Fundamentals of Nursing Skills Lab Quick Sheet

Fundamentals of Nursing Skills Lab Quick Sheet
1. Performing Hand Hygiene

Always practice hand hygiene before and after giving care or
handling dirty equipment. This is the best way to prevent the spread
of infection.
PROCEDURE:
Hand Washing
1. Review the information under Safety and Comfort.
2. Make sure you have soap, paper towels, an orangewood stick or nail
file, and a wastebasket. Collect missing items.
3. Push your watch and any long sleeves up your arm 4 to 5 inches. If
your uniform sleeves are long, push them up too.
4. Stand away from the sink so your clothes do not touch it and so the
soap and faucet are easy to reach. Do not touch the inside of the
sink at any time.
5. Turn on and adjust the water until it feels warm.
6. Wet your wrists and hands. Keep your hands lower than your
elbows. Be sure to wet the area 3 to 4 inches above your wrists.
7. Apply about 1 teaspoon of soap to your hands.
8. Rub your palms together and interlace your fingers to work up a

good lather. Lather your wrists, hands, and fingers. Keep your hands
lower than your elbows. Wash for at least 15 to 20 seconds.
9. Wash each hand and wrist thoroughly. Clean the back of your fingers
and between your fingers.
10. Clean under the fingernails. Rub your fingertips against your
palms.
11. Clean under the fingernails with a nail file or orangewood

stick. Do this at the first hand washing of the day and when your
hands are highly soiled.
12. Rinse your wrists, hands, and fingers well. Let water flow from
your wrists to your fingertips.
13. Repeat steps 7 through 12, if needed.
14. Dry your wrists and hands well with clean, dry, paper towels.
Pat dry starting at your fingertips.
15. Discard the paper towels into the wastebasket.
16. Turn off faucets with clean, dry paper towels. This prevents
you from contaminating your hands. Use a clean paper towel for
each faucet. Or use knee or foot controls to turn off the faucet.
Using an Alcohol-Based Hand Rub ABHR
2. Apply a palmful of an alcohol-based hand rub into a cupped hand.
3. Rub your palms together.
4. Rub the palm of 1 hand over the back of the other. Do the same for
the other hand.
5. Rub your palms together with your fingers interlaced.
6. Interlock your fingers. Rub your fingers back and forth.
7. Rub the thumb of 1 hand in the palm of the other. Do the same for
the other thumb.
8. Rub the fingers of 1 hand into the palm of the other. Use a circular
motion. Do the same for the fingers on the other hand.
9. Continue rubbing your hands until they are dry.
Extended Text
Always practice hand hygiene before and after giving care or

handling dirty equipment. This is the best way to prevent the
spread of infection.
OVERVIEW
Hand hygiene is the easiest and most important way to prevent the
spread of infection. The hands can pick up microbes from a person, place,
or thing and transfer them to other people, places, and things. That is why
hand hygiene is so very important.
The nursing assistant can perform hand hygiene by:
 Washing with soap and water.
 Using an alcohol-based hand rub.
SUPPLIES
See Supplies tab at the top of the page.

PREPARATION
Plan to wash your hands with soap and water:
 When they are visibly dirty or soiled with blood, body fluids,
secretions, or excretions.
 Before eating.
 After using the restroom.
 If exposure to anthrax spore is suspected or proven.
 If an alcohol-based hand rub is not available.
Use an antiseptic hand rub if your hands are not visibly soiled:
 Before direct contact with a person.
 After contact with the person’s intact skin.
 After contact with body fluids or excretions, mucous membranes,

non-intact skin, and wound dressings, if hands are not visibly soiled.
 When moving from a contaminated body site to a clean body site

during care.
 After contact with objects in the care setting.
 After removing gloves.
PROCEDURE
Hand Washing
2. Make sure you have soap, paper towels, an orangewood stick or nail
file, and a wastebasket. Collect missing items.
3. Push your watch and any long sleeves up your arm 4 to 5 inches. If
your uniform sleeves are long, push them up too.
4. Stand away from the sink so your clothes do not touch it and so the
soap and faucet are easy to reach. Do not touch the inside of the
sink at any time.
5. Turn on and adjust the water until it feels warm.
6. Wet your wrists and hands. Keep your hands lower than your
elbows. Be sure to wet the area 3 to 4 inches above your wrists.
7. Apply about 1 teaspoon of soap to your hands.

8. Rub your palms together and interlace your fingers to work up a
good lather. Lather your wrists, hands, and fingers. Keep your hands
lower than your elbows. Wash for at least 15 to 20 seconds.
9. Wash each hand and wrist thoroughly. Clean the back of your fingers
and between your fingers.
10. Clean under the fingernails. Rub your fingertips against your
palms.
11. Clean under the fingernails with a nail file or orangewood

stick. Do this at the first hand washing of the day and when your
hands are highly soiled.
12. Rinse your wrists, hands, and fingers well. Let water flow from
your wrists to your fingertips.
13. Repeat steps 7 through 12, if needed.
14. Dry your wrists and hands well with clean, dry, paper towels.
Pat dry starting at your fingertips.
16. Turn off faucets with clean, dry paper towels. This prevents
you from contaminating your hands. Use a clean paper towel for
each faucet. Or use knee or foot controls to turn off the faucet.
Using an Alcohol-Based Hand Rub
2. Apply a palmful of an alcohol-based hand rub into a cupped hand.
3. Rub your palms together.
4. Rub the palm of 1 hand over the back of the other. Do the same for
the other hand.
5. Rub your palms together with your fingers interlaced.
6. Interlock your fingers. Rub your fingers back and forth.
7. Rub the thumb of 1 hand in the palm of the other. Do the same for
the other thumb.
8. Rub the fingers of 1 hand into the palm of the other. Use a circular
motion. Do the same for the fingers on the other hand.
9. Continue rubbing your hands until they are dry.

2. PPE Quick Sheet
ALERT
 Don appropriate PPE based on the patient’s signs and

symptoms and indications for isolation precautions.
o Determine whether the patient has a known or

suspected airborne transmissible disease. Wear
respiratory protection, such as an N95 respirator or
disposable particulate respirator, when caring for a
patient with a known or suspected airborne
transmissible disease.
o Wear PPE when the anticipated patient interaction

indicates that contact with blood or bodily fluids may
occur. Wear gloves when it is likely that you will touch
blood, bodily fluids, secretions, excretions, nonintact
skin, mucous membranes, or contaminated items or
surfaces.
o Remove your gloves and perform hand hygiene

between patient care encounters and when moving
from a contaminated body site to a clean one.
o Perform hand hygiene with soap and water or use an

alcohol-based hand rub (ABHR) immediately after
removing all PPE.
o Use synthetic nonlatex gloves with patients at high risk

for or with known or suspected sensitivity to latex.
Nurses who have sensitivity or allergy to latex should
also use nonlatex gloves.
o Hypoallergenic, low-powder, and low-protein latex

gloves may still contain enough latex protein to cause
an allergic reaction.
o Protect fellow health care workers from exposure to

infectious agents through proper use and disposal of
equipment.
 Place patients who require airborne isolation in a negative-
pressure airborne infection isolation room (AIIR).
o If an AIIR is not available, place a surgical mask on the

patient.
 The door to the isolation room and the anteroom should

never be open at the same time.
1. Assess the patient and review the patient's history.
2. Verify the health care provider's orders to determine which isolation

precautions need to be used (i.e., contact, droplet, airborne, etc.).
3. Gather the necessary equipment and supplies.
4. Perform hand hygiene.
5. Prepare to enter the isolation room. Your choice of barrier protection

will depend on the type of isolation the patient has been prescribed
(e.g., contact, droplet, airborne infection) and on your agency’s
policy. For example, if Airborne Precautions are being observed for
the patient, apply only a special mask and keep the room door
closed.
a. Apply a gown, making sure it covers all of your outer

garments. Pull the sleeves down to the wrist, and tie the gown
securely at the neck and waist.
b. Apply either a surgical mask, a mask with a face shield, or a

fitted N95 respirator around your mouth and nose. The type of
mask and fit-testing will depend on the type of isolation the
patient has been prescribed and on your agency’s policy. You
must have a medical evaluation and be fit-tested before using
a respirator. Donning an N95 respirator:
i. Hold the N95 respirator in the palm of the hand with the
straps facing the floor.
ii. Place the respirator on the face, covering the nose and
mouth.
iii. Pull the bottom strap up and over the top of the head
and position it behind the head, below the ears.
iv. Take the upper strap and position it behind the head,
toward the crown of the head.
v. Mold the respirator nosepiece snugly over the bridge of

the nose to obtain a tight seal.
vi. Palpate the mask to ensure an adequate seal all around
the face.
vii. Follow the manufacturer’s instructions for wearing the

N95 respirator to ensure a snug fit.
c. If eye wear or goggles are needed, fit them snugly around

over your face and eyes or over prescription glasses. A face
shield may be used to protect the membranes of the eyes,
nose, and mouth when performing tasks that could generate
sprays of blood or other bodily fluids.
d. Apply clean gloves that are unpowdered. If you or the patient

has a latex allergy, the gloves should be latex free. Bring the
glove cuffs over the wrists of the gown sleeves.
6. Enter the patient’s isolation room and close the door. Arrange any
supplies and equipment brought into the patient’s isolation room.
Follow agency policy for items to be reused or cleaned. If additional
supplies are needed, enlist another health care team member to
hand in new supplies without entering the room.
7. Introduce yourself to the patient and the family.
8. Identify the patient using two identifiers, such as name and date of
birth or name and account number, according to agency policy.
Compare these identifiers with the information on the patient's
identification bracelet.
9. Explain the procedure to the patient and ensure that he or she

agrees to treatment. Give patient and family an opportunity to ask
questions. Assess the patient and family for emotions related to
isolation precautions, such as loneliness or boredom, and for signs
or symptoms of depression, for example, decrease or lack of
appetite or difficulty sleeping.
10. Administer medications as ordered while maintaining standard

and isolation precautions.
a. Provide oral medication in a wrapper or cup and then discard

the wrapper or cup in the proper trash receptacle in the
patient’s room.
b. Wear gloves when administering injections.
c. Discard disposable syringes and uncapped or sheathed

needles in the proper sharps receptacle in the patient’s room.
d. Place the reusable plastic syringe holder, if used, on a towel
for eventual removal and disinfection after leaving the
patient’s room.
11. Provide designated care to the patient while maintaining the

correctly designated isolation precautions to limit the spread of
contamination. Keep hands away from own face. Limit touching
surfaces in the room. Remove gloves when torn or heavily
contaminated, perform hand hygiene, and don clean gloves.
12. When finished caring for your patient, let him or her know
when you plan to return. Ask the patient if he or she needs any
personal care items or has questions before leaving the room. Offer
to provide books, magazines, or audiotapes, if available, to help him
or her feel less isolated while alone in the room. Explain to the
patient when you plan to return to the room.
13. At the completion of care, prepare to leave the patient's

isolation room. Dispose of all contaminated supplies and equipment
in a way that prevents the spread of microorganisms to other
people. Follow agency policy regarding the disposal of contaminated
equipment and supplies.
14. Remember to close the door if Airborne Precautions are being

observed or if the patient is in a negative airflow room.
15. The order in which you remove protective barrier equipment

will depend on what you wear in the isolation room. The following
sequence describes the steps to take if you are wearing all barriers:
a. Inspect PPE for visible contamination, cuts, or tears before

starting the doffing process. If PPE is potentially contaminated,
disinfect PPE per agency policy allow it to dry.
b. First remove your gloves.
i. If a glove is visibly soiled, cut, or torn, remove and

discard the gloves, perform hand hygiene with ABHR on
bare hands, and don clean gloves.
ii. If no visible contamination, cuts, or tears are identified

on the outer surfaces of the gloves, remove and discard
the gloves and perform hand hygiene with ABHR on bare
hands.
iii. If a cut or tear is detected on a glove, immediately

review and follow the organization’s practice for
occupation exposure risk.
iv. Remove the first glove by grasping the cuff and pulling
the glove inside out, over your hand. Hold the glove
you’ve removed in your remaining gloved hand. Slide
the fingers of your ungloved hand under the remaining
glove at the level of your wrist. Peel the glove off over
the first glove. Then discard both gloves in the proper
container. Do not touch the outer surface of the gloves;
it is considered contaminated.
c. Remove your eye wear, face shield, or goggles from the back
of the head by lifting the headband or earpieces up and over
the head. The clear faceplate of a face shield may become
contaminated with droplets; therefore, do not touch the outer
surface of the eye protection or face shield. Discard the item
in the proper container. Disinfect reusable eye protection after
each use per the organization’s practice.
d. Remove the gown by first untying the neck strings or

VELCRO® closure and then untying the back strings. Allow the
gown to fall from your shoulders; touch the inside of the gown
only. Remove your hands from the gown sleeves without
touching the outside of the gown; it is considered
contaminated. Hold the gown inside at the shoulder seams,
and fold the gown inside out into a bundle; discard it in the
linen receptacle.
e. Remove your mask. If the patient is in a negative-pressure

AIIR, leave the room and close the door before removing the
N95 respirator or PAPR (as applicable). If the mask is secured
over your ears, remove the elastic from your ears and pull the
mask away from your face. For a tie-on mask, untie
the bottom string and then the top strings before pulling the
mask away from your face. Then drop the used mask into the
trash receptacle, being careful not to touch the outer surface
of the mask, or store per the organization’s practice. Note: for
patients who are under airborne precautions, the N95 mask or
respirator should be removed outside of the patient’s room for
your protection. Don clean gloves, tilt head slightly forward,
and remove without touching the front of the mask or
respirator. Place N95 mask or respirator in appropriate
container for reuse or disposal per the organization’s practice.
Removing the N95 respirator:
i. Tilt the head forward.

ii. Using both hands, grab the bottom strap, pulling it to
the sides and over the head.
iii. Grab the upper strap with both hands and pull it to the
sides and over the head. Keep tension on the upper
strap during removal to let the mask fall forward.
iv. Discard the N95 in the proper trash receptacle or store

per the organization’s practice. Respirators are
disposable, but the same individual may use them more
than once. They should be stored between uses in a
clean, breathable container (e.g., paper bag), in a dry
place, and out of direct sunlight. Discard the respirator if
it becomes wet or damaged.
v. Remove and dispose of gloves.
f. Perform hand hygiene.
16. Document any procedures performed, how patient is handling

the isolation, and any education offered or reinforced.
Extended Text PPE
ALERT
 Don appropriate PPE based on the patient’s signs and

symptoms and indications for isolation precautions.
o Determine whether the patient has a known or

suspected airborne transmissible disease. Wear
respiratory protection, such as an N95 respirator or
disposable particulate respirator, when caring for a
patient with a known or suspected airborne
transmissible disease.1
o Wear PPE when the anticipated patient interaction

indicates that contact with blood or bodily fluids may
occur. Wear gloves when it is likely that you will touch
blood, bodily fluids, secretions, excretions, nonintact
skin, mucous membranes, or contaminated items or
surfaces.
o Remove your gloves and perform hand hygiene

between patient care encounters and when moving
from a contaminated body site to a clean one.
o Perform hand hygiene with soap and water or use an

alcohol-based hand rub (ABHR) immediately after
removing all PPE.2
o Use synthetic nonlatex gloves with patients at high risk

for or with known or suspected sensitivity to latex.
Nurses who have sensitivity or allergy to latex should
also use nonlatex gloves.
o Hypoallergenic, low-powder, and low-protein latex

gloves may still contain enough latex protein to cause
an allergic reaction.3
o Protect fellow health care workers from exposure to

infectious agents through proper use and disposal of
equipment.
 Place patients who require airborne isolation in a negative-

pressure airborne infection isolation room (AIIR).2
o If an AIIR is not available, place a surgical mask on the

patient.4
 The door to the isolation room and the anteroom should

never be open at the same time.
OVERVIEW
Although masks and caps (head coverings) are articles of personal

protective equipment (PPE) usually worn in surgical procedure areas (e.g.,
the operating room [OR]), certain sterile procedures performed at a
patient’s bedside also might require these barriers. For example, it may be
agency policy for a nurse to wear a mask, cap, and gown while inserting a
peripherally inserted central catheter (PICC). Eye protection, such as
goggles or glasses, protect the membranes of the eyes, while face shields
protect the entire face when performing tasks that could generate
splashes or sprays of blood or other bodily fluids. 5
The health care team member should wear a mask when caring for
immunosuppressed patients, patients with open wounds, or patients on
isolation precautions when those precautions require covering the nose
and mouth. Wearing a mask reduces the likelihood of microorganisms
from the person’s mouth and nose contaminating the field.
When all immediate tasks are completed, the PPE is removed carefully to
prevent self-contamination. If hands become contaminated while
removing any article of PPE, immediately perform hand hygiene with soap
and water or use an ABHR before removing the next article. All articles of
PPE should be discarded in the appropriate receptacles per the
organization’s practice. Gloves should be removed first (if worn), followed
by eye protection (goggles or face shield) and then the mask and cap.
Hand hygiene must be performed after removal of PPE and before contact
with subsequent patients.
SUPPLIES
EDUCATION
 Provide education that is developmentally and culturally appropriate

and consider the patient’s desire for knowledge, readiness to learn,
and overall neurologic and psychosocial state.
 Explain to a patient with a known or suspected airborne

transmissible disease that health care team members will wear
respiratory protection, such as an N95 respirator or disposable
particulate respirator during patient care.5
 Explain to a patient with influenza that health care team members

will wear a mask during patient care because the disease is
transmitted through the air.
 Encourage questions and answer them as they arise.
ASSESSMENT AND PREPARATION
 Assess the need for personal protective equipment (PPE) for each
task you plan to perform and for all patients, regardless of their
diagnoses.
 Review the patient’s medical history for possible indications for

isolation2, for example, risk factors for TB, major draining wound, or
purulent productive cough. Wear respiratory protection, such as an
N95 respirator or disposable particulate respirator, when caring for a
patient with a known or suspected airborne transmissible disease. 1
 Assess for signs or symptoms of airborne infections. According to

the World Health Organization (WHO), airborne transmission of
infectious pathogens occurs when droplets from the pathogen
disseminate and remain infectious when suspended in the air over
long distance and time.6 These pathogens can be spread via fine
mist, dust, aerosols, or liquids. In most cases, the pathogen causes
an inflammatory reaction of the upper airways, infecting the nose,
sinuses, throat, and lungs.6 The result of this inflammatory reaction
may cause sinus congestion, sore throat, and lower respiratory tract
symptoms.
 Review laboratory test results.
 Review the patient’s record or confer with other health care team
members regarding the patient’s emotional state and reaction and
adjustment to isolation (as needed).
 Determine from the nursing care plan, medical record, or significant

other if the patient and the family understand the purpose of
isolation procedures.
 Determine whether the patient has a known latex allergy.
 Provide correct PPE access and signage as needed.
 Gather all needed equipment and supplies before entering; limit

trips in and out of the room.
 Inspect the PPE before donning. Ensure that the PPE is intact, that
all required PPE and supplies are available, and that the correct size
of PPE has been selected.
DELEGATION
The skill of caring for patients under isolation precautions can be

delegated to nursing assistive personnel (NAP). However, you must first
assess the patient's status and isolation indications. Be sure to inform NAP
of the following:
 Special precautions regarding individual patient needs, such as

transportation to diagnostic tests.
 Precautions about bringing equipment into the patient's room.
 High-risk factors for infection transmission that pertain to the

assigned patient.
PROCEDURE
1. Assess the patient and review the patient's history.
2. Verify the health care provider's orders to determine which isolation

precautions need to be used (i.e., contact, droplet, airborne, etc.).
5. Prepare to enter the isolation room. Your choice of barrier protection

will depend on the type of isolation the patient has been prescribed
(e.g., contact, droplet, airborne infection) and on your agency’s
policy. For example, if Airborne Precautions are being observed for
the patient, apply only a special mask and keep the room door
closed.
a. Apply a gown, making sure it covers all of your outer

garments. Pull the sleeves down to the wrist, and tie the gown
securely at the neck and waist.
b. Apply either a surgical mask, a mask with face shield, or a

fitted N95 respirator around your mouth and nose. The type of
mask and fit-testing will depend on the type of isolation the
patient has been prescribed and on your agency’s policy. You
must have a medical evaluation and be fit-tested before using
a respirator. Donning an N95 respirator7:
i. Hold the N95 respirator in the palm of the hand with the
straps facing the floor.
ii. Place the respirator on the face, covering the nose and
mouth.
iii. Pull the bottom strap up and over the top of the head
and position it behind the head, below the ears.
iv. Take the upper strap and position it behind the head,
toward the crown of the head.
v. Mold the respirator nosepiece snugly over the bridge of

the nose to obtain a tight seal.
vi. Palpate the mask to ensure an adequate seal all around

the face.
vii. Follow the manufacturer’s instructions for wearing the

N95 respirator to ensure a snug fit.
c. If eye wear or goggles are needed, fit them snugly around

over your face and eyes or over prescription glasses. A face
shield may be used to protect the membranes of the eyes,
nose, and mouth when performing tasks that could generate
sprays of blood or other bodily fluids.8
d. Apply clean gloves that are unpowdered. If you or the patient
has a latex allergy, the gloves should be latex free. Bring the
glove cuffs over the wrists of the gown sleeves.
6. Enter the patient’s isolation room and close the door. Arrange any
supplies and equipment brought into the patient’s isolation room.
Follow agency policy for items to be reused or cleaned. If additional
supplies are needed, enlist another health care team member to
hand in new supplies without entering the room.
7. Introduce yourself to the patient and the family.

agrees to treatment. Give patient and family an opportunity to ask
questions. Assess the patient and family for emotions related to
isolation precautions, such as loneliness or boredom, and for signs
or symptoms of depression, for example, decrease or lack of
appetite or difficulty sleeping.
10. Administer medications as ordered while maintaining standard

and isolation precautions.
a. Provide oral medication in a wrapper or cup and then discard

the wrapper or cup in the proper trash receptacle in the
patient’s room.
b. Wear gloves when administering injections.
c. Discard disposable syringes and uncapped or sheathed

needles in the proper sharps receptacle in the patient’s room.
d. Place the reusable plastic syringe holder, if used, on a towel

for eventual removal and disinfection after leaving the
patient’s room.
11. Provide designated care to the patient while maintaining the

correctly designated isolation precautions to limit the spread of
contamination. Keep hands away from own face. Limit touching
surfaces in the room. Remove gloves when torn or heavily
contaminated, perform hand hygiene, and don clean gloves.
12. When finished caring for your patient, let him or her know
when you plan to return. Ask the patient if he or she needs any
personal care items or has questions before leaving the room. Offer
to provide books, magazines, or audiotapes, if available, to help him
or her feel less isolated while alone in the room. Explain to the
patient when you plan to return to the room.
13. At the completion of care, prepare to leave the patient’s

isolation room. Dispose of all contaminated supplies and equipment
in a way that prevents the spread of microorganisms to other
people. Follow agency policy regarding the disposal of contaminated
equipment and supplies.
14. Remember to close the door if Airborne Precautions are being

observed or if the patient is in a negative airflow room.
15. The order in which you remove protective barrier equipment

will depend on what you wear in the isolation room. The following
sequence describes the steps to take if you are wearing all barriers:
a. Inspect PPE for visible contamination, cuts, or tears before

starting the doffing process. If PPE is potentially contaminated,
disinfect PPE per agency policy allow it to dry.
b. First remove your gloves.
i. If a glove is visibly soiled, cut, or torn, remove and

discard the gloves, perform hand hygiene with ABHR on
bare hands, and don clean gloves.
ii. If no visible contamination, cuts, or tears are identified

on the outer surfaces of the gloves, remove and discard
the gloves and perform hand hygiene with ABHR on bare
hands.
iii. If a cut or tear is detected on a glove, immediately

review and follow the organization’s practice for
occupation exposure risk.
iv. Remove the first glove by grasping the cuff and pulling
the glove inside out, over your hand. Hold the glove
you’ve removed in your remaining gloved hand. Slide
the fingers of your ungloved hand under the remaining
glove at the level of your wrist. Peel the glove off over
the first glove. Then discard both gloves in the proper
container. Do not touch the outer surface of the gloves;
it is considered contaminated.
c. Remove your eye wear, face shield, or goggles from the back
of the head by lifting the headband or earpieces up and over
the head. The clear faceplate of a face shield may become
contaminated with droplets; therefore, do not touch the outer
surface of the eye protection or face shield. 9 Discard the item
in the proper container. Disinfect reusable eye protection after
each use per the organization’s practice.
d. Remove the gown by first untying the neck strings or

VELCRO® closure and then untying the back strings. Allow the
gown to fall from your shoulders; touch the inside of the gown
only. Remove your hands from the gown sleeves without
touching the outside of the gown; it is considered
contaminated. Hold the gown inside at the shoulder seams,
and fold the gown inside out into a bundle; discard it in the
linen receptacle.
e. Remove your mask. If the patient is in a negative-pressure

AIIR, leave the room and close the door before removing the
N95 respirator or PAPR (as applicable). If the mask is secured
over your ears, remove the elastic from your ears and pull the
mask away from your face. For a tie-on mask, untie
the bottom string and then the top strings before pulling the
mask away from your face. Then drop the used mask into the
trash receptacle, being careful not to touch the outer surface
of the mask, or store per the organization’s practice. Note: for
patients who are under airborne precautions, the N95 mask or
respirator should be removed outside of the patient’s room for
your protection. Don clean gloves, tilt head slightly forward,
and remove without touching the front of the mask or
respirator. Place N95 mask or respirator in appropriate
container for reuse or disposal per the organization’s practice.
Removing the N95 respirator7:
i. Tilt the head forward.
ii. Using both hands, grab the bottom strap, pulling it to

the sides and over the head.
iii. Grab the upper strap with both hands and pull it to the
sides and over the head. Keep tension on the upper
strap during removal to let the mask fall forward.
iv. Discard the N95 in the proper trash receptacle or store

per the organization’s practice. Respirators are
disposable, but the same individual may use them more
than once. They should be stored between uses in a
clean, breathable container (e.g., paper bag), in a dry
place, and out of direct sunlight. Discard the respirator if
it becomes wet or damaged.7
v. Remove and dispose of gloves.
f. Perform hand hygiene.
16. Document any procedures performed, how patient is handling

the isolation, and any education offered or reinforced.
MONITORING AND CARE
 While in the patient's room, ask if he or she has had a chance to

discuss any health problems, the course of treatment, or other
topics that are important to him or her.
 Ask the patient to describe the purpose of the isolation, and give
him or her a chance to ask questions.
 Remind the patient to cover his or her mouth with a tissue when
coughing and to wear a surgical mask when leaving the room.
EXPECTED OUTCOMES
 Appropriate PPE is chosen, worn, and discarded properly.
 Health care team members are free from airborne-transmitted

infectious illness.
 PPE is not contaminated during use.
UNEXPECTED OUTCOMES
 Appropriate PPE is not worn or is used improperly.
 Health care team members do not don and doff PPE correctly.
 Health care team members contract an airborne-transmitted

infectious illness.
 PPE is contaminated during use.
 Evidence of suspected breach of isolation precautions exists.
DOCUMENTATION
Documentation Guidelines:
Document any procedures performed (as applicable) and the patient’s

response to social isolation. Also document any patient education
performed or reinforced. Document unexpected outcomes and related
nursing interventions.
Sample Documentation:
0900 Patient in Contact Isolation for left foot wound. Changed dressing;
spouse in attendance and wearing gown and gloves; asked when isolation
would end. Explained to patient and spouse the intention of isolation and
use of antibiotics and wound care to heal the infection. Patient has books
and media the spouse brought to help with being alone in the room;
awaiting results of wound culture sent to determine need to continue
isolation; plan to return at 1030 to provide medications and discuss
discharge planning. — D. Matheson, RN. 8/21/24
PEDIATRIC CONSIDERATIONS
 Children may be afraid of health care team members wearing

masks.
 All isolation precautions should be shown to pediatric patients.

