University. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn//

Berman, A. J., & Snyder S. (2016). Skills in clinical nursing (8th ed.). Pearson.

British Columbia Institute of Technology (BCIT). (2015b). Clinical techniques. In NURS 2020. BCIT. https://circuit.bcit.ca/islandora/object/coutlines%3A400

Blausen.com Staff. (2014). Medical gallery of Blausen Medical 2014. Wikijournal of Medicine, 1(2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

Convatech. (2018). Ostomy care video library. https://www.convatec.com/videos/ostomy-videos/.

Lilley, L., Rainforth Collins, S., Snyder, J., & Swart, B. (2016). Pharmacology for Canadian health care practice (3rd Canadian ed.). Elsevier.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing skills and techniques (9th ed.). Elsevier-Mosby.

United Ostomy Association of America. (2017). Ileostomy guide. http://www.ostomy.org/uploaded/files/ostomy_info/IleostomyGuide.pdf?direct=1.

In health care, all client-handling activities, such as positioning, transfers, and ambulation, are considered high risk for injury to clients and health care providers. This unit reviews the essential guidelines for safe transfer and moving techniques to minimize and eliminate injury in health care. When transferring clients, it is important to consider proper body mechanics (see Unit 3 Body Mechanics).

When it comes to a lift or a transfer, different terminology is used in different workplaces. A liftrefers to using a mechanical device designed to move a client who cannot bear weight on at least one leg, including horizontal or vertical lifts to reposition clients on a bed. A lift is used when the client is incapable of assisting with mobility. A transferis a shared dynamic and cooperative effort in which the client who is able to bear weight on at least one leg helps the care provider with the transfer.

Assisting with Transfers, Turning, and Positioning 

Turning and Positioning the Client 

Figure 8.2.1 Common pressure ulcer sites

Turning a client in bed is an important task of the HCA. It is very important to protect the client’s skin any time they are turned or moved. Friction and shearing can cause skin breakdown and injury. Friction and shearing can also occur when the client slides down in bed. To reduce friction and use a draw sheet when moving a client. When lifting or moving clients in bed use at least two people to assist as often as possible. Never pull on a client’s body part to lift or turn them, as this can cause a serious injury.

Clients should be turned every 2 hours to prevent the development of pressure ulcers (See Figure 8.2.1). There are a number of positions in which a client can be placed. Alternate the positions used to help prevent pressure ulcers and to provide client comfort. Position pillows under bony areas to prevent pressure ulcers. If clients prefer to stay in one particular position, a pillow should be placed under one buttock or hip to prevent pressure ulcers. This pillow can be rotated to the other side with the next position change. For example, the client has a pillow placed under their right buttock at 10 am. With the 12 noon turn and position, the pillow can be moved to under the left buttock.

Before repositioning the client, the HCA should also offer the use of the toilet, bedpan, or urinal. Clients should also be offered a glass of water at this time to ensure proper hydration. Ensure the client’s body is in proper alignment once you are done positioning them, and that pillows are used to support body parts.

Point-of-Care Risk Assessment for Safer Client Handling 

To prevent and minimize MSI injuries related to client handling activities, a point-of-care risk assessment must be done to determine a client’s ability to move, the need for assistance, and the most appropriate means of assistance (Provincial Health Services Authority [PHSA], 2010). There are four important areas to observe and evaluate in order to complete the point-of-care risk assessment:

• The client
• The environment
• The health care provider
• The organization of the work

Checklist 8.2.1 outlines these four areas and what to consider prior to positioning, ambulation, and transfers.

Checklist 8.2.1: Point-of-Care Risk Assessment for Safer Client Handling.

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Safety considerations: 

• The assessment process should not override client-specific needs as determined by the health care team.
• The assessment should be performed before each handling procedure.
• Seek additional help if a procedure requires two or more persons.
• Use assistive devices (gait belts, slider boards, pillows, etc.) to perform the procedure safely.
• Observe and evaluate the client’s ability to tolerate the movement. Acute pain, shortness of breath, and inability to follow directions will place the health care provider and client at risk for injury.
• Always consider the principles of proper body mechanics prior to any procedure, such as raising the head of bed and tucking elbows in to help prevent injuries.
• Avoid lifting shoulders when positioning a client.
• Never lift a client; always use a weight shift to perform the procedure.
• When positioning a client using a sheet, place palms of hands up. A palms-down technique increases risk for injury.
• Vision and hearing impairments as well as language barriers can make communicating with the client difficult and can result in increased risk for injury.
• Ensure the plan of care is updated regularly.

Table 8.2.1 Procedure for Point-of-Care Risk Assessment for Safer Client Handling 

STEP	ACTION	ADDITIONAL CONSIDERATIONS
1.	Observe and evaluate your client.	There are three areas: Is the client cooperative and able to follow directions? Ask the client to squeeze your hands. Is the behaviour predictable (non-aggressive, not fearful, or not fatigued)? Is the client able to follow directions with cues? If yes, proceed to the next question. If no, use a mechanical lift for transfers and/or assistive devices for repositioning in bed if the client has some abilities. Can the client bear weight? Ask the client to lift their buttocks off the bed (also known as “bridging”), and hold the position for 5 seconds. The health care provider may give cues on how to lift buttocks off the bed. Figure 8.2.2 Bridging hips strength test After bridging, ask the client to perform a straight leg raise by lifting one leg up off the bed and holding it for 5 seconds while the other leg is kept bent. Repeat with the opposite leg. Figure 8.2.3 Leg lift strength test If yes, proceed to next question. If no, use an appropriate moving technique, such as a mechanical lift and/or assistive device, to transfer a non-weight-bearing client. Can the client sit up on the side of the bed without support? Can the client sit forward on a chair or the edge of the bed without support? Figure 8.2.4 Sit unassisted on the bed If yes, decide on the amount of assist required (minimum, moderate, or maximum) according to your agency policy. If no, use a mechanical lift for transfers and/or an assistive device for repositioning if client has some movement abilities. A point-of-care risk assessment also involves knowing any activity restrictions associated with recent surgery or injury.
2.	Observe and evaluate your environment.	Is there adequate space? Is available equipment in proper working order? Have all hazards been removed?
3.	Observe and evaluate yourself for readiness to perform procedures.	Complete all required training according to health agency regulations. Wear non-slip footwear. Maintain a neutral spine; do not twist or side bend; and use proper body mechanics when moving or positioning clients. Designate a leader if working in a team to mobilize or position a client. Always use proper weight-shift techniques (side to side, front to back, and up and down).
4.	Observe and evaluate your work organization.	Ensure adequate number of caregivers. Ensure there is enough time to perform the procedure. Take rest breaks and vary activities to promote optimal back health. If the client is complex or bariatric, consult additional resources, seek assistance, and use assistive devices.

The following are useful resources to help you further develop your understanding of point-of-care risk assessment and decision making around client handling activities. 

Read the Mobility Decision Support Tool flowchart, which was provincially developed, to guide decision making about transfers and ambulation.

Watch the Assess Every Time video, which was developed by WorkSafeBC, to review the quick point-of-care risk assessment as described in Checklist 8.2.1.

Critical Thinking Exercises 

1. Name five things the health care worker should evaluate about themselves when considering their own ability to perform a client-handling procedure?
2. Vision impairments, hearing impairments, and language barriers are risk factors when performing client-handling procedures. What additional client risk factors should be considered?