Health care team members should let pediatric patients see their
faces before applying masks so that patients do not become
frightened.
 A pediatric patient requires simple explanations, for example, “You

need to be in this room to help you get better.”
 Use caps and masks that are colored and child-friendly to decrease
child anxiety toward health care team members wearing caps and
masks (if available).
 Preschool-age and school-age children may respond well to making

a game out of wearing the mask (e.g., superheroes), which can
lessen the child’s anxiety regarding PPE.
 -------------------------------------------------------------------------------
2. Making Unoccupied BED
Quick Sheet
Print Quick Sheet
ALERT
 Follow infection control guidelines, because bed making

increases the risk of exposure to—and transmission of—
microorganisms.
 Be sure to wear clean gloves to remove soiled linen.
 Do not carry soiled linen against the body.
 Do not shake used linen and limit the time spent carrying
used linen because doing so increases the risk of
disseminating microorganisms into the air or onto clothing.
2. Introduce yourself to the patient, if present.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, if present.
5. Assess the environment for safety, such as checking the room for
spills, making sure equipment is working properly, and ensuring that
the bed is in the locked, low position. Check the position of the chair
for transfer. Pull the room divider curtain or close the room door to
provide privacy.
6. Assess activity orders and mobility restrictions in deciding whether

the patient can get out of bed for the procedure. Lower the near
side rail and help the patient into a comfortable position in bedside
recliner or other chair.
7. Clean linen should be stacked in the order that it will be used. Apply
gloves to remove the soiled linen.
8. Lower the remaining side rails on both sides of the bed, and raise
the bed to a comfortable working height. Loosen the top linen at the
foot of the bed. Remove the bedspread and blankets. If they are
soiled, fold them into bundles or squares and place them in a linen
bag or linen hamper, holding them away from your uniform. If the
blanket or bedspread is to be reused, fold into a square and place on
the chair. Remove the pillowcase and leave it on the bed. Place the
pillow on the chair.
9. Move to the other side of the bed and lower the side rail. Remove
the soiled linen, holding it away from your uniform and placing it in
a linen bag or linen hamper. Avoid shaking or fanning the linen.
10. Reposition the mattress, and wipe off any moisture using a
washcloth moistened with antiseptic solution (consult agency
housekeeping policy). Dry thoroughly.
11. Remove gloves, perform hand hygiene, and don clean gloves.
12. Apply all bottom linen on one side of the bed before moving to
the opposite side. Apply clean linens to half of the bed in separate
layers. Start with the bottom sheet by placing it lengthwise with the
center crease in the middle of the bed. Fanfold the bottom sheet to
the center of the bed. Repeat the process with the drawsheet if
needed.
a. For a fitted bottom sheet, pull it smoothly over the mattress
edges.
b. For a flat bottom sheet, perform the following steps: Spread

the flat sheet smoothly over the mattress so it hangs evenly
below the mattress’s bottom edges, leaving enough length to
allow for tucking in later. Move to the foot of the bed to ensure
that the sheet is hanging far enough below the mattress
there. The sheet’s lower hem should lie seam down and be
parallel to the bottom edge of the mattress. Move back to the
head of the bed. Pull the remaining top portion of the sheet
over the top edge of the mattress and tuck it underneath the
mattress. While standing at the head of the bed, miter the top
corner of the sheet. Pick up the upper hanging edge of the
sheet several centimeters from a point fairly close to the top
edge of the mattress. Lift the sheet and lay it on top of the
mattress to form a triangular fold, with the lower base of the
triangle even with the side edges of the mattress. Tuck in the
lower edge of the sheet, which is hanging free, under the
mattress. Hold the portion of the sheet covering the side of
the mattress in place with one hand. With the other hand, pick
up the triangular linen fold and bring it down over the side of
the mattress. Tuck with your palms down, without pulling the
triangular fold. Tuck this portion under the mattress. Tuck the
remaining portion of the sheet under the mattress, moving
toward the foot of the bed. Keep the linen smooth.
13. Optional: Apply a drawsheet and/or a waterproof pad, laying

the center fold lengthwise along the middle of the bed. Smooth the
drawsheet and/or waterproof pad over the mattress, and tuck the
excess edge under the mattress, keeping your palms down.
14. Move to the opposite side of the bed, and spread the bottom
sheet smoothly over the edge of the mattress, from the head to the
foot of the bed.
a. For a fitted sheet: Make sure the fitted sheet is placed

smoothly over the mattress, from the head to the foot of the
bed and over the mattress edges.
b. For a flat sheet: Miter the top corner of the bottom sheet,
making sure the corner is taut. Grasp the remaining edge of
the flat bottom sheet, and tuck it tightly under the mattress
while moving from the head to the foot of the bed.
15. Smooth the waterproof pad or folded drawsheet over the
bottom sheet, and tuck it under the mattress, first in the middle,
then at the top, and then at the bottom.
16. Place the top sheet over the bed with the vertical centerfold
positioned lengthwise down the middle of the bed. Open the sheet
out from head to foot, being sure the top edge of the sheet is even
with the top edge of the mattress.
17. Tuck in the remaining portion of the sheet under the foot of
the mattress. Then place the blanket over the bed, with the top
edge parallel to the top edge of the sheet and 15 to 20 cm (6 to 8
inches) down from the edge of the sheet. (Optional: Apply an
additional bedspread over the bed.)
18. Make a cuff by turning the edge of the top sheet down over
the top edge of the blanket and bedspread.
19. Standing on one side at the foot of the bed, lift the mattress
corner slightly with one hand, and with other hand tuck the top
sheet, blanket, and bedspread under the mattress. Make a modified
mitered corner with the top sheet, blanket, and bedspread. After
making a triangular fold, do not tuck the tip of the triangle.
20. Go to the other side of the bed. Make a horizontal toe pleat:
stand at the foot of the bed and fanfold the sheet 5 to 10 cm (2 to 4
inches) across the bed. Pull the sheet up from the bottom to make
the fold approximately 15 cm (6 inches) from the bottom edge of
the mattress.
21. Fanfold the sheet, blanket, and bedspread at the foot of the
bed, with the top layer ready to be pulled up (this leaves an open
bed).
22. Apply a clean pillowcase. Pick up the center of the closed end
of the pillowcase. Hold the pillowcase with a firm grip in one hand.
With the other hand, open the pillowcase from the open end and
fold the back over the closed end (inside-out). Pick up the pillow
with the hand holding the pillowcase. Invert the pillow for the
pillowcase to drape over the pillow. Pull the pillowcase over the
pillow with the other hand. Do not place the pillow or pillowcase
under the chin, in the teeth, or under the arms. Adjust the corners of
the pillowcase with the hands between the pillowcase and the
pillow. Do not shake the pillow to position the pillowcase.
23. Place the call light within the patient's reach on the bed rail or
pillow, and return the bed to its lowest position, to allow for patient
transfer. Help the patient into bed.
24. Place the linen bag into an appropriate receptacle. Remove

and dispose of your gloves.
25. Arrange and organize the patient's room, and perform hand
hygiene.
Extended Text
Print Extended Text
ALERT
 Follow infection control guidelines, because bed making

increases the risk of exposure to—and transmission of—
microorganisms.
 Be sure to wear clean gloves to remove soiled linen.
 Do not carry soiled linen against the body.1
OVERVIEW
Soiled linen can harbor pathogenic microorganisms; however, the risk of

disease transmission is negligible. Soiled linen should be handled as little
as possible and with minimal agitation to prevent microbial contamination
of the air and persons in contact with the linen. Soiled linen must be
bagged or placed in containers at the location it is used. Linen
contaminated with blood or other bodily fluids should be placed in a
clearly marked, leakproof container in the patient care area. 1
Bedmaking may be done with the patient out of the bed (unoccupied) or
in the bed (occupied). In some settings bed linen is not changed every
day; however, you always need to change any wet or soiled linen
promptly. Linens manufactured with silk or silk like fabric may reduce
friction and shear compared to cotton or cotton like linens. 2 An unoccupied
bed is one left open with the top sheets fanfolded down. A postoperative
surgical bed is prepared for patients returning from the operating room
(OR) or procedural area. The bed is left with the top sheets fanfolded
lengthwise and not tucked in to facilitate a patient’s transfer from a
stretcher. A closed bed, which is made with the top sheets pulled up to the
head of the bed, is used after a patient is discharged and housekeeping
cleans the unit.
Preventing the transfer of organisms from soiled linens to clean linens and
keeping newly applied linen smooth and wrinkle free are difficult. If
organized, the procedure can be performed quickly.
The most commonly used bed linens in health care organizations are a flat
or fitted bottom sheet, a flat top sheet, a flat sheet folded and used as a
drawsheet, a blanket or coverlet, and pillowcases.
SUPPLIES
EDUCATION
 Teach the patient and family about the importance of clean bedding;
regular linen changes; and dry, wrinkle-free linen.
 Gather all needed equipment and supplies. Obtain a linen bag and
assemble clean linen, placing it on the bedside table.
 Wear gloves when removing soiled linen. Don appropriate personal

protective equipment (PPE) based on patient’s need for isolation
precautions or risk of exposure to bodily fluids.
 Assess activity orders or restrictions on mobility or positioning, to

ensure that the patient can get out of bed for the procedure.
 Help the patient into a bedside chair, or plan to make the bed when
the patient is out of the room.
DELEGATION
The skill of making an unoccupied bed can be delegated to nursing

assistive personnel (NAP). Before delegating, be sure to inform the NAP of
the following:
 Any position or activity restrictions that affect the patient's ability to

get out of bed.
 Any special linen instructions if the patient is on an airflow mattress.
 Specify that Standard Precautions are to be used when making an

unoccupied bed.
PROCEDURE
2. Introduce yourself to the patient, if present.
4. Explain the procedure to the patient, if present.
5. Assess the environment for safety, such as checking the room for
the bed is in the locked, low position. Check the position of the chair
for transfer. Pull the room divider curtain or close the room door to
provide privacy.
6. Assess activity orders and mobility restrictions in deciding whether

the patient can get out of bed for the procedure. Lower the near
side rail and help the patient into a comfortable position in bedside
recliner or other chair.
7. Clean linen should be stacked in the order that it will be used. Apply
gloves to remove the soiled linen.
8. Lower the remaining side rails on both sides of the bed, and raise
the bed to a comfortable working height. Loosen the top linen at the
foot of the bed. Remove the bedspread and blankets. If they are
soiled, fold them into bundles or squares and place them in a linen
bag or linen hamper, holding them away from your uniform. If the
blanket or bedspread is to be reused, fold into a square and place on
the chair. Remove the pillowcase and leave it on the bed. Place the
pillow on the chair.
9. Move to the other side of the bed and lower the side rail. Remove
the soiled linen, holding it away from your uniform and placing it in
a linen bag or linen hamper. Avoid shaking or fanning the linen.
10. Reposition the mattress, and wipe off any moisture using a
washcloth moistened with antiseptic solution (consult agency
housekeeping policy). Dry thoroughly.
12. Apply all bottom linen on one side of the bed before moving to
the opposite side. Apply clean linens to half of the bed in separate
layers. Start with the bottom sheet by placing it lengthwise with the
center crease in the middle of the bed. Fanfold the bottom sheet to
the center of the bed. Repeat the process with the drawsheet if
needed.
a. For a fitted bottom sheet, pull it smoothly over the mattress
edges.
b. For a flat bottom sheet, perform the following steps: Spread

the flat sheet smoothly over the mattress so it hangs evenly
below the mattress’s bottom edges, leaving enough length to
allow for tucking in later. Move to the foot of the bed to ensure
that the sheet is hanging far enough below the mattress
there. The sheet’s lower hem should lie seam down and be
parallel to the bottom edge of the mattress. Move back to the
head of the bed. Pull the remaining top portion of the sheet
over the top edge of the mattress and tuck it underneath the
mattress. While standing at the head of the bed, miter the top
corner of the sheet. Pick up the upper hanging edge of the
sheet from a point fairly close to the top edge of the mattress.
Lift the sheet and lay it on top of the mattress to form a
triangular fold, with the lower base of the triangle even with
the side edges of the mattress. Tuck in the lower edge of the
sheet, which is hanging free, under the mattress. Hold the
portion of the sheet covering the side of the mattress in place
with one hand. With the other hand, pick up the triangular
linen fold and bring it down over the side of the mattress. Tuck
with your palms down, without pulling the triangular fold. Tuck
this portion under the mattress. Tuck the remaining portion of
the sheet under the mattress, moving toward the foot of the
bed. Keep the linen smooth.
13. Optional: Apply a drawsheet and/or a waterproof pad, laying

the center fold lengthwise along the middle of the bed. Smooth the
drawsheet and/or waterproof pad over the mattress, and tuck the
excess edge under the mattress, keeping your palms down.
14. Move to the opposite side of the bed, and spread the bottom
sheet smoothly over the edge of the mattress, from the head to the
foot of the bed.
a. For a fitted sheet: Make sure the fitted sheet is placed

smoothly over the mattress, from the head to the foot of the
bed and over the mattress edges.
b. For a flat sheet: Miter the top corner of the bottom sheet,
making sure the corner is taut. Grasp the remaining edge of
the flat bottom sheet, and tuck it tightly under the mattress
while moving from the head to the foot of the bed.
15. Smooth the waterproof pad or folded drawsheet over the
bottom sheet, and tuck it under the mattress, first in the middle,
then at the top, and then at the bottom.
16. Place the top sheet over the bed with the vertical centerfold
positioned lengthwise down the middle of the bed. Open the sheet
out from head to foot, being sure the top edge of the sheet is even
with the top edge of the mattress.
17. Tuck in the remaining portion of the sheet under the foot of
the mattress. Then place the blanket over the bed, with the top
edge parallel to the top edge of the sheet and 15 to 20 cm (6 to 8
inches) down from the edge of the sheet. (Optional: Apply an
additional bedspread over the bed.)
18. Make a cuff by turning the edge of the top sheet down over
the top edge of the blanket and bedspread.
19. Standing on one side at the foot of the bed, lift the mattress
corner slightly with one hand, and with other hand tuck the top
sheet, blanket, and bedspread under the mattress. Make a modified
mitered corner with the top sheet, blanket, and bedspread. After
making a triangular fold, do not tuck the tip of the triangle.
20. Go to the other side of the bed. Make a horizontal toe pleat:
stand at the foot of the bed and fanfold the sheet 5 to 10 cm (2 to 4
inches) across the bed. Pull the sheet up from the bottom to make
the fold approximately 15 cm (6 inches) from the bottom edge of
the mattress.
21. Fanfold the sheet, blanket, and bedspread at the foot of the
bed, with the top layer ready to be pulled up (this leaves an open
bed).
pillow with the other hand. Do not place the pillow or pillowcase
under the chin, in the teeth, or under the arms. Adjust the corners of
the pillowcase with the hands between the pillowcase and the
pillow. Do not shake the pillow to position the pillowcase.
23. Place the call light within the patient's reach on the bed rail or
pillow, and return the bed to its lowest position, to allow for patient
transfer. Help the patient into bed.
24. Place the linen bag into an appropriate receptacle. Remove

and dispose of your gloves.
25. Arrange and organize the patient's room, and perform hand
hygiene.
MONITORING AND CARE
 Help the patient back to bed.
 Ensure that the call light is within the patient's reach on the bed rail
or pillow.
 Ask if the patient is comfortable.
 Periodically check the linen for cleanliness and tightness.
 Assess, treat, and reassess pain.
EXPECTED OUTCOMES
 Patient tolerates procedure.
 New sheets are clean, dry, and wrinkle-free.
UNEXPECTED OUTCOMES
 New sheets are soiled, wet, or wrinkled.
 Patient, if present, becomes excessively fatigued.
DOCUMENTATION
 Do not document the making of an unoccupied bed.
 Report unexpected outcomes and related nursing interventions.
OLDER ADULT CONSIDERATIONS
 The skin thickness of older frail adults is decreased, leaving older

adults at greater risk for pressure injuries.3
3. Making Occupied BED
Quick Sheet
Print Quick Sheet

ALERT
 Use Standard Precautions to make an occupied bed.
 Assess the environment for safety before caring for a

patient. Check the floor for spills, and make sure all
equipment is working properly.
 Be aware of the positions in which the patient may be

turned while making the bed, so that the patient remains
safe at all times.
 If the patient is on aspiration precautions or has a

respiratory condition, keep the head of the bed no lower
than a 30-degree angle.
 If you are making the bed without assistance, ensure that

the side rails on the opposite side of the bed are raised, so
that the patient does not roll out of the bed.
 Assess the patient's ability to reposition himself or herself,

and consider making the bed with another person to ensure
the patient's safety.
used linen or carry it across the room because doing so
increases the risk of disseminating microorganisms into the
air or onto clothing.
 Do not carry soiled linen against the body.
1. Perform hand hygiene. Don appropriate personal protective

equipment (PPE) based on patient’s need for isolation precautions or
risk of exposure to bodily fluids.
2. Verify the health care provider's orders. Assess any activity or

mobility restrictions that might affect patient position as the patient
safety and comfort are of the utmost priority.
3. Assemble the necessary equipment and supplies on the bedside

table.
4. Provide for the patient's privacy.
5. Introduce yourself to the patient and family if present.
agrees to treatment. Check the floor for spills. Make sure the bed is
in locked position. Assemble the linen, placing it on a clean, dry
bedside table and in order of use.
8. Raise the bed to a comfortable working height, and lower the head
of the bed as much as the patient can comfortably tolerate. If the
patient is on aspiration precautions, keep the head of the bed no
lower than a 30-degree angle.
9. Perform hand hygiene and apply a clean pair of gloves.
10. Loosen the top linen at the foot of the bed.
11. Remove the bedspread and blanket separately. If they are

soiled, fold them into bundles or squares and place them in the linen
bag, holding them away from your body. If either is to be reused,
fold the item into a square and place it over the back of a chair.
12. Cover the patient with a temporary blanket, placing it over the
topsheet. Have the patient hold the top edge of the bath blanket, or
tuck the blanket under the patient’s shoulders. Reach beneath the
blanket and remove the topsheet. Discard the topsheet in the linen
bag.
13. Lower the side rail on your side of the bed. Help the patient
into a side-lying position, facing the opposite direction. Encourage
the patient to use the side rail to turn. Then adjust the pillow under
the patient's head.
14. Make sure no tension has been placed on any external

medical devices, such as indwelling urinary catheters, wound drains,
or intravenous tubing.
15. Stand on one side of the bed. Loosen the bottom linens,
moving from the head to the foot of the bed. Fanfold or roll the
bottom sheet and drawsheet or waterproof pad toward and under
the patient. Tuck the edges of old bottom linen alongside the
patient's buttocks, back, and shoulders. Clean, disinfect, and dry the
mattress surface, if necessary.
17. Apply clean linens to the exposed half of the bed in separate
layers. Place the fitted bottom sheet on the bed lengthwise. Secure
the top and bottom corners on the near side with the center crease
in the middle of the bed. Fanfold this layer of bedding to the center
of the bed alongside the patient's torso. Repeat this process with the
bottom sheet and the drawsheet or waterproof pad.
18. If you are using a fitted sheet, pull the sheet smoothly over
the exposed mattress corners at the top and the bottom of the bed.
If you are using a flat sheet, allow the edge of the sheet to hang
evenly below mattress’s bottom edges, leaving enough length to
allow for tucking in later. The sheet’s lower hem should lie seam
down and be aligned with the bottom edge of the mattress. Move
back to the head of the bed. Pull the remaining top portion of the
sheet over the top edge of the mattress and tuck it underneath the
mattress.
19. If the bottom sheet is flat, miter the top corner at the head of
the bed. To do so, face the head of the bed in a diagonal position.
With your hand that is farther away from the head of the bed, lift the
top corner of the mattress. With your other hand, tuck the top edge
of the bottom sheet smoothly under the mattress, so that the side
edge of the sheet above and below the mattress meets when
brought together.
20. Next, pick up the upper hanging edge of the sheet at a point
close to the top of the mattress. Lift the sheet, and lay it on top of
the mattress to form a triangular fold. Tuck in the lower, free-
hanging edge of the sheet under the mattress. Tuck with palms
down without pulling the triangular fold. Tuck this portion of the
sheet under the mattress. The lower base of the triangle should be
even with the side edges of the mattress.
21. With one hand, hold in place the portion of the sheet that
covers the side of the mattress. With the other hand, pick up the
triangular linen fold and bring it down over the side of the mattress.
22. Tuck the remaining portion of the sheet under the mattress,
moving toward the foot of the bed and keeping the linen smooth as
you go.
23. Place the open drawsheet or waterproof pad lengthwise along

the middle of the bed, and tuck the remainder under the patient's
buttocks and torso. The drawsheet or waterproof pad should be
fanfolded or rolled on top of the bottom sheet. Keep the linen under
the patient as flat as possible, because the patient will need to roll
over the new layers of linen when you are ready to make the other
side of the bed. You may also place a waterproof pad under the
drawsheet.
24. Raise the side rail, and ask the patient to turn toward the side
rail. Tell the patient that he or she will be rolling over layers of linen.
Help him or her do so if necessary. Make sure the patient turns
slowly, keeping the body in correct alignment.
25. Move to the opposite side of the bed and lower the side rail.
Help position the patient over the fanfolded linen on the other side
of the bed.
26. Loosen the edges of the soiled linen from beneath the
mattress, and remove it by folding it into a bundle or square.
27. Hold the linen away from your body, and place the soiled linen
in the linen bag.
28. Clean, disinfect, and dry the other half of the mattress as
needed.
30. Raise the side rails and perform hand hygiene.
31. Lower the side rails and pull the clean, fanfolded or rolled
linen, as well as the mattress pad and drawsheet or waterproof pad,
over the edge of the mattress from the head to the foot of the bed.
If the bottom sheet is fitted, pull the corners over the edges of the
mattress. If you are using a flat sheet, unfold and pull the sheet
toward you. Miter the top corner of the bottom flat sheet (see Steps
14 to 16).
32. Face the side of the bed, grasp the remaining edge of the
bottom flat sheet. Lean back, keeping your back straight, and pull
the sheet, tucking the excess linen under the mattress from the
head to the foot of the bed.
33. Make sure the sheets and the pad are smooth and wrinkle
free.
34. Help the patient roll back into a supine position.
35. Cover the patient with a topsheet, placing the vertical center
fold lengthwise down the middle of the bed. Open the sheet out
from head to foot as you unfold it over the patient. Be sure the top
edge of the sheet is even with the top edge of the mattress.
36. Have the patient hold on to the sheet as you remove the
temporary blanket.
37. Place a clean or reused bed blanket over the patient. Make
sure the top edge of the blanket is parallel with the top edge of the
sheet and 15 to 20 cm (6 to 8 inches) from the edge of the topsheet.
38. Go to the other side of the bed, and spread out the sheet and
the blanket evenly.
39. Make a cuff by turning the edge of the topsheet down over the
top edge of the blanket.
40. Stand at the side of the bed, tuck the remaining portion of the
sheet and blanket under the foot of the mattress. Tuck the topsheet
and blanket together, being careful not to pull out the toe pleat.
41. Make a modified mitered corner with the topsheet and blanket
simply by leaving the tip of the triangle hanging, rather than tucking
it in, after you make the triangular fold.
42. Go to the other side of the bed, and repeat Steps 37 and 38.
43. Make a horizontal toe pleat by standing at the foot of the bed
and fanfolding the sheet and blanket 5 to 10 cm (2 to 4 inches)
across the bed. Pull the sheet and blanket up from the bottom to
make a fold about 15 cm (6 inches) from the bottom edge of the
mattress.
pillow with the other hand. Do not place pillow or pillowcase under
the chin, in the teeth, or under the arms. Adjust the corners of the
pillowcase with your hands between the pillowcase and the pillow.
Do not shake the pillow to position the pillowcase.
45. Help the patient into a comfortable position. To ensure the

patient’s safety, raise the appropriate number of side rails and lower
the bed to the lowest position.
46. Place the call light within easy reach, and make sure the
patient knows how to use it to summon assistance.
47. Place the linen bag in an appropriate receptacle. Dispose of

used supplies and equipment. Remove and dispose of gloves, if
used.
48. Arrange and organize the patient’s personal items so they are
within reach.
50. Document and report the patient’s response and expected or

unexpected outcomes.
Extended Text
Print Extended Text
ALERT
 Use Standard Precautions to make an occupied bed.
 Assess the environment for safety before caring for a

patient. Check the floor for spills, and make sure all
equipment is working properly.
 Be aware of the positions in which the patient may be

turned while making the bed, so that the patient remains
safe at all times.
 If the patient is on aspiration precautions or has a

respiratory condition, keep the head of the bed no lower
than a 30-degree angle.
 If you are making the bed without assistance, ensure that

the side rails on the opposite side of the bed are raised, so
that the patient does not roll out of the bed.
 Assess the patient's ability to reposition himself or herself,

and consider making the bed with another person to ensure
the patient's safety.
 Do not carry soiled linen against the body.1
OVERVIEW
Soiled linen can harbor pathogenic microorganisms; however, the risk of

disease transmission is negligible. Soiled linen should be handled as little
as possible and with minimal agitation to prevent microbial contamination
of the air and persons in contact with the linen. Soiled linen must be
bagged or placed in containers at the location it is used. Linen
contaminated with blood or other bodily fluids should be placed in a
clearly marked, leakproof container in the patient care area. 1
At times it is necessary to make a bed that is occupied by a patient. If a
patient is confined to bed, you should make the bed in a way that
conserves time and the patient’s energy. In addition, you need to know
how to position the patient safely while the bed linens are changed.
Linens manufactured with silk or silk like fabric may reduce friction and
shear compared to cotton or cotton like linens. 2 It is easier to make an
occupied bed with two people. Try to keep the patient as comfortable as
possible. In cases in which a patient experiences severe pain, an analgesic
administered 30 to 60 minutes before a procedure helps to control pain
and maintain comfort.
Even though a patient is unable to get out of bed, encourage self-help as

much as possible. For example, a patient can turn, help in moving up in
bed, or hold topsheets while you apply linen. These activities help
maintain patient's strength and mobility and allow participation in hygiene
care.
The most commonly used bed linens in health care organizations are a flat
or fitted bottom sheet, a flat top sheet, a flat sheet folded and used as a
drawsheet, a blanket or coverlet, and pillowcases.
SUPPLIES
EDUCATION
 Explain the procedure to the patient, including that he or she will be

asked to roll his or her body over layers of linen.
 Use Standard Precautions to make an occupied bed. Apply gloves if

the linen is soiled or if there is a risk of contact with blood or bodily
fluids.
 If prescribed, administer an analgesic to the patient 30 to 60

minutes before the procedure.
 Assess the environment for safety; check the room for spills, make
sure equipment is working properly, and ensure that the bed is in
the locked, low position.
 Pull the room divider curtain or close the door to provide privacy.
 Determine if the patient has been incontinent or if there is excess

drainage on the linen.
 Assess the patient for mobility or positioning restrictions.
 Obtain a linen bag and assemble clean linen, placing it on the

bedside table.
 Lower the head of the bed, as tolerated. Raise the bed to a

comfortable working position and lower the side rail from the side
where the work will be completed. Ensure that the bed wheels are
locked to prevent unexpected movement of the bed.
DELEGATION
The skill of making an occupied bed can be delegated to nursing assistive

personnel (NAP). Be sure to inform NAP of the following:
 Specify that Standard Precautions are to be used to make an

occupied bed.
 Discuss any patient positions to avoid or activity restrictions to

observe.
 Explain how to look in the linen for wound drainage, drainage from
tubes, or IV tubing.
 Specify when to obtain help with positioning the patient during the
linen change, in order to observe good body mechanics and support
the patient's alignment.
 Review the following if the patient is on aspiration precautions:
o Keep the head of the bed no lower than a 30-degree angle.
o Report to you immediately if any excessive coughing or

choking occurs during the procedure.
PROCEDURE

2. Verify the health care provider's orders. Assess any activity or

mobility restrictions that might affect patient position as the patient
safety and comfort are of the utmost priority.
3. Assemble the necessary equipment and supplies on the bedside

table.


agrees to treatment. Check the floor for spills. Make sure the bed is
in locked position. Assemble the linen, placing it on a clean, dry
bedside table and in order of use.
8. Raise the bed to a comfortable working height, and lower the head
of the bed as much as the patient can comfortably tolerate. If the
patient is on aspiration precautions, keep the head of the bed no
lower than a 30-degree angle.
9. Perform hand hygiene and apply a clean pair of gloves.
10. Loosen the top linen at the foot of the bed.
11. Remove the bedspread and blanket separately. If they are

soiled, fold them into bundles or squares and place them in the linen
bag, holding them away from your body. If either is to be reused,
fold the item into a square and place it over the back of a chair.
12. Cover the patient with a temporary blanket, placing it over the
topsheet. Have the patient hold the top edge of the bath blanket, or
tuck the blanket under the patient’s shoulders. Reach beneath the
blanket and remove the topsheet. Discard the topsheet in the linen
bag.
13. Lower the side rail on your side of the bed. Help the patient
into a side-lying position, facing the opposite direction. Encourage
the patient to use the side rail to turn. Then adjust the pillow under
the patient's head.
14. Make sure no tension has been placed on any external

medical devices, such as indwelling urinary catheters, wound drains,
or intravenous tubing.
15. Stand on one side of the bed. Loosen the bottom linens,
moving from the head to the foot of the bed. Fanfold or roll the
bottom sheet and drawsheet or waterproof pad toward and under
the patient. Tuck the edges of old bottom linen alongside the
patient's buttocks, back, and shoulders. Clean, disinfect, and dry the
mattress surface, if necessary.
17. Apply clean linens to the exposed half of the bed in separate
layers. Place the fitted bottom sheet on the bed lengthwise. Secure
the top and bottom corners on the near side with the center crease
in the middle of the bed. Fanfold this layer of bedding to the center
of the bed alongside the patient's torso. Repeat this process with the
bottom sheet and the drawsheet or waterproof pad.
18. If you are using a fitted sheet, pull the sheet smoothly over
the exposed mattress corners at the top and the bottom of the bed.
If you are using a flat sheet, allow the edge of the sheet to hang
evenly below mattress’s bottom edges, leaving enough length to
allow for tucking in later. The sheet’s lower hem should lie seam
down and be aligned with the bottom edge of the mattress. Move
back to the head of the bed. Pull the remaining top portion of the
sheet over the top edge of the mattress and tuck it underneath the
mattress.
19. If the bottom sheet is flat, miter the top corner at the head of
the bed. To do so, face the head of the bed in a diagonal position.
With your hand that is farther away from the head of the bed, lift the
top corner of the mattress. With your other hand, tuck the top edge
of the bottom sheet smoothly under the mattress, so that the side
edge of the sheet above and below the mattress meets when
brought together.
20. Next, pick up the upper hanging edge of the sheet at a point
close to the top edge of the mattress. Lift the sheet, and lay it on
top of the mattress to form a triangular fold. Tuck in the lower, free-
hanging edge of the sheet under the mattress. Tuck with palms
down without pulling the triangular fold. Tuck this portion of the
sheet under the mattress. The lower base of the triangle should be
even with the side edges of the mattress.
21. With one hand, hold in place the portion of the sheet that
covers the side of the mattress. With the other hand, pick up the
triangular linen fold and bring it down over the side of the mattress.
22. Tuck the remaining portion of the sheet under the mattress,
moving toward the foot of the bed and keeping the linen smooth as
you go.
23. Place the open drawsheet or waterproof pad lengthwise along

the middle of the bed, and tuck the remainder under the patient's
buttocks and torso. The drawsheet or waterproof pad should be
fanfolded or rolled on top of the bottom sheet. Keep the linen under
the patient as flat as possible, because the patient will need to roll
over the new layers of linen when you are ready to make the other
side of the bed. You may also place a waterproof pad under the
drawsheet.
24. Raise the side rail, and ask the patient to turn toward the side
rail. Tell the patient that he or she will be rolling over layers of linen.
Help him or her do so if necessary. Make sure the patient turns
slowly, keeping the body in correct alignment.
25. Move to the opposite side of the bed and lower the side rail.
Help position the patient over the fanfolded linen on the other side
of the bed.
26. Loosen the edges of the soiled linen from beneath the
mattress, and remove it by folding it into a bundle or square.
27. Hold the linen away from your body, and place the soiled linen
in the linen bag.
28. Clean, disinfect, and dry the other half of the mattress as
needed.
30. Raise the side rails and perform hand hygiene.
31. Lower the side rails and pull the clean, fanfolded or rolled
linen, as well as the mattress pad and drawsheet or waterproof pad,
over the edge of the mattress from the head to the foot of the bed.
If the bottom sheet is fitted, pull the corners over the edges of the
mattress. If you are using a flat sheet, unfold and pull the sheet
toward you. Miter the top corner of the bottom flat sheet (see Steps
14 to 16).
32. Face the side of the bed, grasp the remaining edge of the
bottom flat sheet. Lean back, keeping your back straight, and pull
the sheet, tucking the excess linen under the mattress from the
head to the foot of the bed.
33. Make sure the sheets and the pad are smooth and wrinkle
free.
34. Help the patient roll back into a supine position.
35. Cover the patient with a topsheet, placing the vertical center
fold lengthwise down the middle of the bed. Open the sheet out
from head to foot as you unfold it over the patient. Be sure the top
edge of the sheet is even with the top edge of the mattress.
36. Have the patient hold on to the sheet as you remove the
temporary blanket.
37. Place a clean or reused bed blanket over the patient. Make
sure the top edge of the blanket is parallel with the top edge of the
sheet and 15 to 20 cm (6 to 8 inches) from the edge of the topsheet.
38. Go to the other side of the bed, and spread out the sheet and
the blanket evenly.
39. Make a cuff by turning the edge of the topsheet down over the
top edge of the blanket.
40. Stand at the side of the bed, tuck the remaining portion of the
sheet and blanket under the foot of the mattress. Tuck the topsheet
and blanket together, being careful not to pull out the toe pleat.
41. Make a modified mitered corner with the topsheet and blanket
simply by leaving the tip of the triangle hanging, rather than tucking
it in, after you make the triangular fold.
42. Go to the other side of the bed, and repeat Steps 37 and 38.
43. Make a horizontal toe pleat by standing at the foot of the bed
and fanfolding the sheet and blanket 5 to 10 cm (2 to 4 inches)
across the bed. Pull the sheet and blanket up from the bottom to
make a fold about 15 cm (6 inches) from the bottom edge of the
mattress.
pillow with the other hand. Do not place pillow or pillowcase under
the chin, in the teeth, or under the arms. Adjust the corners of the
pillowcase with your hands between the pillowcase and the pillow.
Do not shake the pillow to position the pillowcase.
45. Help the patient into a comfortable position. To ensure the

patient's safety, raise the appropriate number of side rails and lower
the bed to the lowest position.
47. Place the linen bag in an appropriate receptacle. Dispose of
used supplies and equipment. Remove and dispose of gloves, if
used.
48. Arrange and organize the patient's personal items so they are
within reach.
50. Document and report the patient's response and expected or

MONITORING AND CARE
 Ask if the patient is comfortable.
 Observe the patient for signs of fatigue, dyspnea, pain, or

discomfort.
 Periodically check the linen for cleanliness and tightness.
EXPECTED OUTCOMES
 Patient tolerates procedure.
 New sheets are clean, dry, and wrinkle free.
UNEXPECTED OUTCOMES
 New sheets are soiled, wet, and wrinkled.
 Patient becomes excessively fatigued and unable to cooperate with

turning.
DOCUMENTATION
Do not document the making of an occupied bed.
 Report unexpected outcomes and related nursing interventions
 The skin thickness of older frail adults is decreased, leaving older

adults at greater risk for pressure injuries.3
Performing Partial OR Complete Bed Bath
 Assess and control the bathwater temperature, especially

for patients with reduced sensation.
 Do not soak the feet of a patient with diabetes or peripheral

vascular disease.
 To avoid injuring the eyes, ask the patient if he is wearing
contact lenses.
 Avoid using force and friction when bathing a patient. Do

not massage reddened areas, especially over bony
prominences. Massage of the legs is also contraindicated,
because a blood clot may be present and could become
dislodged. Do not use massage for pressure injury
prevention. Pat skin dry and avoid rubbing.
 If one of a patient’s extremities is injured or immobilized,

dress the affected side first.
 Protect the patient from injury by assessing and controlling

the bathwater temperature. This is especially important for
older adult patients and those with reduced sensation, such
as patients who have diabetes, peripheral neuropathy, or
spinal cord injuries and for those who cannot communicate.
 Do not allow a patient with cognitive impairment or

decreased orientation to shower or bathe independently.
 Some hospitals use prepackaged disposable bed baths in

place of a bath basin.
1. Verify the health care provider's orders.
4. Provide for patient privacy.
5. Introduce yourself to the patient and family, if present.

agrees to the treatment.
8. Assess the patient's tolerance for bathing and activity, comfort

level, cognitive ability and musculoskeletal function. Assess for
shortness of breath. Before or during the bath, assess the condition
of the patient's skin.
9. Encourage the patient to void prior to beginning the bath. Offer the
patient a bedpan or urinal. Provide a towel and washcloth.
10. Apply clean gloves.
11. Arrange all supplies on the overbed table.
12. Raise the bed to a comfortable working height. Lower the rail
on your side, and help the patient assume a comfortable supine
position, maintaining body alignment.
13. Place a bath blanket or towel over the patient to provide

warmth and privacy during the bath. Have the patient hold the top
of the bath blanket or towel, and remove the top sheet from
beneath the bath blanket or towel without exposing the patient.
Place soiled linen in the dirty linen bag.
14. Remove the patient’s gown or pajamas using the bath blanket
or towel to cover exposed areas of the patient’s body:
a. Whether or not the patient has an intravenous line, simply

unsnap the sleeves and remove the gown.
b. If an extremity is injured or has reduced mobility, begin

removal from the unaffected side first.
c. If the patient has an intravenous line and is wearing a gown

with no snaps, remove the gown from the arm without the
intravenous line first. Then remove the gown from the arm
with the intravenous line. Pause the intravenous fluid infusion
by pressing the appropriate sensor on the intravenous pump.
Remove the intravenous container from the pole, and slide the
container and tubing through the arm of the patient's gown.
Rehang the intravenous container, check the flow rate, and
reestablish the appropriate rate if necessary. Restart the
intravenous fluid infusion by pressing the appropriate sensor
on the intravenous pump. If intravenous fluids are infusing by
gravity, check the intravenous flow rate and regulate it if
necessary. Do not disconnect the intravenous tubing to
remove the gown.
15. Raise the side rails and adjust the bed to a comfortable
working height for the bath.
16. Fill a washbasin two thirds full of warm water. Check the water
temperature, and have the patient place his or her fingers in the
water to test temperature tolerance. A safe water temperature for
an adult is about 37°C (100°F). Place a plastic bottle of body lotion
in the bathwater to warm, if desired. Remove the pillow if the
patient's condition allows. Raise the head of the bed 30 to 45
degrees. Place a bath blanket or towel under the patient’s head.
Place a second bath towel over the patient’s chest for use in drying
each body part after it has been bathed.
17. Wash the face:
a. Inquire whether the patient is wearing contact lenses.
b. Immerse the washcloth and wring it out thoroughly. Form a

mitt with a washcloth.
c. Wash the patient's eyes with plain warm water, using a clean
area of the cloth for each eye, bathing from the inner to the
outer canthus. Soak any crusts on the eyelid for 2 to 3
minutes with a damp cloth before attempting to remove them.
Dry gently and thoroughly around the eyes.
d. Ask if the patient wishes to use soap on the face. Then wash,
rinse, and dry the forehead, cheeks, nose, neck, and ears. Ask
male patients if they would like to be shaved.
e. Provide eye care for the unconscious patient.
i. Use plain, warm water on a clean washcloth to cleanse

the patient’s eyelids from the inner to the outer canthus.
Gently dry the area around the patient’s eyes.
ii. Instill prescribed eyedrops or ointment per the

physician’s order.
iii. In the absence of a blink reflex, keep the eyelids closed.

Close each eye gently, using the back of your fingertip,
before taping in place an eye patch or shield. Do not
tape the eyelid itself.
18. Wash the patient’s arms and trunk:
a. Expose the arm closest to you and place it on top of the bath
blanket or towel. Bathe the patient’s arm with water and
minimal soap, using long, firm strokes and moving in a distal
to proximal (fingers to axilla) direction. Rinse and dry the arm.
b. Raise and support the arm above the patient’s head (if
possible) to wash, rinse, and dry the axilla thoroughly. Apply
deodorant as desired.
c. Wash the hands and nails. Fold a bath blanket or towel in half,
and lay it on the bed beside the patient. Place a washbasin of
warm water on the towel. Immerse the patient’s hand, and
allow it to soak for 3 to 5 minutes, if necessary, before
cleaning beneath the fingernails. File the patient’s nails as
needed per agency policy. Remove the basin, and rinse and
dry the hand well.
d. Fold the bath blanket or towel covering the patient’s chest

down to the umbilicus. Bathe the chest, using long, firm
strokes. Take special care with the skin beneath a female
patient’s breasts, lifting each breast upward, if necessary,
using the back of the hand. Rinse and dry well.
e. Check the temperature of the bath water, and change the

water if necessary.
19. Wash the abdomen:
a. Fold the bath blanket or towel to expose the abdomen. Drape

a bath blanket or towel crosswise over the patient’s chest.
Place another over the abdomen and fold it down to just
above the pubic region. Bathe and rinse the abdomen, paying
special attention to the umbilicus and the surrounding skin
folds of the abdomen and groin. Keep the abdomen covered
between washing and rinsing. Dry well.
b. Put a clean gown or pajama top on the patient by dressing the

affected side first. If you wish, you can postpone this step until
the bath has been completed.
c. Replace the original bath blanket or towel over the patient’s

chest and abdomen for warmth.
20. Wash the patient’s legs and feet:
a. Cover the chest and abdomen with the top of the bath towel.
Expose the leg closer to you by folding the towel toward the
midline. Be sure the other leg and the perineum remain
draped. Place the towel lengthwise under the leg.
b. Wash the leg, using long, firm strokes and moving from ankle
to knee, and then from knee to thigh. As you work, assess the
leg for signs of redness, swelling, or pain. Thoroughly rinse
and dry the leg.
c. Wash the foot, making sure to clean between the toes. Clean
and file the nails as needed, or per agency policy. Rinse and
dry the toes and feet completely. Place the bath blanket or
towel used for drying in the linen bag. Cover the exposed leg
and foot.
d. Raise the side rail, move to the other side of the bed, lower
the side rail, and repeat for the other leg and foot. If the
patient’s skin is dry, apply a light layer of moisturizing lotion
to both feet. Cover the patient with a clean bath blanket or
towel. Place soiled towels in the dirty linen bag.
e. While the patient is supine, provide perineal care. See the

video skills on performing male and female perineal care.
f. Raise the side rail, and change the bathwater.
21. Wash the back:
a. Apply a clean pair of gloves. Lower the side rail. Help the
patient assume a prone or side-lying position (as applicable).
Place a clean bath blanket or towel lengthwise along the
patient’s side or back.
b. If fecal material is present, enclose it in a fold of underpad or

toilet tissue, and clean the area with disposable wipes.
c. Cleanse the buttocks and anus, moving from front to back. Pay
special attention to the folds of the buttocks and anus. Rinse
and dry the area thoroughly. If needed, place a clean
absorbent pad under the patient’s buttocks.
d. If the patient’s skin is intact, remove your gloves, and give the
patient a back massage if he or she would like one. See the
video skill on performing a back massage.
e. Place soiled linen in the linen bag.
f. Remove gloves and perform hand hygiene.
g. If the patient’s skin is intact, give the patient a back massage

if he or she would like one. See the video skill on performing a
back massage.
22. Apply body lotion to the skin and topical moisturizing agents
to dry, flaky, reddened, or scaling areas. When you are finished,
cover the patient with a bath towel.
23. Straighten the patient’s gown, or, if not done earlier, put a
clean gown or pajamas, or other clothing on the patient by dressing
the affected side first.
24. Assist the patient with additional grooming, if desired. Comb

the patient’s hair. Be aware that female patients might wish to apply
cosmetics.
25. Apply gloves, and make the patient’s bed.

26. Check the function and position of external devices, such as
indwelling catheters, nasogastric tubes, intravenous tubes, and
braces.
27. Replace the call light, and neatly arrange personal

possessions. To ensure the patient’s safety, place the bed in the
locked, low position with at least two but no more than three side
rails raised. Make sure the patient is as comfortable as possible.
28. Dispose of used supplies and equipment.

ALERT
 Assess and control the bathwater temperature, especially

for patients with reduced sensation.
 Do not soak the feet of a patient with diabetes or peripheral

vascular disease.
 To avoid injuring the eyes, ask the patient if he is wearing

contact lenses.
 Avoid using force and friction when bathing a patient. Do

not massage reddened areas, especially over bony
prominences. Massage of the legs is also contraindicated,
because a blood clot may be present and could become
dislodged. Do not use massage for pressure injury
prevention. Pat skin dry and avoid rubbing.1
 If one of a patient’s extremities is injured or immobilized,

dress the affected side first.
 Protect the patient from injury by assessing and controlling

the bathwater temperature. This is especially important for
older adult patients and those with reduced sensation, such
as patients who have diabetes, peripheral neuropathy, or
spinal cord injuries and for those who cannot communicate.

OVERVIEW
Bathing removes sweat, oil, dirt, and microorganisms from the skin. It also
stimulates circulation and provides a refreshed and relaxed feeling.
However, bathing disrupts the normal, protective, acidic pH of the skin,
especially when alkaline soaps are used. Avoiding these products helps
maintain the natural protective function of the skin. 2
The type of bathing required depends on an assessment of the patient’s

physical capabilities and the degree of hygiene necessary. The skin should
be cleansed once daily. Skin cleansing products that have a pH of 4 to 5
are most compatible with the acid mantle of healthy skin. 3
There are two categories of baths: cleansing and therapeutic. Cleansing

baths include the bed bath, tub bath, sponge bath at the sink, shower,
and prepackaged disposable bed bath. The type of cleansing bath to use
depends on the assessment of a patient’s physical capabilities and the
degree of hygiene required. When a person is unable to perform personal
care because of illness or disability, you are responsible for helping with
bathing. The nurse also assists with cleaning and grooming hair, shaving,
and cleaning of nails during or immediately after a bath.
Health care providers generally order therapeutic baths for a specific

effect such as soothing the skin or for promoting the healing process.
Types of therapeutic baths include:
 Sitz bath: Cleans and reduces pain and inflammation of perineal and
anal areas. They are used for a patient who has undergone rectal or
perineal surgery or childbirth or has local irritation from hemorrhoids
or fissures. The patient sits in a special tub or basin.
 Medicated bath (addition of over-the-counter, herbal, or health care

provider–ordered ingredient to bath): Relieves skin irritation and
creates an antibacterial and drying effect.
Perineal care involves thorough cleaning of a patient’s external genitalia

and surrounding skin. A patient routinely receives perineal care during a
bath. For a patient with an indwelling catheter, the urethral meatus and
meatal surface should be cleansed daily with soap and water as part of
overall patient hygiene.4,5,6 Antiseptic cleansers are not recommended for
use with patients who have indwelling urinary catheters because irritation
of the urethral meatus may increase the risk of infection. 4
Skin care products containing chlorhexidine gluconate (CHG) effectively

reduce the number of resident and transient organisms on the skin. 7,8 CHG
decreases skin colonization of methicillin-resistant Staphylococcus aureus;
however, it has little to no effect on Clostridium difficile.9
To avoid embarrassment, the health care team member should conduct

himself or herself in a professional and sensitive manner and provide
privacy for the patient.
SUPPLIES
EDUCATION

 Teach patients how to inspect surfaces between skinfolds for signs

of irritation or breakdown.
 Explain the procedure and necessary precautions related to the

patient’s positioning or physical limitations.
 Don appropriate personal protective equipment (PPE) based on the

patient’s need for isolation precautions or risk of exposure to bodily
fluids.
 Assess the patient’s tolerance for bathing and activity, comfort

level, cognitive ability, and musculoskeletal function. Determine
whether the patient has shortness of breath. If partial bathing out of
bed or a self-bath is to be performed, assess the patient’s fall risk
status.
 Assess the patient’s visual status, ability to maintain a sitting

position, hand grasp, and range of motion (ROM) of the extremities.
 Assess for the presence and position of external medical devices or

equipment.
 Assess the patient’s bathing preferences, including frequency, time

of day, allergies to hygiene products, preferred hygiene products,
desire to participate in the bath, and any factors related to the
patient’s culture.
 Ask if the patient has noticed any problems related to the condition
of the skin and genitalia, such as excess moisture, inflammation,
drainage or excretions from lesions or body cavities, rashes or other
skin lesions, dryness, open or ulcerated areas, or redness.
 Before or during the bath, assess the condition of the patient’s skin.
Note the presence of dryness, indicated by flaking, redness, scaling,
and cracking; also note the presence of excessive moisture,
inflammation, or pressure injuries.
 Identify the patient’s risk factors for skin impairment using an
organization-approved pressure injury assessment tool.
 Assess the patient for allergies.
 Adjust the room temperature and ventilation for the patient’s

comfort.
 Explain the procedure, and ask the patient for his or her preferences
on how to prepare supplies (e.g., water temperature). Gather all
necessary equipment and supplies.
 If a partial bath is planned, ask how much of the bath the patient
wishes to complete.
DELEGATION
The skill of a complete or partial bed bath can be delegated to nursing

assistive personnel (NAP). Before delegating, be sure to teach about the
following:
 Not massaging reddened skin areas during bathing
 Not soaking the feet or trimming the toenails if contraindicated for

the patient
 Reporting to you any changes in the skin or perineal area and any
signs of impaired skin integrity
 Proper positioning of a male or female patient with musculoskeletal

limitations or an indwelling Foley catheter or other equipment, such
as intravenous tubing
PROCEDURE

agrees to the treatment.
8. Assess the patient's tolerance for bathing and activity, comfort
level, cognitive ability and musculoskeletal function. Assess for
shortness of breath. Before or during the bath, assess the condition
of the patient's skin.
9. Encourage the patient to void prior to beginning the bath. Offer the
patient a bedpan or urinal. Provide a towel and washcloth.
11. Arrange all supplies on the overbed table.
12. Raise the bed to a comfortable working height. Lower the rail
on your side, and help the patient assume a comfortable supine
position, maintaining body alignment.
13. Place a bath blanket or towel over the patient to provide

warmth and privacy during the bath. Have the patient hold the top
of the bath blanket or towel, and remove the top sheet from
beneath the bath blanket or towel without exposing the patient.
Place soiled linen in the dirty linen bag.
14. Remove the patient’s gown or pajamas using the bath blanket
or towel to cover exposed areas of the patient’s body:
a. Whether or not the patient has an intravenous line, simply

unsnap the sleeves and remove the gown.
b. If an extremity is injured or has reduced mobility, begin

removal from the unaffected side first.
c. If the patient has an intravenous line and is wearing a gown

with no snaps, remove the gown from the arm without the
intravenous line first. Then remove the gown from the arm
with the intravenous line. Pause the intravenous fluid infusion
by pressing the appropriate sensor on the intravenous pump.
Remove the intravenous container from the pole, and slide the
container and tubing through the arm of the patient's gown.
Rehang the intravenous container, check the flow rate, and
reestablish the appropriate rate if necessary. Restart the
intravenous fluid infusion by pressing the appropriate sensor
on the intravenous pump. If intravenous fluids are infusing by
gravity, check the intravenous flow rate and regulate it if
necessary. Do not disconnect the intravenous tubing to
remove the gown.
15. Raise the side rails and adjust the bed to a comfortable
working height for the bath.
16. Fill a washbasin two thirds full of warm water. Check the water
temperature, and have the patient place his or her fingers in the
water to test temperature tolerance. A safe water temperature for
bathing an adult is about 37°C (100°F).10 Place a plastic bottle of
body lotion in the bathwater to warm, if desired. Remove the pillow
if the patient's condition allows. Raise the head of the bed 30 to 45
degrees. Place a bath blanket or towel under the patient’s head.
Place a second bath towel over the patient’s chest for use in drying
each body part after it has been bathed.
17. Wash the face:
a. Inquire whether the patient is wearing contact lenses.
b. Immerse the washcloth and wring it out thoroughly. Form a

mitt with a washcloth.
c. Wash the patient's eyes with plain warm water, using a clean
area of the cloth for each eye, bathing from the inner to the
outer canthus. Soak any crusts on the eyelid for 2 to 3
minutes with a damp cloth before attempting to remove them.
Dry gently and thoroughly around the eyes.
d. Ask if the patient wishes to use soap on the face. Then wash,
rinse, and dry the forehead, cheeks, nose, neck, and ears. Ask
male patients if they would like to be shaved.
e. Provide eye care for the unconscious patient.
i. Use plain, warm water on a clean washcloth to cleanse

the patient’s eyelids from the inner to the outer canthus.
Gently dry the area around the patient’s eyes.
ii. Instill prescribed eyedrops or ointment per the

physician’s order.
iii. In the absence of a blink reflex, keep the eyelids closed.

Close each eye gently, using the back of your fingertip,
before taping in place an eye patch or shield. Do not
tape the eyelid itself.
18. Wash the patient’s arms and trunk:
a. Expose the arm closest to you and place it on top of the bath
blanket or towel. Bathe the patient’s arm with water and
minimal soap, using long, firm strokes and moving in a distal
to proximal (fingers to axilla) direction. Rinse and dry the arm.
b. Raise and support the arm above the patient’s head (if
possible) to wash, rinse, and dry the axilla thoroughly. Apply
deodorant as desired.
c. Wash the hands and nails. Fold a bath blanket or towel in half,
and lay it on the bed beside the patient. Place a washbasin of
warm water on the towel. Immerse the patient’s hand, and
allow it to soak for 3 to 5 minutes, if necessary, before
cleaning beneath the fingernails. File the patient’s nails as
needed per agency policy. Remove the basin, and rinse and
dry the hand well.
d. Move to the other side of the bed, and repeat these steps with
the patient’s other arm, axilla, hand, and nails.
e. Fold the bath blanket or towel covering the patient’s chest

down to the umbilicus. Bathe the chest, using long, firm
strokes. Take special care with the skin beneath a female
patient’s breasts, lifting each breast upward, if necessary,
using the back of the hand. Rinse and dry well.
f. Check the temperature of the bath water, and change the

water if necessary.
19. Wash the abdomen:
a. Fold the bath blanket or towel to expose the abdomen. Drape

a bath blanket or towel crosswise over the patient’s chest.
Place another over the abdomen and fold it down to just
above the pubic region. Bathe and rinse the abdomen, paying
special attention to the umbilicus and the surrounding skin
folds of the abdomen and groin. Keep the abdomen covered
between washing and rinsing. Dry well.
b. Put a clean gown or pajama top on the patient by dressing the

affected side first. If you wish, you can postpone this step until
the bath has been completed.
c. Replace the original bath blanket or towel over the patient’s

chest and abdomen for warmth.
20. Wash the patient’s legs and feet:
a. Expose the leg closer to you by folding the bath blanket or

towel toward the midline. Be sure the other leg and the
perineum remain draped.
b. Wash the leg, using long, firm strokes and moving from ankle
to knee, and then from knee to thigh. As you work, assess the
leg for signs of redness, swelling, or pain. Thoroughly rinse
and dry the leg.
c. Wash the foot, making sure to clean between the toes. Clean
and file the nails as needed, or per agency policy. Rinse and
dry the toes and feet completely. Place the bath blanket or
towel used for drying in the linen bag. Cover the exposed leg
and foot.
d. Raise the side rail, move to the other side of the bed, lower
the side rail, and repeat for the other leg and foot. If the
patient’s skin is dry, apply a light layer of moisturizing lotion
to both feet. Cover the patient with a clean bath blanket or
towel. Place soiled towels in the dirty linen bag.
e. While the patient is supine, provide perineal care. See the

video skills on performing male and female perineal care.
f. Raise the side rail, and change the bathwater.
21. Wash the back:
a. Apply a clean pair of gloves. Lower the side rail. Help the
patient assume a prone or side-lying position (as applicable).
Place a clean bath blanket or towel lengthwise along the
patient’s side or back.
b. If fecal material is present, enclose it in a fold of underpad or

toilet tissue, and clean the area with disposable wipes.
c. Cleanse the buttocks and anus, moving from front to back. Pay
special attention to the folds of the buttocks and anus. Rinse
and dry the area thoroughly. If needed, place a clean
absorbent pad under the patient’s buttocks. Change the
water.
d. Keep the patient draped by sliding the bath towel over the
shoulders and thighs during bathing. Wash, rinse, and dry the
back from neck to buttocks, using long, firm strokes.
e. Place soiled linen in the linen bag.
f. Remove gloves and perform hand hygiene.
g. If the patient’s skin is intact, give the patient a back massage

if he or she would like one. See the video skill on performing a
back massage.
22. Apply body lotion to the skin and topical moisturizing agents
to dry, flaky, reddened, or scaling areas. When you are finished,
cover the patient with a bath towel.
23. Straighten the patient’s gown, or, if not done earlier, put a
clean gown, pajamas, or other clothing on the patient by dressing
the affected side first.
24. Assist the patient with additional grooming, if desired. Comb

the patient’s hair. Be aware that female patients might wish to apply
cosmetics.
25. Apply gloves, and make the patient’s bed.
26. Check the function and position of external devices, such as

indwelling catheters, nasogastric tubes, intravenous tubes, and
braces.
27. Replace the call light, and neatly arrange personal

possessions. To ensure the patient’s safety, place the bed in the
locked, low position with at least two but no more than three side
28. Dispose of used supplies and equipment.

MONITORING AND CARE
 Continue to monitor the patient's skin condition and risk of

impairment. Pay particular attention to areas that were previously
soiled, reddened, flaking, scaling, or cracking, or that showed early
signs of breakdown. Also, inspect areas normally exposed to
pressure.
 Observe the patient's range of motion during bathing.
 Ask the patient to rate his or her level of comfort (on a scale of 0 to
10).
 Ask if the patient feels fatigued.
 Report signs of altered skin integrity to the nurse in charge or to the

health care provider.
EXPECTED OUTCOMES
 Skin is free of excretions, draining, or odor.

 Skin shows decreased redness, cracking, flaking, and scaling in
regard to subsequent baths.
 Joint ROM remains the same or improves from previous

measurement.
 Patient expresses sense of comfort and relaxation.
 Patient tolerates bath without fatigue, shortness of breath, or

chilling.
 Patient describes benefits and techniques of proper hygiene and

skin care.
UNEXPECTED OUTCOMES
 Areas of excessive dryness, rashes, irritation, or pressure injuries

appear on skin.
 Patient experiences excessive fatigue or is short of breath and

unable to cooperate or participate in bathing.
 Patient seems unusually restless or complains of discomfort.
 Medical equipment or sensory devices are soiled or damaged.
DOCUMENTATION
 Record the procedure, including how much the patient participated

and how the patient tolerated the procedure.
 Record the condition of the skin and any significant findings, such as
reddened areas, bruises, nevi, joint or muscle pain, secretions or
ulcerations.
 Report any evidence of altered skin integrity, breaks in a suture line,

or increased wound secretion to the nurse in charge or to the health
care provider.
 Record the presence of indwelling catheter, if applicable.
 Unexpected outcomes and related nursing interventions.
0900 Complete bed bath given. Patient unable to assist but cooperative
with turning. Skin on both legs dry and flaking, complains of severe
itching. Bath oil added to bath water. Emollient lotion applied after bath.
States itching is less bothersome after bath. —M. Schultz, RN. 4/7/21
0800 Bag bath given. Patient still unable to assist, but cooperative with
turning. Skin on both legs is moist, pink, and no longer dry. Patient denies
itching. Bruise on left forearm from previous venipuncture. —M. Schultz,
RN. 4/9/21
 Some adolescents require and/or prefer more frequent bathing as a

result of more active sebaceous glands.
 Young adolescent girls should learn basic perineal hygiene measures

and know why they are predisposed to urinary tract infections.
 Older adults with incontinence need meticulous skin care to reduce

incontinence-associated dermatitis and the risk of infection.
 When caring for an older adult patient with dementia: 11
o Avoid the words shower and bathe, which are often associated
with a cold, frightening, and uncomfortable experience.
o Ensure that bathing time and methods are patient-centered

because confusion can increase during agitation.
o Ensure that bathing time and methods are patient centered

o Allow the patient to help as much as possible.
o Place a towel over the patient’s shoulders or lap to reduce

exposure.
o Have nonrinse products that shorten the duration of the bath

available if the patient is resistant to traditional methods.
o Bathe the face and hair at the end of the bath to help make
bathing less threatening.
 Do not rush the patient and schedule bathing at the patient’s calm
time of day. Provide reassurance at all times during the procedure
and use a calm voice.
HOME CARE CONSIDERATIONS
 Type of bath chosen depends on assessment of the home, the

patient's presence, availability of running water, and condition of
bathing facilities.
 Set up supplies and equipment according to the patient’s preference
and routine.
 Patients at risk for falls may benefit from the following:
o Installation of grab bars in shower
o Adhesive strips applied to shower or tub floor
o Addition of a shower chair or placement of a chair or stool
6. Assisting with a Tub Bath or Shower
Quick Sheet
Print Quick Sheet
ALERT
 Take measures to prevent falls, such as placing a rubber mat

on the tub or shower floor, using a tub chair or shower seat,
and instructing the patient to use the grab bars. Do not use
bath oil in the tub water.
 Do not massage any reddened area on the patient’s skin.
 Check the temperature of the bath water or shower, and

adjust it if it is too warm or too cold. This is especially
important for older adult patients and patients with reduced
sensation, including those with diabetes, peripheral
neuropathy, or spinal cord injury.

2. Verify the health care provider's orders. Assess the patient's fall risk
status, consider the patient's condition, and review orders
concerning precautions for the patient's movement or positioning.
3. Introduce yourself to the patient and family if present. Identify

patient using two identifiers.

agrees to treatment.
5. Schedule the use of the shower or tub.
6. Check the tub or shower for cleanliness. If necessary clean using the
cleaning techniques outlined in agency policy. Place a rubber mat
inside the tub or shower bottom. Place a skidproof disposable bath
mat or towel on the floor in front of the tub or shower.
7. Gather the necessary equipment and supplies. Collect all hygienic

aids, toiletry items, and linens requested by the patient. Place them
within easy reach of the tub or shower.
8. Place an "Occupied" or an "IN USE" sign on the bathroom door. With

patient wearing a gown, robe and slippers, assist the patient to the
bathroom.
9. Help the patient to the bathroom, if necessary. Have the patient

wear a robe and skidproof slippers to the bathroom.
10. Demonstrate how to use the call signal for assistance.
11. Fill the tub halfway with warm water. Check the temperature
of the bathwater, and then have the patient test the water. Adjust it
if it is too warm or too cold. A safe water temperature for bathing an
adult is approximately 37° (100°F).8 Show him or her how to control
the hot water. Complications of diabetes decrease temperature
sensitivity. Do not use bath oil in the tub water. Help the patient into
the tub.
12. If the patient is taking a shower, provide a shower seat or tub

chair if needed. Turn the shower on, and adjust the water
temperature before the patient enters the shower stall.
13. Show the patient how to use the safety bars when getting in
and out of the tub or shower.
14. Advise the patient that you will not allow him or her to remain
in the tub longer than 20 minutes. Check on the patient every 5
minutes.
15. Return to the bathroom when the patient signals, or after 20

minutes. Knock before entering.
16. Place a bath towel over the patient's shoulders. For a patient
who is unsteady, drain the tub before the patient attempts to get
out. Help the patient out of the tub, as needed. If possible, have a
shower chair ready for the patient to sit in. As you help him or her
dry off, perform a full skin assessment. Thoroughly assess the skin
over bony prominences, such as the coccyx, heels, and occiput, for
signs of pressure injury development.
17. Remove wet gloves and perform hand hygiene. Assist the
patient as needed in donning a clean gown or pajamas, skidproof
slippers, and a robe. (In extended care, rehabilitation, and home
settings, encourage the patient to wear regular clothing.)
18. Help the patient to his or her room and into a comfortable
position in bed or in a chair.
19. Evaluate the patient's tolerance of the bath or shower and his
or her level of fatigue.
20. Return to the bathroom, and return supplies to the storage

area. Clean and dry the bathing equipment and areas surrounding
the bath to ensure the safety of personnel. Apply gloves, remove
the soiled linen, and place it in a dirty linen bag. Discard disposable
equipment in the proper receptacle.
21. Remove your gloves, and discard them in an appropriate

receptacle. Place an "Unoccupied" or "Open" sign on the bathroom
door.
23. Help the patient into a comfortable position, and place

toiletries and personal items (e.g., glasses, hearing aid) within
reach.
25. To ensure the patient's safety, raise the appropriate number of

side rails and lower the bed to the lowest position.
26. Leave the patient's room tidy.

unexpected outcomes. Note level of assistance and tolerance of
procedure. Note condition of skin and any significant findings
including joint or muscle pain.
Extended Text
ALERT
 Take measures to prevent falls, such as placing a rubber mat

on the tub or shower floor, using a tub chair or shower seat,
and instructing the patient to use the grab bars. Do not use
bath oil in the tub water.
 Do not massage any reddened area on the patient’s skin.

 Check the temperature of the bath water or shower, and
adjust it if it is too warm or too cold. This is especially
important for older adult patients and patients with reduced
sensation, including those with diabetes, peripheral
neuropathy, or spinal cord injury.

OVERVIEW
Human skin functions as a barrier against harmful compounds and

dehydration of the body. As the most superficial layer of the skin’s
epidermis, the stratum corneum encounters challenging environmental
conditions on a daily basis to retain barrier integrity and protect the
deeper layers of skin and internal organs. The normal acidic coating of the
stratum corneum, called the acid mantel, protects the skin from damage,
including sun and wind exposure, and reduces the growth of bacteria and
fungi, and potentially harmful microbes.1
Bathing removes sweat, oil, dirt, and microorganisms from the skin. It also
stimulates circulation and provides a refreshed and relaxed feeling.
However, bathing disrupts the normal, protective, acidic pH of the skin,

especially when alkaline soaps are used. Avoiding these soaps helps
maintain the natural protective function of the skin. 2
The type of bathing required depends on an assessment of the patient’s

physical capabilities and the degree of hygiene necessary. The skin should
be cleansed once daily. Skin cleansing products that are most compatible
with the acid mantle of healthy skin have a pH of 4 to 5. 3
Bathing provides an opportunity for the caregiver to assess the patient’s

overall skin condition, including integrity, turgor, color, and abnormalities
(e.g., petechiae, rash, bruising, breakdown).
To help prevent skin breakdown and irritation during bathing: 4
 Avoid force and friction on the patient’s skin.
 Avoid massaging reddened areas.
 Reduce pressure over bony prominences, such as the heels, coccyx,

and occiput.
 Minimize environmental factors that lead to dry skin, such as

extreme temperature and low humidity.
 Pat skin dry; do not rub skin dry.

Patients who are incontinent of urine or stool require more frequent
perineal care and should be bathed after each elimination to reduce skin
exposure to prolonged moisture. For a patient with an indwelling catheter,
the urethral meatus should be cleansed daily with soap and water as part
of overall patient hygiene. Antiseptic cleansers are not recommended for
use with patients who have an indwelling urinary catheter because
irritation of the urethral meatus may increase the risk of infection. 2
Skin care products containing chlorhexidine gluconate (CHG) effectively

reduce the number of resident and transient organisms on the skin. 5,6 CHG
decreases skin colonization of methicillin-resistant Staphylococcus
aureus however, it has minimal to no effect on Clostridium difficile.7
There are two categories of baths: cleansing and therapeutic. Cleansing

baths include the bed bath, tub bath, sponge bath at the sink, shower,
and prepackaged disposable bed bath. The type of cleansing bath to use
depends on the assessment of a patient's physical capabilities and the
degree of hygiene required. When a person is unable to perform personal
care because of illness or disability, you are responsible for helping with
bathing. This includes time for cleaning and grooming hair, shaving, and
cleaning of nails. You can perform many of these procedures during or
immediately after a bath.
Health care providers generally order therapeutic baths for a specific

effect such as soothing the skin or for promoting the healing process.
Types of therapeutic baths include:
 Sitz bath: Cleans and reduces pain and inflammation of perineal and
anal areas. They are used for a patient who has undergone rectal or
perineal surgery or childbirth or has local irritation from hemorrhoids
or fissures. The patient sits in a special tub or basin.
 Medicated bath (addition of over-the-counter, herbal, or health care

provider–ordered ingredient to bath): Relieves skin irritation and
creates an antibacterial and drying effect.
Perineal care involves thorough cleaning of a patient's external genitalia

and surrounding skin. A patient routinely receives perineal care during a
bath. However, patients at risk for acquiring an infection need more
frequent perineal care. These include patients who have incontinence-
associated dermatitis (IAD), an indwelling Foley catheter, are postpartum,
or are recovering from rectal or genital surgery.
To avoid embarrassment, the health care team member should conduct

himself or herself in a professional and sensitive manner and provide
privacy for the patient.
SUPPLIES
EDUCATION
 Provide developmentally and culturally appropriate education based

on the desire for knowledge, readiness to learn, and overall
neurologic and psychosocial state.
 Teach patients how to inspect surfaces between skinfolds for signs

of irritation or breakdown.
 Assess the environment for safety, such as checking the room for
spills, making sure equipment is working properly, ensuring that the
bed is in the locked, low position, and providing privacy.
 Don appropriate personal protective equipment (PPE) based on

patient’s need for isolation precautions or risk of exposure to bodily
fluids.
 Explain the procedure, including precautions taken to reduce falls

and provide privacy.
 Assess the patient's fall risk status, consider the patient's condition,
and review orders concerning precautions to observe in the patient's
movement or positioning. A physician's order is usually needed for a
tub bath or shower.
 Assess the patient for shortness of breath.
 Schedule use of the shower or tub.
 Check the tub or shower for cleanliness. Use cleaning techniques

outlined in agency policy.
 Place a rubber bath mat on the tub or shower bottom. Place a

skidproof disposable bath mat or towel on the floor in front of the
tub or shower. Use a tub chair or shower seat and instruct the
patient to use the grab bars.
 Collect all hygienic aids, toiletry items, and linens requested by the
patient. Place them within easy reach of the tub or shower.
 Do not use bath oil in the tub water.

DELEGATION
The skill of bathing a patient in the tub or shower can be delegated to

nursing assistive personnel (NAP). Before delegating this skill, be sure to
inform NAP of the following:
 Stress the importance of not massaging reddened skin areas during

bathing.
 Explain how to properly position male and female patients with

musculoskeletal limitations.
 Remind NAP to report to you any changes in the skin or perineal

area or any signs of impaired skin integrity.
PROCEDURE
2. Verify the health care provider's orders. Assess the patient's fall risk
status, consider the patient's condition, and review orders
concerning precautions for the patient's movement or positioning.
3. Introduce yourself to the patient and family if present. Identify

patient using two identifiers.

5. Schedule the use of the shower or tub.
6. Check the tub or shower for cleanliness. If necessary clean using the
cleaning techniques outlined in agency policy. Place a rubber mat
inside the tub or shower bottom. Place a skidproof disposable bath
mat or towel on the floor in front of the tub or shower.
7. Gather the necessary equipment and supplies. Collect all hygienic

aids, toiletry items, and linens requested by the patient. Place them
within easy reach of the tub or shower.
8. Place an "Occupied" or an "IN USE" sign on the bathroom door. With

patient wearing a gown, robe and slippers, assist the patient to the
bathroom.
9. Help the patient to the bathroom, if necessary. Have the patient

wear a robe and skidproof slippers to the bathroom.
10. Demonstrate how to use the call signal for assistance.
11. Fill the tub halfway with warm water. Check the temperature
of the bathwater, and then have the patient test the water. Adjust it
if it is too warm or too cold. A safe water temperature for bathing an
adult is approximately 37° (100°F).8 Show him or her how to control
the hot water. Complications of diabetes decrease temperature
sensitivity. Do not use bath oil in the tub water. Help the patient into
the tub.
12. If the patient is taking a shower, provide a shower seat or tub

chair if needed. Turn the shower on, and adjust the water
temperature before the patient enters the shower stall.
13. Show the patient how to use the safety bars when getting in
and out of the tub or shower.
14. Advise the patient that you will not allow him or her to remain
in the tub longer than 20 minutes. Check on the patient every 5
minutes.
15. Return to the bathroom when the patient signals, or after 20

minutes. Knock before entering.
16. Place a bath towel over the patient's shoulders. For a patient
who is unsteady, drain the tub before the patient attempts to get
out. Help the patient out of the tub, as needed. If possible, have a
shower chair ready for the patient to sit in. As you help him or her
dry off, perform a full skin assessment. Thoroughly assess the skin
over bony prominences, such as the coccyx, heels, and occiput, for
signs of pressure injury development.
17. Remove wet gloves and perform hand hygiene. Assist the
patient as needed in donning a clean gown or pajamas, skidproof
slippers, and a robe. (In extended care, rehabilitation, and home
settings, encourage the patient to wear regular clothing.)
18. Help the patient to his or her room and into a comfortable
position in bed or in a chair.
19. Evaluate the patient's tolerance of the bath or shower and his
or her level of fatigue.
20. Return to the bathroom, and return supplies to the storage

area. Clean and dry the bathing equipment and areas surrounding
the bath to ensure the safety of personnel. Apply gloves, remove
the soiled linen, and place it in a dirty linen bag. Discard disposable
equipment in the proper receptacle.
21. Remove your gloves, and discard them in an appropriate

receptacle. Place an "Unoccupied" or "Open" sign on the bathroom
door.

toiletries and personal items (e.g., glasses, hearing aid) within
reach.

26. Leave the patient's room tidy.

unexpected outcomes. Note level of assistance and tolerance of
procedure. Note condition of skin and any significant findings
including joint or muscle pain.
MONITORING AND CARE
 Determine the patient's comfort and level of fatigue.
 Inspect for signs of skin breakdown, irritation, and infection, and

take steps to prevent them. Use an organization-approved
assessment tool.
 Report signs of altered skin integrity to the nurse in charge or to the

EXPECTED OUTCOMES
 Patient acknowledges that skin feels clean and refreshed, and

patient feels relaxed.
 Sweat, oil, dirt, and microorganisms are removed from patient's

skin, and circulation is stimulated.
 Skin is free of excretions, draining, odor, rashes, irritation, excessive

dryness, or breakdown.
 Patient tolerates procedure without fatigue, shortness of breath, or

chilling.
UNEXPECTED OUTCOMES
 Areas of excessive dryness, rashes, irritation, or pressure injuries

appear on skin.
 Patient becomes fatigued and unable to participate in bathing.
 Patient does not tolerate bathing.

o Seems unusually restless
o Complains of discomfort
o Exhibits or reports shortness of breath
 Patient falls, slips, or sustains injury.
 Medical equipment or sensory devices are soiled or damaged.
DOCUMENTATION
 Record the tub bath or shower, noting the level of assistance

needed and how the patient tolerated the procedure.
 Record the condition of the skin and any significant findings, such as
reddened areas, discharge, bruises, nevi, and joint or muscle pain.
 Record unexpected outcomes and related nursing interventions.
 Report any evidence of altered skin integrity, breaks in the suture

line, or increased wound secretion to the nurse in charge or to the
0900 Tub bath taken. Patient able to bathe self, but needed assistance
getting in and out of tub. Skin on both legs dry and flaking; patient reports
severe itching. Emollient lotion applied after bath to both legs. Patient
states itching is less now. –M. Anderson, RN. 11/22/21
 Some adolescents require and/or prefer more frequent bathing as a

result of more active sebaceous glands.
 Young adolescent girls should learn basic perineal hygiene measures

and know why they are predisposed to urinary tract infections.
 Older adult patients have thinner skin that is more sensitive to time
and exposure to water temperature.
 Recommend an antiscalding device be installed on home hot water

heaters with the thermostat set below 48.9°C (120°F). 8
 Incontinent older adults need frequent skin care to reduce skin

irritation from urine and feces.
 When caring for cognitively impaired older adults, approach bathing
in a calm manner and use the same bathing method and when
possible the same caregiver each time.
 It is best to use the least distressing method first such as soaking in

a bathtub or using a disposable bag bath. These approaches must
be modified for each patient (i.e., soaking the feet rather than the
whole body).
 Older adults with incontinence need meticulous skin care to reduce

incontinence-associated dermatitis and the risk of infection.
 When caring for an older adult patient with dementia, do the

following:9
o Avoid the words shower and bathe, which are often associated
with a cold, frightening, and uncomfortable experience. Words
such as clean or freshen up may be preferable.
o Ensure that bathing time and methods are patient-centered

o Do not rush the patient and schedule bathing at the patient’s

calm time of day.
o Provide reassurance at all times during the procedure and use

a calm voice.
o Inform the patient of each step during bathing.
o Allow the patient to help as much as possible.
o Place a towel over the patient’s shoulders or lap to reduce

exposure.
o Have nonrinse products that shorten the duration of the bath

available if the patient is resistant to traditional methods.
o Bathe the face and hair at the end of the bath to help make
bathing less threatening.
 Type of bath chosen depends on assessment of the home,

availability of running water, and condition of bathing facilities.
 The thermostat setting on a home hot water heater should be below

48.9°C (120°F).8
 In the home setting, set up equipment according to established
routines. Patient is the best resource for what works in terms of
convenience and saving time.
 Patients at risk for falls may benefit from the following:
o Installation of grab bars in shower
o Adhesive strips applied to shower or tub floor
o Addition of a shower chair or placement of a chair or stool
7. Performing Back Massage
Quick Sheet
Print Quick Sheet
ALERT
 Do not perform massage over bruised, swollen, or inflamed

areas or bones of the spine.
 Massage is contraindicated in patients with muscle, bone, or

joint injury.
 A patient with an epidural infusion cannot receive a back

massage.
 Know the patient's medical history, type of therapies used,

and medications, including over-the-counter (OTC) products.
Many patients do not mention using such products for fear
of being criticized, or because they do not want them to be
taken away.
 Know your agency policy for how often pain should be

assessed and when follow-up assessments should be done.
During the first 24 hours a patient is on opioids, an
assessment must be done at least every 4 hours.
 While a level of zero pain is an ideal goal, in some patients

with chronic/persistent pain, it is not a realistic one.
3. Provide privacy for the patient.
5. Identify patient using two identifiers.

7. Assess patient's pain level and offer analgesics if needed.
8. Reassess the patient’s pain status, allowing for sufficient onset of

action per medication, route, and the patient’s condition.
10. Prepare the patient's environment:
a. Temperature: The room temperature should be suited to the

patient.
b. Lighting: Bright or very dim lighting can aggravate pain

sensation.
c. Sound: Eliminate unnecessary interruptions, and coordinate

care activities to allow for the patient's rest.
11. Adjust the bed to a comfortable position for you by lowering

the upper side rail on your side.
12. Place the patient in a comfortable position, such as prone or

side-lying. If the patient has difficulty breathing, have him or her lie
on the side of the bed with the head of the bed elevated. Use
alternate position based on patient condition.
13. Offer to play background music if patient desires.
14. Assess for allergies.
15. Untie the hospital gown and drape the patient with a folded
sheet, exposing only the areas to be massaged.
16. Assess the skin, and apply gloves if necessary. Don additional
appropriate personal protective equipment (PPE) based on patient’s
need for isolation precautions or risk of exposure to bodily fluids.
17. Warm the lotion in your hands. During a bath, the lotion could
be warmed in a basin of water.
18. Choose the stroke technique to achieve the desired effect, or

select a technique based on the body part being massaged.
Different types of Swedish massage include effleurage (gliding or
sliding), petrissage (kneading), friction (cross-fiber motion):
a. Effleurage: A technique in which a gliding stroke is used to

massage upward and outward from the vertebral column and
back again. This motion does not manipulate deep muscles;
rather, it smooths and extends them, increasing nutrient
absorption and improving lymphatic and venous circulation.
b. Pétrissage is a light kneading motion used to relax tense

muscle groups and stimulate local circulation.
c. Friction is accomplished by using strokes perpendicular to the

fibers of the tendon to provide a method of mild stimulation of
natural tissue repair mechanisms.
19. Encourage the patient to breathe deeply and relax during the
massage.
20. Do not allow your hands to leave the patient's skin.

Continuous contact with the skin's surface is soothing and
stimulates circulation to tissues. Breaking contact with the skin can
startle the patient.
21. Begin by using a circular motion to massage the sacral area.

Stroke the skin upward, from buttocks to shoulders. Use smooth,
firm strokes to massage over the scapulae. Continue in one smooth
stroke to the upper arms, moving laterally along the sides of the
back down to the iliac crests. Continue this massage pattern for 3
minutes.
22. Use effleurage along the muscles of the spine, moving upward
and outward.
23. Use pétrissage on the muscles of each shoulder, toward the

front of the body.
24. Use the palms in a circular motion to massage upward and

outward from the lower buttocks to the neck.
25. Knead the muscles of the upper back and shoulder between
your thumb and forefinger.
26. Use both of your hands to knead the muscles up one side of
the patient's back, and then the other side.
27. End the massage with long, stroking effleurage movements.
28. Tell the patient you are finished.
29. Wipe excess lotion or oil from the patient's body with a bath
towel.
30. Instruct the patient to inhale deeply and exhale. Caution him
or her to move slowly after resting for a few minutes.
31. Have the patient turn slowly after resting for a few minutes.

toiletries and personal items within reach.
34. Assess pain level.
36. Dispose of used supplies and equipment. Leave the patient's

room tidy.
37. Remove and dispose of gloves, if used. Perform hand hygiene.

unexpected outcomes. Document the patient's response and
comfort level.
ALERT
 Do not perform massage over bruised, swollen, or inflamed

areas or bones of the spine.
 Massage is contraindicated in patients with muscle, bone, or

joint injury.
 A patient with an epidural infusion cannot receive a back

massage.
 Know the patient's medical history, type of therapies used,

and medications, including over-the-counter (OTC) products.
Many patients do not mention using such products for fear
of being criticized, or because they do not want them to be
taken away.
 Know your agency policy for how often pain should be

assessed and when follow-up assessments should be done.
During the first 24 hours a patient is on opioids, an
assessment must be done at least every 4 hours.
 While a level of zero pain is an ideal goal, in some patients

with chronic/persistent pain, it is not a realistic one.
OVERVIEW
The pain experience is a product of a person’s past pain experiences,

values, cultural expectations, and emotions. Pain is a subjective
measurement and will vary between patients. Nonpharmacologic pain-
relief measures include massage and the application of heat and
cold.1,2 Such measures should be used in conjunction with pharmacologic
interventions and can reduce the amount of analgesic medication
required. Nonpharmacologic techniques diminish the physical effects of
pain, alter a patient’s perception of pain, and provide a patient with a
greater sense of control. Some strategies may alter ascending nociceptive
input or stimulate descending pain modulation mechanisms. 1,2 Distraction,
relaxation, guided imagery, and cutaneous stimulation such as massage
and acupressure are a few examples of effective nonpharmacologic
measures.
Nonpharmacologic interventions are appropriate for patients who find

such interventions appealing, express anxiety or fear, may benefit from
avoiding or reducing drug therapy, and have incomplete pain relief with
pharmacologic interventions alone. You will have an excellent opportunity
to help patients control their pain by teaching them to add a variety of
nonpharmacologic techniques. Patients and families today are more aware
of complementary techniques and should be encouraged to continue
whatever has worked for them.
Certain diagnostic and therapeutic procedures commonly cause pain.

Evidence suggests that fewer than half of surgical patients report
adequate postoperative pain relief.3 Many times, multimodal regimens for
postoperative pain relief are required. The administration of an analgesic
before implementing a nonpharmacologic strategy, such as massage, heat
therapy, or cold therapy, may help the patient gain a level of comfort.
Adding nonpharmacologic interventions may enhance the effects
consistent with the biopsychosocial model of pain. 4 The patient, setting,
and surgical procedure affect the exact components of effective pain
relief.4 Because everyone responds differently, finding new methods that
work for a patient may take more time than finding pharmacologic
techniques.
Cutaneous Stimulation Massage
Massage can be used for acute or chronic pain and involves a range of
techniques that manipulate soft tissues and joints. A gentle massage, a
form of cutaneous stimulation, is the application of touch and movement
to muscles, tendons, and ligaments without manipulation of the joints. A
proper massage not only blocks perception of pain impulses but also helps
relax muscle tension and spasm that otherwise might increase pain.
Massage therapy is believed to decrease pain perception through the
stimulation of large diameter nerve fibers. This contributes to inhibiting
nociceptive stimuli transmitted by smaller nerve fibers in the spinal
cord.1,2,5
Massage therapy can increase the volume of blood in an area, improve
tissue suppleness, reduce edema, and boost the immune system. 6 A
massage of the back, shoulders, and lower part of the neck is sometimes
referred to as a backrub. Offering a backrub after a bath or before a
patient prepares for sleep promotes relaxation and comfort. An effective
backrub takes 3 to 6 minutes and is an important intervention for
decreasing pain and improving sense of well-being. Massage also involves
the feet and hands. Massage is contraindicated in areas of recent injuries
or trauma, recent surgery, open wounds, deep vein thrombosis,
inflammation or infections, bleeding, edema, or decreased sensation. 1,2 Do
not perform massage over bruised, swollen, or inflamed areas or bones of
spine.
SUPPLIES
EDUCATION
 Provide developmentally and culturally appropriate education based

on the desire for knowledge, readiness to learn, and overall
neurologic and psychosocial state.
 Provide patient information about each nonpharmacologic therapy,

including purpose, rationale for how pain is relieved, how patient
can maximize benefits. If NAP performs massage, you still need to
provide patient education.
 Explain what is expected of the patient during the procedure.
 Some techniques require more practice before patients achieve

results. Pharmacologic intervention is sometimes required to
augment comfort promotion measures.
 Teach patient to rest between periods of activity at home and

hospital because fatigue increases pain perception.
 Teach family member how to perform massage (if not

contraindicated) as part of home care.
 Assess the patient’s pain status using a pain rating scale.
 Assess the patient's physiological, behavioral, and emotional signs

and symptoms of pain, including the patient self-reporting of having
pain.
 Assess the characteristics of the patient's pain and the possible
underlying cause.
 Administer an analgesic before implementing a nonpharmacological

strategy so that the patient is more comfortable during the back
massage.
 Examine the site of the patient's pain or discomfort. Include the

following techniques:
o Inspection: discoloration, swelling, or drainage
o Palpation: change in temperature, area of altered sensation,

painful areas, or areas that trigger pain
o Range of motion of involved joints, if applicable
 Review the health care provider's orders for pain relief.
 Assess the patient's understanding of pain and his or her willingness

to receive nonpharmacological pain-relief measures.
 Assess the patient's language level, and identify descriptive terms

to use when employing nonpharmacological pain-relieving
strategies.
 Gather all necessary equipment and supplies.
DELEGATION
Assessment of the patient's pain cannot be delegated to nursing assistive

personnel (NAP). The skill of the nonpharmacological pain management
strategy of massage, however, can be delegated to NAP. Be sure to inform
NAP of the following:
 Identify and explain which nonpharmacological measures work best

for the patient.
 Explain the importance of eliminating environmental conditions that

intensify pain.
 Identify the need to adapt strategies to the patient's restrictions,

such as massaging a patient in the side-lying position instead of the
prone position.
PROCEDURE
3. Provide privacy for the patient.

5. Identify patient using two identifiers.

7. Assess patient's pain level and offer analgesics if needed.
8. Reassess the patient's pain status, allowing for sufficient onset of

action per medication, route, and the patient's condition.
10. Prepare the patient's environment:
a. Temperature: The room temperature should be suited to the

patient.
b. Lighting: Bright or very dim lighting can aggravate pain

sensation.
c. Sound: Eliminate unnecessary interruptions, and coordinate

care activities to allow for the patient's rest.
11. Adjust the bed to a comfortable position for you by lowering

the upper side rail on your side.
12. Place the patient in a comfortable position, such as prone or

side-lying. If the patient has difficulty breathing, have him or her lie
on the side of the bed with the head of the bed elevated. Use
alternate position based on patient condition.
13. Offer to play background music if patient desires.
14. Assess for allergies.
15. Untie the hospital gown and drape the patient with a folded
sheet, exposing only the areas to be massaged.
16. Assess the skin, and apply gloves if necessary. Don additional
17. Warm the lotion in your hands. During a bath, the lotion could
be warmed in a basin of water.
18. Choose the stroke technique to achieve the desired effect, or

select a technique based on the body part being massaged.
Different types of Swedish massage include effleurage (gliding or
sliding), petrissage (kneading), friction (cross-fiber motion): 7,8
a. Effleurage: A technique in which a gliding stroke is used to
massage upward and outward from the vertebral column and
back again. This motion does not manipulate deep muscles;
rather, it smooths and extends them, increasing nutrient
absorption and improving lymphatic and venous circulation. 2,8
b. Pétrissage is a light kneading motion used to relax tense

muscle groups and stimulate local circulation. 7
c. Friction is accomplished by using strokes perpendicular to the

fibers of the tendon to provide a method of mild stimulation of
natural tissue repair mechanisms.9
19. Encourage the patient to breathe deeply and relax during the
massage.
20. Do not allow your hands to leave the patient's skin.

Continuous contact with the skin's surface is soothing and
stimulates circulation to tissues. Breaking contact with the skin can
startle the patient.
21. Begin by using a circular motion to massage the sacral area.

Stroke the skin upward, from buttocks to shoulders. Use smooth,
firm strokes to massage over the scapulae. Continue in one smooth
stroke to the upper arms, moving laterally along the sides of the
back down to the iliac crests. Continue this massage pattern for 3
minutes.
22. Use effleurage along the muscles of the spine, moving upward
and outward.
23. Use pétrissage on the muscles of each shoulder, toward the

front of the body.
24. Use the palms in a circular motion to massage upward and

outward from the lower buttocks to the neck.
25. Knead the muscles of the upper back and shoulder between
your thumb and forefinger.
26. Use both of your hands to knead the muscles up one side of
the patient's back, and then the other side.
27. End the massage with long, stroking effleurage movements.
28. Tell the patient you are finished.
29. Wipe excess lotion or oil from the patient's body with a bath
towel.
30. Instruct the patient to inhale deeply and exhale. Caution him
or her to move slowly after resting for a few minutes.
31. Have the patient turn slowly after resting for a few minutes.


34. Assess pain level.

room tidy.

unexpected outcomes. Document the patient's response and
comfort level.
MONITORING AND CARE
 Observe the character of the patient's respiration, body position,

facial expression, tone of voice, mood, mannerisms, and
verbalization of discomfort.
EXPECTED OUTCOMES
 Patient is relaxed and comfortable after procedure as evidenced by

slow, deep respirations; calm facial expressions and vocal tone; and
relaxed muscles and posture.
 Patient verbalizes pain relief.
 Patient requires less pain medication.
UNEXPECTED OUTCOMES
 Patient is not able to concentrate on technique because of intense

pain.
 Patient states pain intensity unchanged or escalating, or patient

demonstrates nonverbal behavior indicative of pain.
DOCUMENTATION
 Record procedure and pain-relief technique.
 Record the effectiveness of the procedure, including the massage

technique used, the patient’s tolerance to the massage (his or her
pain rating and comfort level), any change in the patient’s overall
condition, and further comfort needs provided, if any, after the
massage. Incorporate pain relief techniques into your nursing care
plan.
 Record unexpected outcomes and related interventions.
 If the patient has any unusual responses to the massage, such as

muscle spasms or uncontrolled or aggravated pain, report them to
the nurse in charge or to the health care provider.
0800 After complete bed bath, provided back massage using pétrissage
and friction. Patient reported muscle tension and rated pain a 4 before
back massage; reported muscle relaxation and rated pain a 2 after back
massage. Skin is moist, pink, and intact with no bruises, swelling, or
redness. After back massage, patient's respirations decreased from 20 to
16 per minute and pulse decreased from 78 to 70 beats per minute. –A.
Petta, RN. 4/8/21
 You can use nonpharmacologic pain-management therapies

successfully with children. Adapt distraction and relaxation
strategies to the developmental level of the child (e.g., use a
pacifier for an infant, offer reading or playing a recording of a
favorite story for a preschooler, encourage a teenager to listen to
music on a CD player with headphones). Play therapists are usually
available at large pediatric hospitals and are good resources for
appropriate distraction techniques.
 Because children usually have an active imagination, relaxation is

often a powerful adjuvant in pain control.
 Parents are very helpful in providing pain relief. For example, they
provide comfort by their presence, conversation, and holding and
cuddling their child.
 Visual, hearing, cognitive, and motor impairments make it difficult

for older adults to be able to effectively use procedures such as
distraction, relaxation, or guided imagery. Make certain that glasses,
hearing aids, and other assistive devices are in place. Do not
assume that complementary techniques will not work on the elderly.
 Family members need to collaborate on planning time to reduce

noise and other stimuli in the home to promote patient's relaxation.
 Discuss nonpharmacologic pain management interventions with

patient's family and friends.
 If appropriate, teach a family member how to perform massage (if

not contraindicated) as part of home care.
8. Performing Perineal care for Female patient
ALERT
 Always wear clean gloves, due to the risk of contact with

infectious microorganisms.
 Assess the water temperature, and avoid hot or excessively

cold water. Use a mild cleansing agent to minimize irritation.
 Avoid using force or excessive friction during cleansing.
 Avoid placing tension on an indwelling urinary catheter, if

present. Clean the area around it thoroughly.
 Wash downward from the pubic area toward the rectum, to

prevent contamination of the vagina and urethral meatus
with microorganisms.
 Report any signs of impaired skin integrity to the nurse in

charge or to the health care provider.
 Some facilities use prepackaged disposable bed baths in

1. Verify the health care provider’s orders.
2. Gather the necessary equipment and supplies and arrange them on

the patient’s over-bed table or bedside table.
3. Provide privacy.
4. Perform hand hygiene and apply gloves. Don appropriate personal


6. Identify the patient using two identifiers.
7. Explain the procedure and its importance in preventing infection and

ensure that she agrees to treatment.
8. Perineal care for a female patient:
a. If the patient is able to maneuver and handle a washcloth,

allow her to cleanse the perineum on her own.
b. Note any restrictions or limitations on the patient’s

positioning. Help the patient assume the dorsal recumbent or
supine position. Assist the patient to flex the knees and
slightly spread the legs to increase exposure of the area.
c. If fecal material is present, wrap it in an underpad or piece of

toilet tissue and remove it with disposable wipes.
d. Place a waterproof pad under the patient’s buttocks.
e. Drape the patient with a bath towel placed in the shape of a

diamond. Lift the lower edge of the bath towel to expose the
perineum. Cover thighs with bath towels.
f. Wet and wring out the washcloth. Apply a cleaning product to

the washcloth. Wash and dry the patient’s upper thighs. Rinse
and dry this area.
g. Wash the labia majora. Use your nondominant hand to gently

retract the labium from the thigh. Use your dominant hand to
wash carefully within the skin folds. Wipe from the perineum
to the rectum (front to back). Repeat this process on the
opposite side, using a separate section of the washcloth. Rinse
and dry the area thoroughly.
h. Gently separate the labia with your nondominant hand to

expose the urethral meatus and vaginal orifice. With your
dominant hand, wash downward from the pubic area toward
the rectum in one smooth stroke. Use a separate section of
the cloth for each stroke. Cleanse thoroughly over the labia
minora, clitoris, and vaginal orifice. For a woman who is
menstruating, use a clean washcloth or perineal wipe instead
of a separate section of the same cloth to cleanse the vaginal
area. For a woman with an indwelling catheter, use a clean
washcloth or perineal wipe to cleanse the catheter. Avoid
placing tension on an indwelling urinary catheter, if present,
and thoroughly clean the area around it.
i. Rinse and dry the area thoroughly, from front to back.

j. Observe the perineal area for redness, swelling, irritation,
discharge, or signs of skin breakdown that persist after
performing perineal hygiene.
k. Ask the patient to lower her legs. Remove the towel and bath
towel. Pull the patient’s gown down and the blankets up.
9. Remove and dispose of gloves in receptacle and perform hand

hygiene.

12. To ensure the patient’s safety, raise the appropriate number of

13. Assess patient's comfort level and level of fatigue.

unexpected outcomes including how much she participated, her
tolerance of the procedure, the condition of the skin and any
significant findings.
ALERT


 Avoid placing tension on an indwelling urinary catheter, if

present. Clean the area around it thoroughly.

prevent contamination of the vagina and urethral meatus
with microorganisms.


OVERVIEW
Perineal care involves thorough cleansing of the patient’s external
genitalia and surrounding skin. A patient routinely receives perineal care
during a complete bed bath. However, patients who have fecal or urinary
incontinence, an indwelling Foley catheter, or rectal or genital surgery
may need more frequent perineal care. Wear gloves during perineal care
because of the risk of contracting an infection.

perineal care. Routine perineal cleansing is performed with soap and
water. The periurethral area should not be cleaned with antiseptic
solutions when a urinary catheter is in place. 1 For a patient with an
indwelling catheter, the urethral meatus should be cleansed daily with
soap and water as part of overall patient hygiene. 1,2 Daily cleansing of the
meatal surface is recommended for patients with indwelling urinary
catheters.3,4 Antiseptic cleansers are not recommended for use with
patients who have indwelling urinary catheters because irritation of the
urethral meatus may increase the risk of infection. 3
To avoid embarrassment, always act in a professional and sensitive

manner and provide privacy at all times.
SUPPLIES
EDUCATION

 Educate the patient on how to inspect surfaces between skinfolds

for signs of irritation or breakdown.
 Assess the patient's need for perineal care. Patients at risk for
infection need more frequent care. These include patients with
incontinence-associated dermatitis (IAD), patients with an indwelling
urinary catheter, postpartum patients, and those recovering from
rectal or genital surgery.
 Assess the patient’s tolerance of perineal care and activity, comfort,
cognitive ability, and musculoskeletal function. Assess the patient
for shortness of breath.
 Evaluate the patient's knowledge of perineal hygiene.
 Ask the patient about her preferences for how to prepare for
perineal care (e.g., water temperature).
 Note any restrictions or limitations on patient positioning.
 Determine how much of the perineal care the patient wants to

complete herself.
 Offer the patient the opportunity to void in a bedpan. Fill a

washbasin two-thirds full with warm water.
 Adjust the room temperature and ventilation and provide privacy.
DELEGATION
The skill of perineal care can be delegated to nursing assistive personnel

(NAP). Before delegating, be sure to inform NAP of the following:
 Any physical restrictions that affect the proper positioning of the

patient.
 The proper ways in which to position a patient with an indwelling

urinary catheter.
 The need to inform you of any perineal drainage, excoriation, or

rash.
 Any cultural differences that may affect the perineal care process.
PROCEDURE

3. Provide privacy.
4. Perform hand hygiene and apply gloves. Don appropriate personal


7. Explain the procedure and its importance in preventing infection and
ensure that she agrees to treatment.
8. Perineal care for a female patient:

allow her to cleanse the perineum on her own.

positioning. Help the patient assume the dorsal recumbent or
supine position. Assist the patient to flex the knees and
slightly spread the legs to increase exposure of the area. 5
c. If fecal material is present, wrap it in an underpad or piece of

toilet tissue and remove it with disposable wipes.
d. Place a waterproof pad under the patient’s buttocks.
e. Drape the patient with a bath towel placed in the shape of a

diamond. Lift the lower edge of the bath towel to expose the
perineum.
f. Wet and wring out the washcloth. Apply a cleaning product to

the washcloth. Wash and dry the patient’s upper thighs. Rinse
and dry this area. Cover thighs with bath towels.
g. Wash the labia majora. Use your nondominant hand to gently

retract the labium from the thigh. Use your dominant hand to
wash carefully within the skin folds. Wipe from the perineum
to the rectum (front to back). Repeat this process on the
opposite side, using a separate section of the washcloth. Rinse
and dry the area thoroughly.
h. Gently separate the labia with your nondominant hand to

expose the urethral meatus and vaginal orifice. With your
dominant hand, wash downward from the pubic area toward
the rectum in one smooth stroke. Use a separate section of
the cloth for each stroke. Cleanse thoroughly over the labia
minora, clitoris, and vaginal orifice. For a woman who is
menstruating, use a clean washcloth, cotton ball, or perineal
wipe instead of a separate section of the same cloth to
cleanse the vaginal area. For a woman with an indwelling
catheter, use a clean washcloth or perineal wipe to cleanse
the catheter. Avoid placing tension on an indwelling urinary
catheter, if present, and thoroughly clean the area around it.
i. Rinse and dry the area completely, from front to back.

k. Ask the patient to lower her legs. Remove the towel and bath
towel. Pull the patient’s gown down and the blankets up.
9. Remove and dispose of gloves in receptacle and perform hand

hygiene.


13. Assess patient's comfort level and level of fatigue.

unexpected outcomes including how much she participated, her
tolerance of the procedure, the condition of the skin and any
significant findings.
MONITORING AND CARE
 Monitor the perineum, particularly noting areas that were previously

soiled or reddened, or that had swelling, discharge, irritation, or
signs of skin breakdown.
 Assess vital signs if the patient is experiencing distress or

restlessness.
EXPECTED OUTCOMES
 Patient receives appropriate perineal care.
 Patient does not experience skin breakdown.
 Patient does not acquire urinary infection.
UNEXPECTED OUTCOMES
 Patient has skin breakdown.
 Patient develops urinary infection.
DOCUMENTATION
and how she tolerated the procedure.
 Record the condition of the patient’s skin prior to the procedure and
after the procedure and any significant findings, such as reddened
areas, bruises, nevi, and joint or muscle pain.
 Document the presence of an indwelling catheter, if applicable.
 Report any evidence of altered skin integrity, any break in a suture

line, or increased wound secretions to the nurse in charge or to the
0800 Perineal care given. Patient unable to assist but cooperative with
positioning. No redness, drainage, or open areas noted. Patient
complained of mild itching before perineal care. Patient reports reduced
itching after perineal care. –K.Grady, RN. 5/9/21
 Older adults have fragile skin and may need lower water
temperatures.5

10. Performing Perineal care for a male patient
ALERT



prevent contamination of the urethral meatus with
microorganisms.
 After administering perineal care for an uncircumcised male,

gently return the foreskin to its natural position.


3. Provide privacy, perform hand hygiene and apply gloves.
4. Introduce yourself to the patient and family if present. Explain the

procedure and its importance in preventing infection and ensure
that he agrees to treatment.
6. Bring the bed to the appropriate working height. Apply clean gloves.
7. Check the water temperature.
8. Perineal care for a male patient:

allow him to cleanse the perineum on his own.
b. Note any restrictions or limitations on the patient's

positioning. Help the patient into a supine position. Place a
waterproof pad under the patient's buttocks.
c. Drape the patient with a bath blanket placed over the

abdomen.
d. Wash, rinse and thoroughly dry the upper thighs. Cover the
thighs with a bath towel. Raise the bath blanket to expose the
patient's genitalia.
e. Gently raise the penis, and place the bath towel underneath.
Gently grasp the shaft of the penis. If patient is uncircumcised,
retract the foreskin. If patient has an erection, defer the
procedure until later.
f. Wash the tip of the penis at the urethral meatus first. Using a
circular motion, cleanse from the meatus outward. With a
separate section of the washcloth, continue until the tip of the
penis is clean.
g. Rinse and dry the tip of the penis gently and thoroughly. If the
patient is uncircumcised, return the foreskin to its natural
position.
h. Gently cleanse the shaft of the penis and the scrotum by

having the patient abduct his legs. Pay special attention to the
underlying surface of the penis. Lift the scrotum carefully, and
wash the underlying skin folds.

k. Remove the towel and bath blanket. Pull the patient's gown
down and the blankets up.
9. Help the patient into a comfortable position, and place toiletries and
personal items within reach.
10. Dispose of gloves in receptacle.


ALERT



prevent contamination of the urethral meatus with
microorganisms.
 After administering perineal care for an uncircumcised male,

gently return the foreskin to its natural position.

OVERVIEW
Perineal care involves thorough cleansing of the patient’s external

genitalia and surrounding skin. A patient routinely receives perineal care
during a complete bed bath. However, patients who have fecal or urinary
incontinence, an indwelling Foley catheter, or rectal or genital surgery
may need more frequent perineal care. Wear gloves during perineal care
because of the risk of contracting an infection.

perineal care. Routine perineal cleansing is performed with soap and
water. The periurethral area should not be cleaned with antiseptic
solutions when a urinary catheter is in place. 1 For a patient with an
indwelling catheter, the urethral meatus should be cleansed daily with
soap and water as part of overall patient hygiene. 1,2 Daily cleansing of the
meatal surface is recommended for patients with indwelling urinary
catheters.3,4 Antiseptic cleansers are not recommended for use with
patients who have indwelling urinary catheters because irritation of the
urethral meatus may increase the risk of infection. 3
To avoid embarrassment, always act in a professional and sensitive

manner and provide privacy at all times.
SUPPLIES
EDUCATION

 Educate the patient on how to inspect surfaces between skinfolds

for signs of irritation or breakdown.
 Assess the patient's need for perineal care. Patients at risk for
infection need more frequent care. These include patients with
incontinence-associated dermatitis (IAD), patients with an indwelling
urinary catheter, and those recovering from rectal or genital surgery.
 Assess the patient's tolerance of perineal care and activity, comfort,

cognitive ability, and musculoskeletal function. Assess the patient
for shortness of breath.
 Evaluate the patient's knowledge of perineal hygiene.
 Note any restrictions or limitations on patient positioning.
 Determine how much of the perineal care the patient wants to

complete himself.
 Offer the patient the opportunity to void in a bedpan or urinal.
 Fill a washbasin two-thirds full with warm water.
 Adjust the room temperature and ventilation and provide privacy.
DELEGATION
The skill of perineal care can be delegated to nursing assistive personnel

(NAP). Before delegating, be sure to inform NAP of the following:
 Any physical restrictions that affect the proper positioning of the

patient
 The proper ways in which to position a patient with an indwelling

urinary catheter
 The need to inform you of any perineal drainage, excoriation, or

rash
 Any cultural differences that may affect the perineal care process
PROCEDURE

3. Provide privacy, perform hand hygiene and apply gloves. Don

4. Introduce yourself to the patient and family if present. Explain the

procedure and its importance in preventing infection and ensure
that he agrees to treatment.
6. Bring the bed to the appropriate working height. Apply clean gloves.
7. Check the water temperature.
8. Perineal care for a male patient:

allow him to cleanse the perineum on his own.

positioning. Help the patient into a supine position. If the
patient is unable to lie supine, position the patient side-lying.
Place a waterproof pad under the patient’s buttocks.
c. Drape the patient with a bath blanket placed over the

abdomen.
d. Wash, rinse and thoroughly dry the upper thighs. Cover the
thighs with a bath towel. Raise the bath blanket to expose the
patient's genitalia.
e. Gently raise the penis, and place the bath towel underneath.
Gently grasp the shaft of the penis. If patient is uncircumcised,
retract the foreskin. If patient has an erection, defer the
procedure until later.
f. Wash the tip of the penis at the urethral meatus first. Using a
circular motion, cleanse from the meatus outward. With a
separate section of the washcloth, continue until the tip of the
penis is clean.
g. Rinse and dry the tip of the penis gently and thoroughly. If the
patient is uncircumcised, return the foreskin to its natural
position.
h. Gently cleanse the shaft of the penis and the scrotum by

having the patient abduct his legs. Pay special attention to the
underlying surface of the penis. Lift the scrotum carefully, and
wash the underlying skin folds.

k. Remove the towel and bath blanket. Pull the patient's gown
down and the blankets up.
9. Help the patient into a comfortable position, and place toiletries and
personal items within reach.
10. Dispose of gloves in receptacle.


MONITORING AND CARE
 Monitor the perineum, particularly noting areas that were previously

soiled or reddened, or that had swelling, discharge, irritation, or
signs of skin breakdown. Take steps to relieve pressure if you notice
redness, blistering, or other signs of skin irritation.
 Assess vital signs if the patient is experiencing distress or

restlessness.
EXPECTED OUTCOMES
 Patient receives appropriate perineal care.
 Patient does not experience skin breakdown.
 Patient does not acquire urinary infection.
UNEXPECTED OUTCOMES
 Patient has skin breakdown.
 Patient develops urinary infection.
DOCUMENTATION

and how he tolerated the procedure.
 Record the condition of the patient’s skin prior to the procedure and
after the procedure and any significant findings, such as reddened
areas, bruises, nevi, and joint or muscle pain.
 Document the presence of an indwelling catheter, if applicable.
 Report any evidence of alterations in skin integrity, any break in a

suture line, or increased wound secretions to the nurse in charge or
to the health care provider.
0800 Perineal care given. Patient unable to assist but cooperative with
positioning. External genitalia show no signs of redness, swelling, or
drainage. Indwelling catheter is intact and draining clear amber urine.
Patient denies pain, but states that he feels "very weak." –P.Novattny, RN
3/26/21
 Older adults have fragile skin and may need lower water
temperatures.5

11. Assisting with Gown Change
ALERT
 Observe Standard Precautions, including wearing clean gloves,

when providing care. Additional precautions requiring other personal
protective equipment (PPE) may be necessary, depending on the
patient’s condition.
 Be aware of the presence and position of external medical devices

or equipment, such as intravenous lines, nasogastric tubes, or
oxygen tubing.
 Be aware of the range of motion of the patient’s upper extremities

during the gown change. Avoid moving the patient beyond these
limitations.
 Review any orders for specific precautions concerning the patient’s

movement or positioning.
 Use proper body mechanics when positioning or moving the patient.
2. Gather the necessary equipment and supplies, and place them on

the bedside table.
4. Provide for the patient’s privacy.
6. Identify the patient using at least two identifiers, such as name and
date of birth or name and account number, according to agency
policy. Compare these identifiers with the information on the
patient’s identification bracelet.
7. Before changing the patient’s gown, identify any mobility

restrictions. Check the gown to see if it is wet or soiled.
8. Raise the bed to a comfortable working height. Lower the side rail
closest to you. If needed, bring the patient toward the side closest
to you. Help the patient assume a comfortable supine position,
maintaining body alignment.
9. Place a bath blanket over the patient.
10. If necessary, apply clean gloves.
11. Remove the patient’s gown or pajamas:
a. If the gown has snaps, unsnap the sleeves and remove the
gown.
b. If the gown does not have snaps and if the patient has an
injured extremity, reduced mobility, or an IV line, begin
removing the gown from the unaffected side first.
c. If the patient has an intravenous line and the gown does not
have snap sleeves, remove the gown from the arm without the
IV first. Then remove the gown from the arm with the IV. If an
IV pump is present, pause the IV fluid infusion by pressing the
appropriate sensor on the IV pump. Before removing the
tubing from the pump, remember to slow the rate down by
using the roller clamp. If you do not slow the flow down, the
patient may receive a large bolus of IV fluid while the tubing is
off the pump. Remove the IV infusion bag and tubing, and
slide through the arm of the patient’s gown. Before rehanging
the IV infusion bag, you may begin dressing the patient in a
clean gown starting with the affected side. Rehang the IV
infusion bag on the pole, and restart the IV fluid infusion by
pressing the appropriate sensor on the IV pump. If the IV fluids
are infusing by gravity, check the flow rate and adjust it to the
prescribed rate, if necessary. Do not disconnect the IV
tubing to remove a patient’s gown.
12. Check the position and function of any external devices, such
as a brace, an indwelling urinary catheter, or a nasogastric tube.
13. Place the soiled gown in the linen bag. Do not allow the soiled
linen to come into contact with your uniform. If needed, apply clean
gloves.
14. Finish applying the clean gown, reversing the process of

removing the gown.
15. To ensure the patient’s safety, make sure the bed is in the
locked, low position, with at least two, but no more than three, side
Place toiletries and personal items within reach.
16. Remove the bath blanket keeping the linen away from your
uniform. Place it in the linen bag.
18. Dispose of used supplies and equipment. Leave the patient’s

room tidy.
19. Remove and dispose of gloves. Perform hand hygiene.

unexpected outcomes if necessary.
ALERT
 Observe Standard Precautions, including wearing clean gloves,

when providing care. Additional precautions requiring other personal
protective equipment (PPE) may be necessary, depending on the
patient’s condition.
 Be aware of the presence and position of external medical devices

or equipment, such as intravenous lines, nasogastric tubes, or
oxygen tubing.
 Be aware of the range of motion of the patient’s upper extremities

during the gown change. Avoid moving the patient beyond these
limitations.
 Review any orders for specific precautions concerning the patient’s

 Use proper body mechanics when positioning or moving the patient.
OVERVIEW
Removing patient’s gown or pajamas.
SUPPLIES
 Review orders for specific precautions concerning the patient’s

the bed is in the locked, low position.
 Identify any restrictions on the patient’s mobility.
 Assess the patient’s hand grasp and the range of motion of the
extremities.
 Assess for the presence and position of external medical devices or

equipment, such as intravenous lines, nasogastric tubes, or oxygen
tubing.
 Determine what specific clothing is required for the patient.
 Ask if the patient has any clothing preferences or requests.
 Apply clean gloves if the patient’s gown is wet or soiled with blood
or body fluids.
 Identify risks for skin impairment, including the following:
o Weakened or disabled patients and those with immobilization

because of paralysis, immobilized extremities, or traction
o External devices applied to or around skin, such as casts,

braces, restraints, dressings, catheters, or tubes
o Incontinence of bowel or bladder
DELEGATION
The skill of assisting with a gown change can be delegated to nursing

assistive personnel (NAP) if the patient’s gown has snap sleeves. Do
not delegate the skill of assisting with a gown change if the patient has
intravenous lines and the gown does not have snap sleeves. Be sure to
inform NAP of the following:
 Explain the proper way to position the patient with musculoskeletal

limitations or an indwelling urinary catheter or other equipment,
such as a nasogastric tube or intravenous line.
 What to report to the nurse, such as any limitations with positioning
of the patient or complications caused by equipment like an
indwelling catheter, nasogastric tube or intravenous line.
PROCEDURE
2. Gather the necessary equipment and supplies, and place them on

the bedside table.
6. Identify the patient using at least two identifiers, such as name and
date of birth or name and account number, according to agency
policy. Compare these identifiers with the information on the
patient’s identification bracelet.
7. Before changing the patient’s gown, identify any mobility

restrictions. Check the gown to see if it is wet or soiled.
8. Raise the bed to a comfortable working height. Lower the side rail
closest to you. If needed, bring the patient toward the side closest
to you. Help the patient assume a comfortable supine position,
maintaining body alignment.
9. Place a bath blanket over the patient.
10. If necessary, apply clean gloves.
11. Remove the patient’s gown or pajamas:
a. If the gown has snaps, unsnap the sleeves and remove the
gown.
b. If the gown does not have snaps and if the patient has an
injured extremity, reduced mobility, or an IV line, begin
removing the gown from the unaffected side first.
c. If the patient has an intravenous line and the gown does not
have snap sleeves, remove the gown from the arm without the
IV first. Then remove the gown from the arm with the IV. If an
IV pump is present, pause the IV fluid infusion by pressing the
appropriate sensor on the IV pump. Before removing the
tubing from the pump, remember to slow the rate down by
using the roller clamp. If you do not slow the flow down, the
patient may receive a large bolus of IV fluid while the tubing is
off the pump. Remove the IV infusion bag and tubing, and
slide through the arm of the patient’s gown. Before rehanging
the IV infusion bag, you may begin dressing the patient in a
clean gown starting with the affected side. Rehang the IV
infusion bag on the pole, and restart the IV fluid infusion by
pressing the appropriate sensor on the IV pump. If the IV fluids
are infusing by gravity, check the flow rate and adjust it to the
prescribed rate, if necessary. Do not disconnect the IV
tubing to remove a patient’s gown.
12. Check the position and function of any external devices, such
as a brace, an indwelling urinary catheter, or a nasogastric tube.
13. Place the soiled gown in the linen bag. Do not allow the soiled
linen to come into contact with your uniform. If needed, apply clean
gloves.
14. Finish applying the clean gown, reversing the process of

removing the gown.
15. To ensure the patient’s safety, make sure the bed is in the
locked, low position, with at least two, but no more than three, side
Place toiletries and personal items within reach.
16. Remove the bath blanket keeping the linen away from your
uniform. Place it in the linen bag.

room tidy.

unexpected outcomes if necessary.
MONITORING AND CARE
 Observe the patient’s range of motion during the gown change.
 Ask the patient to rate his or her level of comfort, using a scale of 0
to 10.
 Ask if the patient feels fatigued.
EXPECTED OUTCOMES
 Skin is free of excretions, draining, or odor.

 Skin shows decreased redness, cracking, flaking, and scaling in
regard to subsequent baths.
 Joint ROM remains the same or improves from previous

measurement.
 Patient expresses sense of comfort and relaxation.
UNEXPECTED OUTCOMES
 Areas of excessive dryness, rashes, irritation, or pressure ulcer

appear on skin.
 Patient experiences excessive fatigue or is short of breath and

unable to cooperate or participate in bathing.
 Patient seems unusually restless or complains of discomfort.
DOCUMENTATION
 The skill of changing a patient’s gown is not documented.
12. Performing Oral hygiene for an unconscious patient
ALERT
 If the patient has an impaired gag reflex, determine the type

of suction apparatus needed at the bedside to protect the
airway from aspiration.
 Use Standard Precautions when providing oral care,

including wearing clean gloves. Additional precautions
requiring other personal protective equipment (PPE) may be
necessary, depending on the patient’s condition.
 Do not use your fingers to inspect the mouth of an

unconscious or unresponsive patient. Always use a tongue
blade to avoid the patient’s reflex to bite down.
 Bleeding should not result from performing usual oral

hygiene such as flossing or brushing; if bleeding from gums
or other soft oral tissues is seen, assess the oral cavity
carefully for sores and inflammation and consult the
practitioner.
1. Introduce yourself to the patient and family if present, and explain

the procedure. If patient is conscious, ensure he or she agrees to
treatment.
birth or name and account number. Compare these identifiers on the
EMR record with the information on the patient’s identification
bracelet.
4. Draw the curtain around the bed, or close the room door to provide
for patient privacy.
5. Place a towel on the overbed table, and arrange your equipment.
6. Raise the bed to a comfortable working height, and position the

patient close to the side of the bed from which you will be working.
Lower the side rails.
8. Test for the presence of a gag reflex by placing a tongue blade on

the back half of the tongue. Use a tongue blade and penlight to
inspect the condition of the oral cavity.
9. Inspect the patient’s mouth for signs of tartar, swollen or bleeding

gums, ulcerations, debris, and severe halitosis. Remove the
patient’s dentures or partial plates if present, and safely store them
for proper cleaning in an appropriate container labeled with the
patient’s name.
10. Remove and dispose of gloves.
11. If needed, connect the tubing to the suction catheter, turn on

the suction machine, and test the suction catheter.
12. Position the patient close to the side of the bed from which
you will be working. Unless contraindicated, as in patients with head
injury or neck trauma, position the patient in the lateral recumbent
or side-lying position. Turn the patient’s head toward the mattress in
a dependent position, with the head of the bed elevated to at least
30 degrees.
13. Turn the patient’s head toward the mattress in a dependent

position, and place a towel under the patient’s head. Verify the head
of the bed elevated to at least 30 degrees.
14. Apply a clean pair of gloves.
15. Place an emesis basin under the patient’s chin.
16. If the patient is unconscious or has a bite reflex, put an oral

airway in place. Insert the airway upside down, and then turn it
sideways and over the tongue to keep the teeth apart. Do not use
force.
17. If possible, use floss or another interdental device (soft pick)

at least once a day before brushing the teeth.
18. Next, suction any accumulated secretions, and clean the

mouth using a toothbrush moistened with water. Apply toothpaste
or a therapeutic solution to the toothbrush, and use it to loosen any
crusts.
19. Apply toothpaste to the toothbrush, and cleanse the tooth

surfaces using a gentle up-and-down motion. A toothette sponge
can be used for patients in whom toothbrushing is contraindicated.
A tongue blade may be used to move the lips and cheek mucosa
away from the teeth as you brush or clean.
20. Clean the chewing and inner surfaces of the teeth first. Then
clean the outer surfaces by holding the toothbrush so that its
bristles are at a 45-degree angle to the gum line. Be sure that the
tips of the bristles rest against and penetrate beneath the gum line.
21. Brush the inner and outer surfaces of the upper and lower
teeth from the gum line to the crown of each tooth. Clean the biting
surfaces of the teeth by holding the toothbrush bristles
perpendicular to the teeth and brushing gently back and forth.
Brush the sides of the teeth by gently moving the bristles back and
forth.
22. Use a bulb syringe filled with water to rinse the mouth and
repeat as needed. Moisten the toothbrush or foam-tipped applicator
with an appropriate therapeutic mouth rinse and cleanse the oral
cavity, ensuring contact of the therapeutic mouth rinse with all oral
cavity structures. Use the brush or a toothette to clean the roof of
the mouth, the gums, and inside the cheeks.
23. Gently brush the tongue, taking care to avoid stimulating the
gag reflex if one is present. Repeat this rinsing action several times,
and use suction to remove any secretions.
24. If a toothbrush cannot be used, rinse the roof of the mouth,

gums, and inside of the cheeks with a toothette sponge.
25. Use a gloved finger or toothette sponge to apply a thin layer

of water-soluble moisturizer to the patient’s lips.
26. Inform the patient that the procedure has been completed.
Return the patient to a comfortable and safe position.
27. Raise the side rails as appropriate, and return the bed to the
locked and lowest position.
28. Dispose of all soiled linen in an appropriate receptacle.
29. Remove and discard your gloves, and perform hand hygiene.
30. Document the patient’s oral care.
ALERT
 If the patient has an impaired gag reflex, determine the type

of suction apparatus needed at the bedside to protect the
airway from aspiration.
 Use Standard Precautions when providing oral care,

including wearing clean gloves. Additional precautions
 Do not use your fingers to inspect the mouth of an

unconscious or unresponsive patient. Always use a tongue
blade to avoid the patient’s reflex to bite down.
 Bleeding should not result from performing usual oral

hygiene such as flossing or brushing; if bleeding from gums
or other soft oral tissues is seen, assess the oral cavity
carefully for sores and inflammation and consult the
practitioner.
OVERVIEW
Unconscious or debilitated patients pose challenges because of their risk

for alterations of the oral cavity from drying of the mucous membrane,
thickened secretions, and the inability to eat or drink. They are susceptible
to infection because of the change in the normal flora of the oral cavity
and at risk for infection because of increased plaque formation from the
dryness of the mouth and decreased salivation. Dryness of the oral
mucosa is also caused by mouth breathing and oxygen therapy.
Respiratory secretions often are thick and place patients at risk for
ineffective airway clearance, requiring suction. They are also at risk for
aspiration. Although saliva production is decreased, saliva is present and
can pool in the back of the oral cavity, which is another contributing factor
to placing the patient at risk of aspiration. The secretions in the oral cavity
change very rapidly to gram-negative pneumonia-producing bacteria if
aspiration occurs.
The critically ill patient faces the same risk factors for oral problems as
other patients such as dehydration, dryness of the oral mucosa, chemical
injury to the mucosa, and oral trauma. Once intubated, an endotracheal
tube causes a bypass of normal defenses, which also causes a rapid
change in the normal oral flora. Some patients require mouth care as
often as every 1 to 2 hours until the mucosa returns to normal. Optimal
oral care should focus on plaque removal and stimulation of salivary flow.
Currently more research is underway in establishing oral-care regimens for
all critically ill patients.
Many patients have no gag reflex as a result of change in consciousness

or a neurologic injury. While providing oral care to an unconscious patient,
protect him or her from choking and aspiration. The safest technique is to
have two nurses provide care. You provide oral care while another nurse or
nursing assistive personnel (NAP) suctions oral secretions as necessary
with a Yankauer suction tip. You can also delegate oral care to two NAPs
with instructions. Place the unconscious or unresponsive patient in a
lateral recumbent or side-lying position with the head in a dependent
position. Raise the head of bed (HOB) to at least 30 degrees, with
patient’s head turned to the side and toward the mattress in a dependent
position. Proper oral hygiene requires keeping the oral mucosa moist and
removing secretions that lead to infection. Use a moisturizing emollient for
the lips as well. Evaluate the level and frequency of oral care on a daily
basis during assessment of the oral cavity. Routine suctioning of the
mouth and pharynx is required to manage oral secretions to reduce the
risk for aspiration. Research also suggests that toothbrushing provides
additional benefit in reducing colonization of dental plaque. 1 For patients
who are not on ventilated-assisted breathing, toothbrushing and
chlorhexidine are also effective. For patients with arthritis or other
conditions that may limit dexterity, an electric or battery-operated
toothbrush may be used.2
Therapeutic mouth rinses contain a variety of active ingredients that can

reduce plaque and gingivitis, or bad breath, and may also reduce viral
load in a patient’s saliva.3 Therapeutic mouth rinses are available in over-
the-counter and prescription strength formulations and may contain one
or several active ingredients, including fluoride, peroxide, and
chlorhexidine. Current recommendations do not support using oral
products containing chlorhexidine for patients in an acute care setting
until more data is gathered.4
SUPPLIES
EDUCATION
 Provide the patient and family with an explanation of the procedure

and the equipment. Do not assume that an unconscious person is
unable to hear.
 Family members may care for debilitated patient in the home.

Instructions for mouth care are necessary so family understands
how to protect patient from aspirating while thoroughly cleaning oral
cavity. Observe family caregiver perform mouth care procedure.
the bed is in the locked, low position.
 Perform hand hygiene, and apply clean gloves. Don appropriate

personal protective equipment (PPE) based on the patient’s need for
isolation precautions and the risk of exposure to bodily fluids.
 Test for the presence of a gag reflex by placing a tongue blade on

the back half of the tongue.
 Inspect the condition of the oral cavity with a tongue blade and
penlight.
 Remove gloves and perform hand hygiene.
 Assess the patient’s risk for oral hygiene problems, including the
following:
o Dehydration
o Ill-fitting dentures or partials
o Presence of nasogastric or oxygen tubes
o Mouth breathing
o Receiving chemotherapeutic drugs
o Having radiation therapy to the head and/or neck
o Presence of an artificial airway or endotracheal tube
o Having a blood-clotting disorder, such as leukemia or aplastic

anemia
o Having had oral surgery or trauma to the mouth
o Chemical injury
o Diabetes mellitus
o Nutritional disorders
 Assess the patient’s respiration on an ongoing basis.
DELEGATION
After assessing the patient for a gag reflex, the skill of performing oral
care for an unconscious or debilitated patient can be delegated to nursing
assistive personnel (NAP). Be sure to inform NAP of the following:
 Discuss proper positioning of the patient for mouth care.
 Explain any special precautions, such as Aspiration Precautions.
 Review the use of an oral suction catheter to clear oral secretions.
 Instruct NAP to report to you any signs of impaired integrity of the

oral mucosa.
 Instruct NAP to report to you immediately any bleeding of mucosa or

gums, or excessive coughing or choking.
PROCEDURE
1. Introduce yourself to the patient and family, if present, and explain

the procedure. If patient is conscious, ensure he or she agrees to
treatment.
birth or name and account number. Compare these identifiers on the
EMR record with the information on the patient’s identification
bracelet.
4. Draw the curtain around the bed, or close the room door to provide
for patient privacy.
5. Place a towel on the overbed table, and arrange your equipment.
6. Raise the bed to a comfortable working height, and position the

patient close to the side of the bed from which you will be working.
Lower the side rails.

8. Test for the presence of a gag reflex by placing a tongue blade on
the back half of the tongue. Use a tongue blade and penlight to
inspect the condition of the oral cavity.
9. Inspect the patient’s mouth for signs of tartar, swollen or bleeding

gums, ulcerations, debris, and severe halitosis. Remove the
patient’s dentures or partial plates if present, and safely store them
for proper cleaning in an appropriate container labeled with the
patient’s name.
10. Remove and dispose of gloves.
11. If needed, connect the tubing to the suction catheter, turn on

the suction machine, and test the suction catheter.
12. Position the patient close to the side of the bed from which
you will be working. Unless contraindicated, as in patients with head
injury or neck trauma, position the patient in the lateral recumbent
or side-lying position. Turn the patient’s head toward the mattress in
a dependent position, with the head of the bed elevated to at least
30 degrees.
13. Turn the patient’s head toward the mattress in a dependent

position, and place a towel under the patient’s head. Verify the head
of the bed elevated to at least 30 degrees.
14. Apply a clean pair of gloves.
15. Place an emesis basin under the patient’s chin.
16. If the patient is unconscious or has a bite reflex, put an oral

airway in place. Insert the airway upside down, and then turn it
sideways and over the tongue to keep the teeth apart. Do not use
force.
17. If possible, use floss or another interdental device (soft pick)

at least once a day before brushing the teeth.5
18. Next, suction any accumulated secretions, and clean the

mouth using a toothbrush moistened with water. Apply toothpaste
or a therapeutic solution to the toothbrush, and use it to loosen any
crusts.
19. Apply toothpaste to the toothbrush, and cleanse the tooth

surfaces using a gentle up-and-down motion. A toothette sponge
can be used for patients in whom toothbrushing is contraindicated.
A tongue blade may be used to move the lips and cheek mucosa
away from the teeth as you brush or clean.
20. Clean the chewing and inner surfaces of the teeth first. Then
clean the outer surfaces by holding the toothbrush so that its
bristles are at a 45-degree angle to the gum line. 1 Be sure that the
tips of the bristles rest against and penetrate beneath the gum line. 1
21. Brush the inner and outer surfaces of the upper and lower
teeth from the gum line to the crown of each tooth. Clean the biting
surfaces of the teeth by holding the toothbrush bristles
perpendicular to the teeth and brushing gently back and forth.
Brush the sides of the teeth by gently moving the bristles back and
forth.
22. Use a bulb syringe filled with water to rinse the mouth and
repeat as needed. Moisten the toothbrush or foam-tipped applicator
with an appropriate therapeutic mouth rinse and cleanse the oral
cavity, ensuring contact of the therapeutic mouth rinse with all oral
cavity structures. Use the brush or a toothette to clean the roof of
the mouth, the gums, and inside the cheeks.
23. Gently brush the tongue, taking care to avoid stimulating the
gag reflex if one is present.1 Repeat this rinsing action several times,
and use suction to remove any secretions.
24. If a toothbrush cannot be used, rinse the roof of the mouth,

gums, and inside of the cheeks with a toothette sponge.
25. Use a gloved finger or toothette sponge to apply a thin layer

of water-soluble moisturizer to the patient’s lips.
26. Inform the patient that the procedure has been completed.
Return the patient to a comfortable and safe position.
27. Raise the side rails as appropriate, and return the bed to the
locked and lowest position.
28. Dispose of all soiled linen in an appropriate receptacle.
29. Remove and discard your gloves, and perform hand hygiene.
30. Document the patient’s oral care.
MONITORING AND CARE
 Assess the patient for aspiration. If aspiration is suspected, perform

the following:
o In order to maintain airway patency, suction the oral airway as

secretions accumulate.
o Elevate the head of the bed to facilitate breathing.

o Notify the physician, and prepare the patient for a chest x-ray
examination.
 Apply clean gloves, and inspect the oral cavity for cleanliness on a
regular basis. Compare your preprocedure and postprocedure
findings. Schedule the frequency of oral care based on the patient’s
condition. An unconscious or unresponsive patient requires mouth
care as often as every 1 to 2 hours. Report any unusual findings to
the practitioner to prompt an order for an oral health professional
consultation.
EXPECTED OUTCOMES
 Buccal mucosa and tongue are pink, moist, and intact. Gums are
moist and intact. Teeth are clean, smooth, and shiny. Tongue does
not have a coating. Lips are moist, smooth, and without cracks.
 Debilitated patient (if able) expresses feeling of cleanliness.
 Oral pharynx remains clear of secretions.
UNEXPECTED OUTCOMES
 Secretions or crusts remain on mucosa, tongue, or gums.
 Localized inflammation or bleeding of gums/mucosa is present.
 Lips are cracked or inflamed.
 Patient aspirates secretions.
DOCUMENTATION
 Record the oral care procedure, including the patient’s ability to

cooperate, patient’s tolerance of the procedure, and whether
suctioning was necessary.
 Document and report any pertinent observations, such as the

presence of a gag reflex and the presence of bleeding gums, dry
mucosa, ulcerations, or crusts on the tongue.
 Report any unusual findings to the nurse in charge or to the health

care provider.
 Record pain assessment and management.
0700 Mouth care given. Mucous membranes moist, pink, no inflammation.
Lips dry, cracked. Moisturizing gel applied to lips. Patient unresponsive. No
gag reflex elicited. Oropharynx suctioned frequently during oral hygiene. –
M. Bialowarczyk, RN 2/17/21
Mouthwash is not recommended for children under 6 years of age. 1
 Pharmocokinetics of medications are altered in older adult patients,

and interactions among antihypertensives, antidepressants, and
other medications are unpredictable and may cause issues with oral
integrity.6
 Older adults have high rates of untreated dental caries, periodontal

disease, and missing teeth. Anticipate compromised oral integrity
and a deterioration of overall health during the initial clinical
assessment.
 Irrigate oral cavity with bulb syringe; if unavailable, substitute gravy

baster or large syringe. Caution family caregiver against instilling a
large amount of water or rinsing agent in the oral cavity because of
the risk of aspiration.
 Encourage family caregiver to perform oral care for the patient at

least twice a day. If the patient breathes through his or her mouth,
explain that frequent use of a moistened soft-bristle toothbrush
followed by the application of a water-based mouth moisturizer and
emollient lip moisturizer help keep the mouth moist and fresh.
13. Cleaning dentures
ALERT
 Dentures are a patient’s personal property, so be sure to

handle them with care, because they are easy to break.
When the patient is not wearing his or her dentures, store
them in water in an enclosed cup labeled with the patient’s
name.

3. Perform hand hygiene. Don additional PPE based on the patient’s
need for isolation precautions or the risk of exposure to bodily fluids.
birth or name and account number. Compare these identifiers with
the information on the patient’s identification bracelet.
7. Before cleaning a patient’s dentures, determine if the patient can

clean the dentures independently, or if he or she requires
assistance. Ask the patient about denture care product preference.
8. Apply gloves.
9. Remove the dentures from the patient’s mouth. If the patient is

unable to do this independently, grasp the upper denture at the
front with your thumb and index finger wrapped in gauze, and pull
downward. Gently lift the lower denture from the jaw, and rotate one
side of the bottom denture downward to remove it from the
patient’s mouth.
10. Place the dentures in a denture cup or an emesis basin. Place

a washcloth at the bottom of the sink, and fill the sink with
approximately 1 inch (2.5 cm) of water. Do not soak dentures in hot
or boiling water as this may damage or warp them.
11. Apply a cleaning agent to a toothbrush, and brush the

surfaces of the dentures.
12. Hold the dentures close to the water. Hold the brush
horizontally, and use a back-and-forth motion to cleanse the biting
surfaces. To clean the outer tooth surfaces, use short strokes,
moving from the top of the denture to the biting surfaces. To clean
the inner tooth surfaces, hold the brush vertically and use short
strokes. To clean the undersurface of the denture, hold the brush
horizontally and use a back-and-forth motion.
13. Rinse the denture thoroughly in tepid water. If the water is too
cold, the denture can crack. If the water is too hot, the denture can
warp and will no longer fit properly in the patient’s mouth.
14. Repeat the cleaning and rinsing process with the other
denture if the patient has one.
15. Offer mouthwash for the patient to rinse his or her mouth to
clean the oral cavity prior to inserting clean dentures. A 50/50
solution of mouthwash and water or other antimicrobial solution
may be used. The gums may be cleaned with a small amount of
toothpaste applied to a soft-bristled toothbrush.
16. If the patient needs help inserting the dentures, moisten the
upper denture and press it firmly to the gums to seal it in place. Use
the same process to insert the moistened lower denture.
17. Some patients use an adhesive to seal the dentures in place. If

the patient uses an adhesive, apply a thin layer to the undersurface
of the denture before insertion.
18. Ask the patient if the denture(s) feel(s) comfortable. Assist the
patient with drying his or her face.
19. Dispose of all used supplies and equipment.
21. Some patients prefer to store their dentures, to give their

gums a rest and to reduce the risk of infection. Store the dentures in
tepid water in a denture cup. An effervescent cleaning tablet may
be added to the cup at the patient’s request. Label the cup with the
patient’s name, and put it in a secure place to keep the dentures
from getting lost or being accidentally thrown away.



ALERT
 Dentures are a patient’s personal property, so be sure to

handle them with care, because they are easy to break.
When the patient is not wearing his or her dentures, store
them in water in an enclosed cup labeled with the patient’s
name.
OVERVIEW
Oral care is especially important for older adults. Oral biofilm on dentures
are associated with systemic illnesses and pneumonia. 1,2 Dentures can
harbor bacteria associated with pneumonia. 2 Encourage patients who
wear dentures to continue to care for them and provide this care as
frequently as with natural teeth. Loose dentures can cause discomfort and
make it difficult for patients to chew food and speak clearly. Routine
denture care reduces the risk for gingival infection. Some patients are
unable to care for their dentures, and nurses become responsible for
providing denture and oral care. Dentures are a patient’s personal
property; thus be sure to handle them with care because they are easy to
break.
Store dentures in an enclosed, labeled cup and soak them when not worn
(e.g., at night, during surgery) in clean water or a commercially prepared
denture solution, following the manufacturer’s recommendation for soak
time.3,5 The solution should be nontoxic, leave no aftertaste, be cost
effective, and effectively remove biofilm. Before being soaked, the
dentures should be brushed with a soft-bristle toothbrush and toothpaste
to remove plaque, bacteria, and food debris. Dentures may also be
cleaned with warm water and mild soap using a soft-bristle
toothbrush.5 After soaking, the dentures should be rinsed well with water
to remove soaking residues. Most patients prefer to have their dentures
inserted as soon as possible after procedures and upon awakening.
SUPPLIES
EDUCATION

 Instruct the patient and family members regarding proper denture

care and the recommended frequency of care.
 Assess the environment for safety, including checking the room for
spills, making sure that equipment is working properly, and ensuring
that the bed is in the locked, low position.
 Determine if the patient can clean his or her own dentures

independently or requires assistance. Dentures need to be cleaned
as often as natural teeth.
 Ask the patient about denture care product preference.

 Fill an emesis basin with tepid water. (If using the sink, place a
washcloth in the bottom of the sink, and fill the sink with
approximately 1 inch [2.5 cm] of water.)
DELEGATION
The skill of denture care can be delegated to nursing assistive personnel

(NAP). Be sure to inform NAP of the following:
 The importance of not using excessively hot or cold water when

caring for dentures.
 The need to inform you if there are cracks in the patient’s dentures.
 The need to inform you if the patient has any oral discomfort.
PROCEDURE
3. Provide for the patient’s privacy and perform hand hygiene. Don
additional PPE based on the patient’s need for isolation precautions
or the risk of exposure to bodily fluids.
birth or name and account number. Compare these identifiers with
the information on the patient’s identification bracelet.

7. Before cleaning a patient’s dentures, determine if the patient can

clean the dentures independently, or if he or she requires
assistance. Ask the patient about denture care product preference.
8. Apply gloves.
9. Remove the dentures from the patient’s mouth. If the patient is

unable to do this independently, grasp the upper denture at the
front with your thumb and index finger wrapped in gauze, and pull
downward. Gently lift the lower denture from the jaw, and rotate one
side of the bottom denture downward to remove it from the
patient’s mouth.
10. Place the dentures in a denture cup or an emesis basin. Place

a washcloth at the bottom of the sink, and fill the sink with
approximately 1 inch (2.5 cm) of water. Do not soak dentures in hot
or boiling water as this may damage or warp them. 5
11. Apply a cleaning agent to a toothbrush, and brush the

surfaces of the dentures.
12. Hold the dentures close to the water. Hold the brush
horizontally, and use a back-and-forth motion to cleanse the biting
surfaces. To clean the outer tooth surfaces, use short strokes,
moving from the top of the denture to the biting surfaces. To clean
the inner tooth surfaces, hold the brush vertically and use short
strokes. To clean the undersurface of the denture, hold the brush
horizontally and use a back-and-forth motion.
13. Rinse the denture thoroughly in tepid water. If the water is too
cold, the denture can crack. If the water is too hot, the denture can
warp and will no longer fit properly in the patient’s mouth.
14. Repeat the cleaning and rinsing process with the other
denture if the patient has one.
15. Offer mouthwash for the patient to rinse his or her mouth to
clean the oral cavity prior to inserting clean dentures. A 50/50
solution of mouthwash and water or other antimicrobial solution
may be used. The gums may be cleaned with a small amount of
toothpaste applied to a soft-bristled toothbrush.
16. If the patient needs help inserting the dentures, moisten the
upper denture and press it firmly to the gums to seal it in place. Use
the same process to insert the moistened lower denture.
17. Some patients use an adhesive to seal the dentures in place. If

the patient uses an adhesive, apply a thin layer to the undersurface
of the denture before insertion.
18. Ask the patient if the denture(s) feel(s) comfortable. Assist the
patient with drying his or her face.
19. Dispose of all used supplies and equipment.
21. Some patients prefer to store their dentures, to give their

gums a rest and to reduce the risk of infection. Store the dentures in
tepid water in a denture cup. An effervescent cleaning tablet may
be added to the cup at the patient’s request. Label the cup with the
patient’s name, and put it in a secure place to keep the dentures
from getting lost or being accidentally thrown away.


MONITORING AND CARE
 Ask the patient if any area of the oral cavity feels uncomfortable or
irritated.
 Apply clean gloves, and inspect the condition of the patient’s oral
cavity.
 Store dentures in tepid water or in a preferred soaking solution in a

denture cup labeled with the patient’s name. Store the denture cup
in a cool, secure place.
EXPECTED OUTCOMES
 Clean oral cavity and dentures
 Adequately moist mouth and tongue
UNEXPECTED OUTCOMES
 Gingivitis
 Pneumonia
 Uncomfortable or irritated oral cavity
DOCUMENTATION
 Record the denture care, and note the condition of the patient’s oral
cavity.
 Note any breaks, chips, or cracks in the dentures.
 Report any bleeding, pain, or presence of oral lesions to the nurse in

0700 Dentures cleaned as part of mouth care. Dentures intact, with no
cracks. Gums and mucous membranes pink and intact. Patient denies oral
lesions or pain. —A. Garavaglia, RN 10/29/21
14. Performing Hair care and shampooing in bed
ALERT
 A patient with a medical condition such as a head and neck

injury, spinal cord injury, or arthritis is at risk for injury
during shampooing because of the positioning and
manipulation of the head and neck.
 Patients with positional vertigo are not able to tolerate neck

hyperextension because this may increase dizziness.
 Remove hearing aids before shampooing, as water can

damage them.
1. Introduce yourself to the patient.

4. Combing and brushing hair:
a. Provide for the patient’s privacy.
b. Perform hand hygiene.
c. Arrange the supplies on the bedside table, and adjust the

lighting.
d. Determine if there are any contraindications to the procedure.
e. Ask the patient about any specific hair care products, cultural
hair care preferences, or styling preferences.
f. Encourage the patient to inform you if they are uncomfortable

at any time.
g. Apply clean gloves.
h. Place a towel over the patient’s shoulders or under his or her

head if the patient is in bed.
i. Using a comb, part the hair into two sections, and then
separate the hair into two more sections.
j. Inspect the condition of the patient’s hair and scalp.

Thoroughly examine the color, texture, quantity, and
characteristics of the hair.
k. Moisten the hair lightly with water, conditioner, or an alcohol-

free detangling product before combing it.
l. Move your fingers through the hair to loosen any larger

tangles.
m. Using a wide-tooth comb, begin on either side of the head and

comb from the scalp toward the ends of the hair. Continue
until all hair has been combed through, and then comb it into
place to shape and style it.
5. Shampooing a bed-bound patient:
a. Provide privacy.
b. Before washing the patient’s hair, determine that there are no

contraindications to the procedure. Verify the physician’s
order, if required.
c. Gather needed supplies.
d. Carefully position the patient into a supine position with head

and shoulders at the top edge of the bed.
e. Perform hand hygiene, and apply clean gloves.
f. Inspect the hair and scalp before beginning the shampoo.

Inspect the hair and scalp for abrasions, lacerations,
inflammation, and infestation. Determine if special shampoos
or treatments, such as those for dandruff, lice, or removal of
blood, are necessary. If lice are present, wear a disposable
gown in addition to gloves.
g. When shampooing the hair while using a shampoo board:
i. Place a waterproof pad under the patient’s shoulders,

neck, and head. Place the shampoo board or tray under
the patient’s head and a washbasin under the end of the
trough spout. Be sure that the spout extends beyond the
edge of the mattress.
ii. Place a rolled towel or gel roll under the patient’s neck
and a towel over the patient’s shoulders.
iii. Carefully brush and comb the patient’s hair to remove
any tangles.
iv. Obtain a pitcher filled with warm water.
v. Place a towel or washcloth over the patient’s eyes. Ask

the patient to hold a towel or washcloth over his or her
eyes if they wish to do so.
vi. Slowly pour the water from the pitcher over the
patient’s hair until it is completely wet. If the hair
contains matted blood, apply hydrogen peroxide to the
hair to dissolve the clots, being careful when near open
wounds, and then rinse the hair and any scalp areas
affected with warm water. Apply a small amount of
shampoo.
vii. Work up a lather using both of your hands. Begin at the

hairline, and work toward the nape of the neck. Then
shampoo the sides of the head. Massage the scalp by
applying pressure with your fingertips. Lift the patient’s
head slightly with one hand to wash the back of the
head.
viii. Rinse the hair with warm water. Make sure that the
water drains into the basin. Continue rinsing the hair
until it is free of all soap.
ix. Wrap the patient’s head in a towel. Dry the patient’s

face with the cloth he or she used earlier to protect the
eyes. Dry off any moisture along the patient’s neck,
ears, and shoulders.
x. Dry the patient’s hair and scalp. Use a second towel if

the first one becomes saturated.
xi. Carefully brush or comb the patient’s hair to remove any

tangles.
xii. Apply an oil preparation or conditioning product to the

hair, if needed or desired by the patient.
xiii. Variation for patients with coarse, curly hair: condition

the hair after washing. To untangle the hair, use the
wide-toothed comb. Begin at the nape of the neck and
comb small subsections of the hair, starting at the hair
ends. Continue to work through small sections of the
hair until the hair is free of tangles.
xiv. Assist the patient into a comfortable position, and finish
styling the patient’s hair.
xv. Dispose of and store supplies used during the

procedure. Remove your gloves, and perform hand
hygiene.
xvi. Document shampooing if required by the agency.
h. Shampooing using a disposable shampoo cap product:
i. Perform hand hygiene and don clean gloves.
ii. Help the patient into a comfortable position. The patient

can be sitting on a chair or upright in the bed.
iii. Place a waterproof pad under the patient’s shoulders,

neck, and head.
iv. Carefully brush or comb the hair to remove any tangles

or debris. Inspect scalp and hair. To untangle hair, use a
wide-tooth comb and, beginning at the nape of the neck,
comb small sections of the hair, starting at the hair
ends. Continue to work through small sections until the
hair is tangle free.
v. Preheat shampoo cap per manufacturer’s instructions.

Open the package, apply the cap to the patient’s head,
and secure all of the hair beneath the cap.
vi. Check the snugness of the cap around the patient’s

head to maintain a correct fit. Massage the patient’s
head through the cap for 2 to 4 minutes, according to
package directions; additional time may be required for
longer hair or hair that is matted with blood.
vii. Remove and discard the cap in the trash; do not dispose
of it in the toilet, because it may clog the plumbing.
viii. If the patient desires, towel-dry the hair.
ix. Brush or comb the patient’s hair as patient prefers.
x. Dispose of used towel.
xi. Remove and dispose of your gloves and PPE, if worn,

and perform hand hygiene.
ALERT
 A patient with a medical condition such as a head and neck
injury, spinal cord injury, or arthritis is at risk for injury
during shampooing because of the positioning and
manipulation of the head and neck.
 Patients with positional vertigo are not able to tolerate neck

 Remove hearing aids before shampooing, as water can

damage them.
OVERVIEW
The frequency of shampooing depends on the condition of the hair and

the person's daily routines and cultural preferences. The normal aging
process changes texture, quantity, and characteristics of hair. 1 With aging,
there is a decrease in the production of melanocytes, which are
responsible for the color of the hair.1 Aging also affects the productivity of
the follicles, which reduces the volume of hair. 1 Dry hair, which commonly
results from aging and protein deficiency, requires less frequent
shampooing than oily hair or the hair of people who actively exercise and
perspire. Thin, dry, or fragile hair is more prone to damage or
breakage.2 Curly hair is drier due to variations in the hydration properties
of the hair shaft.2 Additional hair care products may be necessary to
reduce the risk of damage.2 In some health care agencies you need a
health care provider’s order to shampoo a patient who is dependent or
has limited mobility because it is challenging to find ways to shampoo the
hair without causing injury.
Remind hospitalized patients that more frequent shampooing is necessary

when they remain in bed for extended periods of time, have excessive
perspiration, or undergo treatments that leave blood or solutions in the
hair. Ethnic considerations may indicate weekly or biweekly shampooing
and the use of a conditioner after each shampooing. 3 Two types of
shampooing are available for patients: (1) traditional shampoo and water,
or (2) a disposable dry shampoo cap. You can shampoo patients who are
allowed to sit in a chair in front of a sink. Make sure that a patient's
condition does not contraindicate neck hyperextension. Caution is needed
with patients who have suffered neck injuries because flexion and
hyperextension of the neck could cause further injury. In addition, patients
with positional vertigo are not able to tolerate neck hyperextension if it
increases their dizziness. A folded towel placed under the neck on the
edge of the sink provides added comfort. If a patient cannot sit in a chair
or be transferred to a stretcher, you will need to shampoo the patient in
bed, using traditional shampoo and water or a disposable shampoo
product.
SUPPLIES
EDUCATION

 Explain the procedure, and assess the patient’s hair care product
preferences, such as type of shampoo. If the patient has small
braids, obtain consent to undo the braids. 4
 If infestation is suspected, discard gloves and perform hand hygiene

after inspection.
 If infestation is present, don additional personal protective

equipment (PPE), such as a gown, and administer treatment as
prescribed. Also, on appropriate personal protective equipment PPE
based on the patient’s need for isolation precautions or risk of
exposure to bodily fluids. Wearing protective equipment reduces the
risk of exposure to the organisms and also reduces the risk of
pesticide poisoning when administering a chemical treatment. 5
 Inspect the condition of the hair and scalp. Assess for abrasions,
lacerations, lesions, inflammation, and infestation (such as
pediculosis).
 Remove personal protective equipment PPE and perform hand

hygiene.
 Position the patient sitting in a chair or in the bed with the head of
the bed elevated 45 to 90 degrees, as tolerated.
 Ensure the room is well lit.
 Review medications (e.g., anticoagulation therapy), medical history

(e.g., bleeding disorders, neck injury), and laboratory results (e.g.,
platelet counts, prothrombin time).
 Assess the patient’s ability to manipulate a comb.
DELEGATION
The tasks of hair care, shampooing the hair of a bed-bound patient, and
using a disposable shampoo product can be delegated to nursing assistive
 The proper ways in which to position the patient with head or neck
mobility restrictions.
 The proper ways in which to shampoo a patient’s hair when the

patient has abrasions, scalp lacerations, or open wounds.
 The proper procedure for using a medicated lice shampoo, stressing

the steps to take in order to prevent transmission of the infestation
to other patients.
PROCEDURE

4. Combing and brushing hair:
a. Provide for the patient's privacy.
b. Perform hand hygiene.
c. Arrange the supplies on the bedside table, and adjust the

lighting.
d. Determine if there are any contraindications to the procedure.
e. Ask the patient about any specific hair care products, cultural
hair care preferences, or styling preferences.
f. Encourage the patient to inform you if they are uncomfortable

at any time.
g. Apply clean gloves.
h. Place a towel over the patient's shoulders to protect clothing

or under his or her head if the patient is in bed. For the bed-
bound patient, provide hair care before changing linens.
i. Using a comb, part the hair into two sections, and then
separate the hair into two more sections. Thick hair may be
divided into multiple, smaller sections.4 If heat styling is
desired, use the minimum time necessary and use a low
setting on the dryer.2
j. Inspect the condition of the patient’s hair and scalp.
Thoroughly examine the color, texture, quantity, and
characteristics of the hair.
k. Moisten the hair lightly with water, conditioner, or an alcohol-

free detangling product before combing it.
l. Move your fingers through the hair to loosen any larger

tangles.
m. Using a wide-tooth comb, begin on either side of the head and

comb from the scalp toward the ends of the hair. Continue
until all hair has been combed through, and then comb it into
place to shape and style it.
n. For long or curly hair, start at the neck and work upward
toward the scalp. Additional conditioning products may be
applied with the patient’s permission.4
5. Shampooing a bed-bound patient:
a. Provide privacy.
b. Before washing the patient’s hair, determine that there are no

contraindications to the procedure. Verify the physician’s
order, if required.
c. Gather needed supplies.
d. Carefully position the patient into a supine position with head

and shoulders at the top edge of the bed.
e. Perform hand hygiene, and apply clean gloves.
f. Inspect the hair and scalp before beginning the shampoo.

Inspect the hair and scalp for abrasions, lacerations,
inflammation, and infestation. Determine if special shampoos
or treatments, such as those for dandruff, lice, or removal of
blood, are necessary. If lice are present, wear a disposable
gown in addition to gloves.
g. When shampooing the hair while using a shampoo board:
i. Place a waterproof pad under the patient’s shoulders,

neck, and head. Place the shampoo board or tray under
the patient’s head and a washbasin under the end of the
trough spout. Be sure that the spout extends beyond the
edge of the mattress.
ii. Place a rolled towel or gel roll under the patient’s neck
and a towel over the patient’s shoulders.
iii. Carefully brush and comb the patient’s hair to remove

any tangles.
iv. Obtain a pitcher filled with warm water.
v. Place a towel or washcloth over the patient’s eyes. Ask

the patient to hold a towel or washcloth over his or her
eyes if they wish to do so.
vi. Slowly pour the water from the pitcher over the
patient’s hair until it is completely wet. If the hair
contains matted blood, apply hydrogen peroxide to the
hair to dissolve the clots, being careful when near open
wounds, and then rinse the hair and any scalp areas
affected with warm water. Apply a small amount of
shampoo.
vii. Work up a lather using both of your hands. Begin at the

hairline, and work toward the nape of the neck. Then
shampoo the sides of the head. Massage the scalp by
applying pressure with your fingertips. Lift the patient’s
head slightly with one hand to wash the back of the
head.
viii. Rinse the hair with warm water. Make sure that the
water drains into the basin. Continue rinsing the hair
until it is free of all soap.
ix. Wrap the patient’s head in a towel. Dry the patient’s

face with the cloth he or she used earlier to protect the
eyes. Dry off any moisture along the patient’s neck,
ears, and shoulders.
x. Dry the patient’s hair and scalp. Use a second towel if

the first one becomes saturated.
xi. Carefully brush or comb the patient’s hair to remove any

tangles.
xii. Apply an oil preparation or conditioning product to the

hair, if needed or desired by the patient.
xiii. Variation for patients with coarse, curly hair: condition

the hair after washing. To untangle the hair, use the
wide-toothed comb. Begin at the nape of the neck and
comb small subsections of the hair, starting at the hair
ends. Continue to work through small sections of the
hair until the hair is free of tangles.
xiv. Assist the patient into a comfortable position, and finish

styling the patient’s hair.
xv. Dispose of and store supplies used during the

procedure. Remove your gloves, and perform hand
hygiene.
xvi. Document shampooing if required by the agency.
h. Shampooing using a disposable shampoo cap product:
i. Perform hand hygiene and don clean gloves.
ii. Help the patient into a comfortable position. The patient

can be sitting on a chair or upright in the bed.
iii. Place a waterproof pad under the patient’s shoulders,

neck, and head.
iv. Carefully brush or comb the hair to remove any tangles

or debris. Inspect scalp and hair. To untangle hair, use a
wide-tooth comb and, beginning at the nape of the neck,
comb small sections of the hair, starting at the hair
ends. Continue to work through small sections until the
hair is tangle free.
v. Preheat shampoo cap per manufacturer’s instructions.

Open the package, apply the cap to the patient’s head,
and secure all of the hair beneath the cap.
vi. Check the snugness of the cap around the patient’s

head to maintain a correct fit. Massage the patient’s
head through the cap for 2 to 4 minutes, according to
package directions; additional time may be required for
longer hair or hair that is matted with blood.
vii. Remove and discard the cap in the trash; do not dispose
of it in the toilet, because it may clog the plumbing.
viii. If the patient desires, towel-dry the hair.
ix. Brush or comb the patient’s hair as patient prefers.
x. Dispose of used towel.
xi. Remove and dispose of your gloves and PPE, if worn,

and perform hand hygiene.
MONITORING AND CARE
 Assess the patient’s comfort level during the procedure.
 Ask if the patient is satisfied with his or her degree of participation.
 Reassess the patient for continued hair or scalp problems.
EXPECTED OUTCOMES
 Patient expresses satisfaction with the procedure.
 Absence of hair and scalp problems.
 Patient experiences no pain or discomfort during procedure.
UNEXPECTED OUTCOMES
 Patient experiences pain or discomfort during procedure.
 Hair and scalp problems.
DOCUMENTATION
 Document type of hair care and shampooing if required by agency

policy.
 Document positioning devices, if used.
 Record the start and end time of the procedure, and the name of the
person who performed the procedure.
0915 Healthcare order verified and hair shampooing completed with

shampoo board. No contraindications noted. Scalp without lacerations,
abrasions, lesions, inflammation, and infestation. Hair dried with towel.
Patient tolerated hair shampooing without complaint. –W. Samuelson, RN
8/21/24
 Many treatments for pediculosis are not recommended for children

under 2 years of age.7
 Hair styles are important to teenagers. Hair should be styled in a

manner consistent with the patient’s preferences. 4

 The skin of an older adult is friable and susceptible to tearing.
Combing and brushing should be done with care.
 An older adult experiencing hair loss may require a head covering to

prevent loss of body heat.
 Older adult patients with weakened immune systems are at greater

risk for contagious skin conditions such as scabies. 3
 Patients with lice should use the appropriate treatment following the
manufacturer’s instructions for use. Caregivers shoulder perform a
visual examination for nits after the treatment.
15. Shaving a male patient
ALERT
 Patients who take anticoagulant and antiplatelet

medications are at greater risk for bleeding complications
during shaving.
 Avoid flexion and hyperextension of the neck during shaving

for patients who have suffered neck injuries because this
could cause further injury.
 Patients with positional vertigo are unable to tolerate neck

3. Provide for the patient’s privacy and perform hand hygiene.

Introduce yourself to the patient and family if present.
Compare these identifiers with the information on the patient’s
5. Explain the procedure to the patient and ensure that he agrees to

treatment. Encourage the patient to assist with grooming if he is
able.
6. Before shaving a patient with a disposable razor, review medical

history and lab values to assess bleeding risk.
7. Inspect the condition of the skin, beard and mustache.
a. Assess the hair’s color, texture, quantity, and characteristics.

b. Assess for the presence of infestations (e.g., pediculosis,
scabies) and skin conditions (e.g., sores or open lesions,
dandruff). If an infestation is present, notify the practitioner. If
infestation is suspected, discard gloves and perform hand
hygiene after inspection.
c. If infestation is present, don additional personal protective

equipment (PPE), such as a gown, and administer treatment
as prescribed.
8. Raise the bed to a comfortable working height and lower the side
rail.
9. Shaving with a disposable razor:
a. Apply clean gloves.
b. Test the water to ensure that it is not too hot.
c. Place a washcloth in the basin.
d. Place a bath towel over the patient’s chest and shoulders.
e. Wring out the washcloth thoroughly. Apply the warm, moist

washcloth over the patient’s facial hair for several seconds.
f. Apply approximately 1/4-inch layer of shaving cream or soap

to the patient’s face. Smooth the cream evenly over the sides
of the patient’s face, over his chin, and under his nose.
g. Hold the razor in your dominant hand at a 45-degree angle to

the patient’s skin. Use your nondominant hand to gently pull
the skin taut while shaving.
h. Begin by shaving across one side of the patient’s face, using

short, firm strokes in the direction in which the hair grows.
i. Check with the patient, and ask him if he feels comfortable.
j. Dip the razor in the water as shaving cream accumulates on

the blade.
k. After the patient has been shaved, change the water in the
basin and cleanse his face thoroughly with another warm,
moist washcloth.
l. Dry the face thoroughly, and apply aftershave lotion if the

patient wishes.
m. Help the patient into a comfortable position.

n. Return the used equipment to its proper place. Discard soiled
linen in the linen bag, and perform hand hygiene.
10. Shaving with an electric razor:
a. Apply clean gloves if necessary.
b. Place a bath towel over the patient’s chest and shoulders.
c. Apply a skin conditioner or pre-shave preparation to the

patient’s face.
d. Turn the razor on, and begin by shaving across the side of the
patient’s face. Gently hold the patient’s skin taut while
shaving over the skin’s surface. Use a gentle downward stroke
of the razor in the direction of the hair growth.
e. When you finish, apply an aftershave lotion if the patient

wishes, unless it is contraindicated.
f. Help the patient into a comfortable position.
g. Return the used equipment to its proper place. Discard soiled

linen in the linen bag, remove gloves, and perform hand
hygiene.
11. Providing moustache and beard care:
a. Place a bath towel over the patient’s chest and shoulders.
b. If necessary, gently comb the patient’s moustache or beard.
c. Allow the patient to use a mirror and direct you to the beard or
moustache areas to trim with scissors. Use your dominant
hand to hold a pair of small scissors as you groom those
areas.
d. Inspect the condition of the patient’s shaved face. Inspect the

skin beneath the beard or moustache. Ask patient if patient
feels clean and if he is comfortable.



room tidy.
16. Remove and dispose of gloves and PPE, if used. Perform hand
hygiene.
17. Document and report the patient’s response (i.e., tolerated or

not), and expected or unexpected outcomes, such as bleeding, pain,
or problem skin areas
ALERT
 Patients who take anticoagulant and antiplatelet

medications are at greater risk for bleeding complications
during shaving.1
 Avoid flexion and hyperextension of the neck during shaving

for patients who have suffered neck injuries because this
could cause further injury.
 Patients with positional vertigo are unable to tolerate neck

OVERVIEW
A male patient’s sense of well-being can be influenced by how he looks

and feels. Shaving facial hair is a task most men prefer to do for
themselves daily. Health care team members should assist with shaving
male patients who desire to be shaved but are unable to accomplish the
task independently.
Dependent patients with beards or mustaches need assistance keeping

the facial hair clean, especially after eating. Food particles easily collect in
the hair. The facial hair of an immobile patient can become tangled if not
groomed regularly.
Because the patient may have cultural considerations related to shaving,

it is important to assess each situation individually. Some cultures forbid
cutting or shaving any body hair.
Assess the patient’s hair before shaving begins. The normal aging process
changes hair’s texture, quantity and characteristics. 2 A decrease in the
production of melanocytes (which are responsible for the color of the hair)
and a decrease in the productivity of the follicles (which reduces the
volume of hair) can occur with age.2
SUPPLIES
EDUCATION
 Provide the patient and family with an explanation of the equipment

and the procedure.
 Teach family member(s) how to shave the patient or how to assist

the patient to do so.
 Teach safety precautions for shaving, especially if patient is

receiving anticoagulant therapy.
 Instruct the patient and family about safety precautions if the

patient must limit neck movement.
spills, making sure that all equipment is working properly, and
ensuring that the bed is in the locked, low position.
 Assess the patient’s shaving product preferences, such as

aftershave lotion or skin conditioner.
 Ask the patient if he has any cultural considerations for grooming.
 Ask the patient if he has a tendency to bleed.
 Review medications (e.g., anticoagulation therapy), medical history

(e.g., bleeding disorders), and laboratory results (e.g., platelet
counts, prothrombin time).
 Assess the patient’s ability to manipulate a razor.
 Ask the patient to explain during the procedure the steps he uses to
shave. Ask the patient to indicate if he becomes uncomfortable.
 Position the patient sitting in a chair or in the bed with the head of
the bed elevated to 45 to 90 degrees, as tolerated.
DELEGATION
The skill of shaving a male patient can be delegated to nursing assistive

 A male patient should not be shaved with a disposable razor if he

has a bleeding tendency.
 A male patient should be encouraged to use his own electric razor
from home unless doing so is contraindicated.
 Report how the patient tolerated the procedure and any concerns.
PROCEDURE
3. Provide for the patient’s privacy and perform hand hygiene.

Introduce yourself to the patient and family if present.
Compare these identifiers with the information on the patient’s
5. Explain the procedure to the patient and ensure that he agrees to

treatment. Encourage the patient to assist with grooming if he is
able.
6. Before shaving a patient with a disposable razor, review medical

history and lab values to assess bleeding risk.
7. Inspect the condition of the skin, beard and mustache.
a. Assess the hair’s color, texture, quantity, and characteristics.
b. Assess for the presence of infestations (e.g., pediculosis,

scabies) and skin conditions (e.g., sores or open lesions,
dandruff). If an infestation is present, notify the practitioner. If
infestation is suspected, discard gloves and perform hand
hygiene after inspection.
c. If infestation is present, don additional personal protective

equipment (PPE), such as a gown, and administer treatment
as prescribed.
8. Raise the bed to a comfortable working height and lower the side
rail.
9. Shaving with a disposable razor:
a. Apply clean gloves.
b. Test the water to ensure that it is not too hot.
c. Place a washcloth in the basin.
d. Place a bath towel over the patient’s chest and shoulders.

e. Wring out the washcloth thoroughly. Apply the warm, moist
washcloth over the patient’s facial hair for several seconds.
f. Apply approximately 1/4-inch layer of shaving cream or soap

to the patient’s face. Smooth the cream evenly over the sides
of the patient’s face, over his chin, and under his nose.
g. Hold the razor in your dominant hand at a 45-degree angle to

the patient’s skin. Use your nondominant hand to gently pull
the skin taut while shaving.
h. Begin by shaving across one side of the patient’s face, using

short, firm strokes in the direction in which the hair grows.
i. Check with the patient, and ask him if he feels comfortable.
j. Dip the razor in the water as shaving cream accumulates on

the blade.
k. After the patient has been shaved, change the water in the
basin and cleanse his face thoroughly with another warm,
moist washcloth.
l. Dry the face thoroughly, and apply aftershave lotion if the

patient wishes.
m. Help the patient into a comfortable position.
n. Return the used equipment to its proper place. Discard soiled

linen in the linen bag, and perform hand hygiene.
10. Shaving with an electric razor:
a. Apply clean gloves if necessary.
b. Place a bath towel over the patient’s chest and shoulders.
c. Apply a skin conditioner or pre-shave preparation to the

patient’s face.
d. Turn the razor on, and begin by shaving across the side of the
patient’s face. Gently hold the patient’s skin taut while
shaving over the skin’s surface. Use a gentle downward stroke
of the razor in the direction of the hair growth.
e. When you finish, apply an aftershave lotion if the patient

wishes, unless it is contraindicated.
f. Help the patient into a comfortable position.

g. Return the used equipment to its proper place. Discard soiled
linen in the linen bag, remove gloves, and perform hand
hygiene.
11. Providing moustache and beard care:
a. Place a bath towel over the patient’s chest and shoulders.
b. If necessary, gently comb the patient’s moustache or beard.
c. Allow the patient to use a mirror and direct you to the beard or
moustache areas to trim with scissors. Use your dominant
hand to hold a pair of small scissors as you groom those
areas.
d. Inspect the condition of the patient’s shaved face. Inspect the

skin beneath the beard or moustache. Ask patient if patient
feels clean and if he is comfortable.



room tidy.
16. Remove and dispose of gloves and PPE, if used. Perform hand
hygiene.
17. Document and report the patient’s response (i.e., tolerated or

not), and expected or unexpected outcomes, such as bleeding, pain,
or problem skin areas.
MONITORING AND CARE
 Inspect the condition of the shaved area and the skin underneath
the beard or moustache.
 Ask the patient if his face feels clean and comfortable.
 Ask the patient if he is satisfied with his degree of participation.
EXPECTED OUTCOMES
 Patient expresses sense of comfort, with face feeling clean and

refreshed.
 Skin surface is smooth, well hydrated, and free of cuts.
 Patient assists with procedure, as tolerated.
UNEXPECTED OUTCOMES
 Small isolated nicks or cuts appear on skin.
 Skin surface appears dry.
DOCUMENTATION
 Record the shaving procedure. If there is no area indicated for

shaving, make a nurse’s note in the medical record. Note how the
patient tolerated the procedure, who performed the procedure, and
if there were any complications, such as bleeding, pain, or problem
skin areas.
 Record beard and hair assessment.
Patient G.J. shaved after morning care using a disposable razor. Skin
surface smooth, without nicks or scratches. Does not like to use
aftershave lotion. Prefers to be shaved every other day. –W. Samuelson,
RN 8/21/21
 Usually the facial hair of adolescents does not grow quickly; thus
shaving daily is not necessary.
 Adolescents who shave should be asked about the frequency and

allowed to perform activity as desired. Family caregivers may wish
to be involved in shaving their adolescent child if the child is unable
to perform the activity on his own.
 Usually the facial hair of older patients does not grow quickly; thus
shaving daily is not necessary.
 The skin of older adults is thinner and at greater risk for injury when
shaving.

 Patients with lice should use the appropriate treatment following the
manufacturer’s instructions for use. A visual examination for nits
should be completed after treatment.
16. Performing anil and foot care
ALERT
 Most agencies require a health care provider’s order for a

nurse to trim a patient’s nails. Be aware of your agency’s
policy regarding the filing and trimming of nails.
 Check your agency’s policy regarding the appropriate

process for cleaning beneath the nails. Do not use an orange
stick or the end of a cotton swab; these items can splinter
and injure the patient.
 Observe Standard Precautions when providing care, which

include wearing clean gloves. Additional precautions
 If trimming is indicated, all nail clippers and files should be

for single-patient use only.
 Do not soak the feet of a patient who has diabetes mellitus,

peripheral neuropathy, or peripheral vascular disease (PVD)
because of the potential for increased dryness. Do not cut
the nails of a patient who has diabetes mellitus, impaired
peripheral circulation, or an increased risk of bleeding. Refer
the patient to a podiatrist or other appropriate health care
professional.

3. Identify the patient using two patient identifiers.

7. Apply clean gloves. Arrange all needed equipment on the overbed

table.
8. Inspect the patient’s fingers, toes, and feet and evaluate the
circulatory status.
9. Assist the ambulatory patient in sitting up in a chair. Assist the

bedfast patient in assuming the supine position, with the head of
the bed elevated 45 degrees. Place a disposable bath mat on the
floor under the patient’s feet, or place a waterproof pad on the
mattress.
10. Fill a washbasin half full with warm water. Test the water
temperature. Place the basin on the floor or on the pad on the
mattress. Have the patient immerse his or her feet in the water.
11. Adjust the overbed table to the low position, and place it over
the patient’s lap.
12. Fill an emesis basin half full with warm water. Test the water
temperature. Place the basin on a towel on the overbed table.
13. Instruct the patient to place his or her fingers in the emesis
basin, with the arms in a comfortable position.
14. Unless the patient has diabetes mellitus, peripheral

neuropathy, or PVD, allow the patient’s feet and fingernails to soak
for 10 minutes.
15. Clean gently under the fingernails with the end of a plastic
applicator stick. Use a soft cuticle brush or nail brush to clean
around the cuticles to decrease overgrowth.
16. Thoroughly dry the patient’s hand and fingers with a towel.
Trim the fingernails straight across at the level of the finger (follow
your agency policy for filing and trimming of nails). Using a
disposable emery board, file the nail to dull any sharp corners.
17. Repeat the process on the other hand.
18. Use a moistened washcloth to clean between the toes. Gently

scrub any callused areas of the patient’s foot with the moistened
washcloth.
19. Dry the patient’s foot thoroughly, ensuring the area between
the toes is completely free from moisture, and then trim or cut the
toenails. Trim the nails straight across at the level of the toe (follow
Repeat the process on the other foot.
20. Rub lotion thoroughly into the top and bottom of the patient’s
feet and hands. Assist the patient in getting back into bed, and
ensure that he or she is in a comfortable and safe position.
21. Clean the patient’s nail clippers with soap and water (each set
of nail clippers is for single-patient use only). If the nail clippers are
soiled with blood or body fluids, clean them according to your
agency’s policy. Return the other equipment to its proper place.
Dispose of emery boards. Discard soiled linen in the linen bag.
Remove your gloves, and perform hand hygiene.
22. Place toiletries and personal items within reach.

25. Leave the patient’s room tidy.

ALERT
 Most agencies require a health care provider’s order for a

nurse to trim a patient’s nails. Be aware of your agency’s
policy regarding the filing and trimming of nails.
 Check your agency’s policy regarding the appropriate

process for cleaning beneath the nails. Do not use an orange
stick or the end of a cotton swab; these items can splinter
and injure the patient.
 Observe Standard Precautions when providing care, which

include wearing clean gloves. Additional precautions
 If trimming is indicated, all nail clippers and files should be

for single-patient use only.
 Do not soak the feet of a patient who has diabetes mellitus,

peripheral neuropathy, or peripheral vascular disease (PVD)
because of the potential for increased dryness.1 Do not cut
the nails of a patient who has diabetes mellitus, impaired
peripheral circulation, or an increased risk of bleeding. Refer
the patient to a podiatrist or other appropriate health care
professional.2
OVERVIEW
Include nail and foot care in a patient’s daily hygiene; the best time is
during the bath. Many agencies require a health care provider’s order
before you can trim nails. Feet and nails often require special care to
prevent infection, odors, pain, and injury to soft tissues. Often people are
unaware of foot or nail problems until discomfort or pain occurs. For
proper foot and nail care, instruct patients to protect the feet from injury,
keep them clean and dry, and wear appropriate footwear. Instruct patients
in the proper way to inspect the feet for lesions, dryness, or signs of
infection.
Common conditions of the feet include corns, which are usually cone-
shaped, round, and raised area over the bony prominence of the toe. A
callus is usually flat and painless and often found on the underside of the
foot or on the palm of the hand. A plantar wart is a fungating lesion on the
sole of the foot. Tinea pedis is a condition characterized by scaliness and
cracking of the skin between the toes and on the soles of the feet.
Patients most at risk for developing serious foot problems are those with
peripheral neuropathy and PVD. These two disorders, commonly found in
patients with diabetes mellitus, cause a reduction in blood flow to the
extremities and a loss of sensory, motor, and autonomic nerve function.
As a result, a patient is unable to feel heat and cold, pain, pressure, and
positioning of the foot or feet. The reduction in blood flow impairs healing
and promotes risk of infection. The development of diabetic foot ulcers
has three contributing factors: (1) peripheral neuropathy (changes in the
function and efficiency of the nerves), (2) ischemia (decrease in the blood
flow related to plaque formation in arteries), and (3) a pivotal event
(trauma caused by banging the toe or stepping on a foreign object).
The use of specialized custom therapeutic footwear is now recommended

for high-risk patients with diabetes mellitus. 3 If foot ulcers do not heal,
they can quickly become infected and lead to gangrene and subsequent
amputation. Foot ulcers and subsequent amputations are significant
contributors to morbidity and mortality in patients with DM and peripheral
artery disease.2 To maintain and promote foot and nail health, diabetic
patients or patients with peripheral vascular disease should visit a
podiatrist or specialist annually.2
SUPPLIES

PATIENT AND FAMILY EDUCATION
 Use a variety of teaching formats regarding foot and nail care (e.g.,
brochures, videos) that are consistent with patient’s health literacy
level.
 Show the patient how to inspect his or her feet. Demonstrate by

using a hand mirror, if needed, to inspect the bottom of the feet.
 Instruct patient not to walk barefoot or use corn or callus products.
 Instruct a patient with diabetes, peripheral neuropathy, or PVD to do

the following:
o Inspect and bathe feet daily.
o Inspect all surfaces of each foot.
o Use a mirror to view bottom of each foot.
o Clean around nails with a soft brush.
o Dry the feet and pay special attention to drying between the
toes.
o Use lambswool between the toes if the skin stays moist or

becomes macerated.
o Wear socks made of natural fiber such as cotton that absorb

perspiration and “breathe.”
o Wear nonconstricting shoes with soft leather and an adequate

toe box.
o See a podiatrist to develop a regular schedule for nail care.
 Inspect all surfaces of the patient’s hands, fingers, toes, feet, and
nails. Pay particular attention to any areas of dryness, inflammation,
or cracking. Also, inspect the heels, the soles of the feet, and
between the toes.
 Assess the color and temperature of the patient’s hands, toes, feet,
and fingers. Assess the capillary refill time of the fingernail and
toenail beds. Palpate the radial and ulnar pulse of each of the
patient’s wrists and the dorsalis pedis pulse of the patient’s feet;
note the character and symmetry of the patient’s pulses.
 Identify the patient's risk for foot or nail problems. Those at risk
include older adults and those with diabetes mellitus, heart failure,
renal disease, stroke, or history of leg pain.
 Assess for the types of home remedies that the patient uses for
existing foot problems, such as those used to treat or remove warts,
corns, and calluses.
 Explain the nail care procedure.
 Obtain the health care provider’s order for trimming the patient’s
nails (required by most agencies).
DELEGATION
The skill of nail and foot care for patients without diabetes or circulatory
compromise can be delegated to nursing assistive personnel (NAP). Be
sure to inform NAP of the following:
 Instruct NAP not to trim the patient’s nails.
 Explain any special considerations for patient positioning.
 Report any breaks in skin, redness, numbness, swelling or pain to

the nurse.
PROCEDURE

3. Identify the patient using two patient identifiers.

7. Apply clean gloves. Arrange all needed equipment on the overbed

table.
8. Inspect the patient’s fingers, toes, and feet and evaluate the
circulatory status.
9. Assist the ambulatory patient in sitting up in a chair. Assist the

bedfast patient in assuming the supine position, with the head of
the bed elevated 45 degrees. Place a disposable bath mat on the
floor under the patient’s feet, or place a waterproof pad on the
mattress.
10. Fill a washbasin half full with warm water. Test the water
temperature. Place the basin on the floor or on the pad on the
mattress. Have the patient immerse his or her feet in the water.
11. Adjust the overbed table to the low position, and place it over
the patient’s lap.
12. Fill an emesis basin half full with warm water. Test the water
temperature. Place the basin on a towel on the overbed table.
13. Instruct the patient to place his or her fingers in the emesis
basin, with the arms in a comfortable position.
14. Unless the patient has diabetes mellitus, peripheral

neuropathy, or PVD, allow the patient’s feet and fingernails to soak
for 10 minutes.
15. Clean gently under the fingernails with the end of a plastic
applicator stick. Use a soft cuticle brush or nail brush to clean
around the cuticles to decrease overgrowth.
16. Thoroughly dry the patient’s hand and fingers with a towel.
Trim the fingernails straight across at the level of the finger (follow
17. Repeat the process on the other hand.
18. Use a moistened washcloth to clean between the toes. Gently

scrub any callused areas of the patient’s foot with the moistened
washcloth.
19. Dry the patient’s foot thoroughly, ensuring the area between
the toes is completely free from moisture, and then trim or cut the
toenails. Trim the nails straight across (follow your agency policy for
filing and trimming of nails). Using a disposable emery board, file
the nail to dull any sharp corners. Repeat the process on the other
foot.
20. Rub lotion thoroughly into the top and bottom of the patient’s
feet and hands. Assist the patient in getting back into bed, and
ensure that he or she is in a comfortable and safe position.
21. Clean the patient’s nail clippers with soap and water (each set
of nail clippers is for single-patient use only). If the nail clippers are
soiled with blood or body fluids, clean them according to your
agency’s policy. Return the other equipment to its proper place.
Dispose of emery boards. Discard soiled linen in the linen bag.
Remove your gloves, and perform hand hygiene.


MONITORING AND CARE
 Inspect the nails, the areas between the fingers and toes, and the
surrounding skin surfaces.
 Ask the patient to explain or demonstrate nail care.
 Observe the patient’s walking after foot and nail care.
 Instruct the patient not to walk barefoot or use corn or callus

products.
 Initiate the process to obtain an order for a podiatry consult if the

patient has diabetes, peripheral arterial disease (PAD), or PVD.
Instruct such patients to do the following:
o Inspect all surfaces of each foot, using a mirror if necessary to

view the bottom of the foot.
o Bathe the feet daily, cleaning around the nails with a soft
brush.
o Dry the feet, paying special attention to the skin between the
toes.
o Use lambswool between the toes if the skin stays moist or

becomes macerated.
o Wear socks made of natural fibers that breathe and absorb

perspiration, such as cotton.
o Wear nonconstricting shoes with soft leather and an adequate

toe box.
EXPECTED OUTCOMES
 Nails are smooth. Cuticles and tissues surrounding nails are clear
and of normal color. Surfaces of feet are smooth.
 Patient walks freely, without pain or unusual gait caused by the nail
care.
 Patient explains or demonstrates nail care correctly.
UNEXPECTED OUTCOMES
 Cuticles and surrounding tissues are inflamed and tender to touch.
 Localized areas of tenderness occur on feet with calluses or corns at

point of friction.
 New ulcerations involving toes or feet.
DOCUMENTATION
 Record the type of procedure performed and the condition of the

patient’s hands and feet before and after the procedure.
 Document patient teaching about nail or foot care.
 Document unexpected outcomes and related interventions.
0900 Right great toe red, inflamed, and tender. Patient states this was first
noted before admission, 1 week ago. Feet soaked for 10 minutes in warm
water and dried thoroughly. Lotion applied. Instructed patient on
appropriate foot care, and continued observation of reddened area.
Patient is able to perform foot care independently at home and verbalized
understanding of teaching. Toe inflammation reported to nurse in charge.
–H. Padilla, RN 5/26/19
 Children’s nails should be assessed and trimmed to prevent injury

from scratching themselves.
 Use appropriate-size clippers when clipping the nails of infants and

small children (check agency policy).
 Do not use scissors.
GERONTOLOGICAL CONSIDERATIONS
 Changes in aging skin include thinning of epidermis and

subcutaneous fat and dryness because of decreased activity of oil
and sweat glands. These changes are often evident in the feet. In
addition, nails become discolored, thickened, deformed, and brittle.
 PVD, peripheral neuropathy, and long periods of limited exercise or

bed rest impact balance, stability, and sensory impairment, resulting
in impaired mobility.
 Assess the home for any areas where a person could accidentally
injure the feet such as rugs, objects that block pathways, or uneven
walks or flooring.
 Avoid going barefoot or wearing open-toed shoes.
 Alternative therapy: Apply moleskin to friction areas of the foot or

feet or wrap small pieces of lambswool around toes to reduce
irritation from corns or bunions.
 Include family caregiver in foot and nail care education.
 Place contact information of podiatrist, health care provider, and

home care nurse close by for easy access.
17. Applying Elastic stockings
ALERT
 Apply the stockings so the toe opening is over the top of the
toes or under the toes. Follow the manufacturer’s
instructions. Use the opening to check circulation, skin color,
and skin temperature in the toes.
 Stockings should not have twists, creases, or wrinkles after

you apply them. Twists can affect circulation. So can
stockings that roll or bunch up. Creases and wrinkles can
cause skin breakdown.
 Loose stockings do not promote venous blood return to the

heart. Stockings that are too tight can affect circulation. Tell
the nurse if the stockings are too loose or too tight.
PROCEDURE
Applying Elastic Stockings
1. Lower the bed rail.
2. Position the person supine.
3. Expose the legs. Fan-fold top linens up toward the thighs.

4. Turn the stocking inside out down to the heel.
5. Slip the foot of the stocking over the toes, foot, and heel. Make sure
the heel pocket is properly positioned on the person’s heel. The toe
opening is over or under the toes.
6. Grasp the stocking top. Pull the stocking up the leg. It turns right
side out as it is pulled up. The stocking is even and snug.
7. Remove twists, creases, or wrinkles.
8. Repeat steps 4 through 7 for the other leg.
 Apply the stockings so the toe opening is over the top of the
toes or under the toes. Follow the manufacturer’s
instructions. Use the opening to check circulation, skin color,
and skin temperature in the toes.
 Stockings should not have twists, creases, or wrinkles after

you apply them. Twists can affect circulation. So can
stockings that roll or bunch up. Creases and wrinkles can
cause skin breakdown.
 Loose stockings do not promote venous blood return to the

heart. Stockings that are too tight can affect circulation. Tell
the nurse if the stockings are too loose or too tight.
OVERVIEW
 Elastic stockings exert pressure on the veins. The pressure promotes

venous blood return to the heart. The stockings help prevent blood
clots (thrombi) in the leg veins. A blood clot is called a thrombus.
 If blood flow is sluggish, thrombi may form in the deep veins in the
lower leg or thigh. A thrombus can break loose and travel through
the bloodstream. It then becomes an embolus—a blood clot that
travels through the vascular system until it lodges in a blood vessel.
An embolus from a vein lodges in the lungs (pulmonary embolism).
A pulmonary embolism can cause severe respiratory problems and
death. Report chest pain or shortness of breath at once.
 Persons at risk for thrombi include those who:
o Have heart and circulatory disorders.
o Are on bedrest.
o Have had surgery.
o Are older.
o Are pregnant.
 Elastic stockings also are called AE (anti-embolic or anti-emboli)

stockings. They also are called TED (thrombo-embolic disorder)
hose.
 The person usually has two pairs of stockings. Wash one pair while
the other pair is worn. Wash them by hand with a mild soap. Hang
them to dry.
SUPPLIES
PREPARATION
 Observe quality-of-life measures.
 Review the information under Delegation and Safety and Comfort.
 Practice hand hygiene.
 Obtain elastic stockings in the correct size and length. Note the
location of the toe opening.
 Identify the person. Check the ID bracelet against the assignment

sheet. Also call the person by name.
 Provide for privacy.
 Raise the bed for body mechanics. Bed rails are up if used.
DELEGATION
 Follow delegation guidelines. Before applying elastic stockings,

obtain this information from the nurse and care plan:
o What size to use—small, medium, large, or extra-large
o What length to use—thigh-high or knee-high
o When to remove them and for how long—usually every 8

hours for 30 minutes
o What observations to report and record
o When to report observations
o What patient or resident concerns to report at once
PROCEDURE
Applying Elastic Stockings

1. Lower the bed rail.
2. Position the person supine.
3. Expose the legs. Fan-fold top linens up toward the thighs.
4. Turn the stocking inside out down to the heel.
5. Slip the foot of the stocking over the toes, foot, and heel. Make sure
the heel pocket is properly positioned on the person’s heel. The toe
opening is over or under the toes.
6. Grasp the stocking top. Pull the stocking up the leg. It turns right
side out as it is pulled up. The stocking is even and snug.
7. Remove twists, creases, or wrinkles.
8. Repeat steps 4 through 7 for the other leg.
MONITORING AND CARE
 Cover the person.
 Provide for comfort.
 Place the call light within reach.
 Lower the bed to its lowest position.
 Raise or lower the bed rails. Follow the care plan.
 Unscreen the person.
 Complete a safety check of the room.
REPORTING/RECORDING
Report and record your observations, including:
 The size and length of the stockings applied
 When you applied the stockings
 Skin color and temperature
 Leg and foot swelling
 Skin tears, wounds, or signs of skin breakdown
 Complaints of pain, tingling, or numbness
 When you removed the stockings and for how long
 When you re-applied the stockings

 When you washed the stockings
 Older persons are at risk for thrombi (blood clots) and emboli (more
than 1 embolus). Blood is pumped through the body with less force.
Circulation is already sluggish.
13. Assisting with meals
ALERT
 Assess the patient for signs and symptoms of malnutrition, and

identify if the patient is malnourished or at risk for malnutrition.
 Identify if the patient is at risk for dysphagia, and collaborate with

other members of the health care team to minimize complications,
such as aspiration pneumonia.
 Verify the health care provider's diet order, and ensure that the
patient is receiving the correct therapeutic diet.
 Assess the patient's level of consciousness before feeding.
 If you suspect that the patient is aspirating, stop feeding the patient
immediately, and suction the patient's airway.
 If the patient's intake falls below 75% for any length of time, refer
the patient to a RD (registered dietitian) for medical nutrition
therapy.
7. Assess the patient for nausea, the ability to pass gas, and an intact
gag reflex.
8. Check the condition of the patient's teeth, or that dentures (if

present) fit properly.
9. Check for bowel sounds in all four quadrants.

10. Assess the patient for the ability to feed himself/herself and
what his/her appetite has been like.
11. Prepare the patient's room for mealtime:
a. Clear the overbed table to make room for the meal tray.
b. Help the patient into a comfortable sitting position in a chair,

or place the patient's bed in the high-Fowler's position. If the
patient is unable to sit, turn the patient onto his or her side,
with the head of the bed elevated.
12. Prepare the patient for the meal:
a. Help the patient with elimination needs, if necessary.
b. Help the patient put in dentures and put on eyeglasses or

insert contact lenses if used.
c. Help the patient with hand hygiene.
13. Verify the meal is the patient's.
14. Ask the patient in what order he or she would like to eat the
meal. Ask the patient about desired seasonings. Help the patient cut
food into bite-size pieces if he or she is unable to do so
independently. Patients with dementia may manage better with
finger foods that may be easily picked up and put in their mouths as
they may have difficulty using silverware.
15. Use adaptive eating and drinking aids for the patient as
needed, according to your assessment, such as a two-handled cup
with lid, a plate with plate guard, utensils with splints, or utensils
with oversized handles.
16. If the patient is disoriented, visually impaired, or easily

fatigued, identify food placement by locating the food items as if the
plate were a clock face.
17. If the patient needs assistance, feed the patient in a way that
facilitates chewing and swallowing.
a. For the older adult, provide small amounts of food at a time.

Watch the patient bite, chew, and swallow, and be aware of
his or her level of fatigue. Be sure the patient swallows the
food between bites.
b. For the neurologically impaired patient, provide small amounts

of food at a time. Assess the patient's ability to chew,
manipulate the tongue to form a bolus, and swallow. Check
the patient's mouth for food left inside the cheeks, known as
"pocketing."
18. Provide fluids as requested. Encourage the patient not to drink

all of the liquid at the beginning of the meal.
19. Talk with the patient during the meal. Use the meal as an
opportunity to educate the patient about topics such as those
related to nutrition, postoperative exercises, and discharge
planning.
20. Assist the patient with hand hygiene and mouth care after the
meal has ended.
21. Ask the seated patient their preference for staying in the chair
or being assisted into bed.
22. If the patient is still in bed, help the patient into a resting
position, leaving the head of the bed elevated at 30 to 45 degrees
for 30 to 60 minutes after the meal. To ensure the patient's safety,
raise the appropriate number of side rails and lower the bed to the
lowest position.
24. Return the patient's tray to the appropriate place, and perform
hand hygiene.
25. Document the procedure in the patient’s record. If necessary,

record the calorie count. If monitoring I&O, record the fluid intake.
Document any swallowing difficulties or refusal to eat.
ALERT
 Assess the patient for signs and symptoms of malnutrition, and

identify if the patient is malnourished or at risk for malnutrition.
 Identify if the patient is at risk for dysphagia, and collaborate with

other members of the health care team to minimize complications,
such as aspiration pneumonia.
 Verify the health care provider's diet order, and ensure that the
patient is receiving the correct therapeutic diet.
 Assess the patient's level of consciousness before feeding.
 If you suspect that the patient is aspirating, stop feeding the patient
immediately, and suction the patient's airway.
 If the patient's intake falls below 75% for any length of time, refer
the patient to a RD (registered dietitian) for medical nutrition
therapy.
OVERVIEW
Hospitalized patients receive a number of different oral diets that require

a health care provider's order. A therapeutic diet treats many illness and
disease states. For specific information about special diets see the agency
dietary manual or contact a registered dietitian (RD). You can modify a
regular diet in two ways: quantitatively or qualitatively. 4 Qualitative diets
include modifications in consistency, texture, or nutrients such as clear or
full liquid. Quantitative diets include modifications in number or size of
meals served or amounts of specific nutrients such as six small feedings
or kcalorie diets. You can supplement any diet with oral nutrition
supplements. You prepare a patient so he or she can be comfortable and
not interrupted during a meal. You may be asked to maintain a calorie
count. Usually the percentage of each food that a patient eats is recorded
next to the food choice directly on the menu for each meal. The RD is able
to determine caloric intake and need for nutrition supplements or dietary
change. Liquid supplements with or between meals can significantly
increase protein and calorie intake.6
Helping adults with oral nutrition requires time, patience, knowledge, and
understanding. Most people eat without assistance. However, the older
adult commonly loses some fine-motor skills required to get food from the
plate and into the mouth. When they are ill, many patients require
assistance either to feed themselves or, if necessary, to be fed by another
person if unable to eat independently.7,8 Altered dentition, improperly
fitted dentures, oral lesions or infections, or diseases causing impaired
digestion limit the types and consistencies of foods tolerated. Hemiplegia,
fractured arm, quadriplegia, debilitating illness, or generalized weakness
limits self-feeding ability and appetite. The presence of intravenous (IV)
catheters or tubing, dressings, and bandages also limits mobility needed
for self-feeding. An occupational therapist should collaborate with the
nurse to assess patients with identified limited self-feeding abilities and to
recommend adaptive equipment and supplies for self-feeding. An adult
who needs help to eat needs compassion and understanding. Use
common sense when feeding an adult and provide a socially meaningful
mealtime experience.
SUPPLIES

 Discuss dietary concerns of patient’s illness with the patient and
family. Explain why specific foods are not included in a meal or why
only limited amounts are allowed.4
 Instruct patient and family to maintain a balanced diet and monitor

intake of fluids and percent or amount of meals and snacks
consumed. If intake falls below 75% for any length of time, refer
patient to a RD for medical nutrition therapy.
 Teach family caregivers techniques to safely help patient in feeding.

Have family encourage patient to do as much as possible to feed
self.
 Encourage questions, and answer them as they arise.
 Assess the patient’s knowledge of the procedure.
 Ensure that the patient passes flatus, is free of nausea, and has
healthy bowel sounds on auscultation.
 Assess for the presence and condition of the patient’s teeth. Assess
the patient’s dentures for fit.
 Assess patient's ability to swallow.
 Observe for signs of dysphagia (e.g., throat clearing or cough, vocal

changes, oral or nasal food regurgitation, pocketing, drooling,
refusal to open mouth).
 In many patients with a neurologic disorder, the complex process of

swallowing is impaired. Consult with the interdisciplinary team to
facilitate the diagnoses and management of dysphasia.
 Determine to what extent the patient is able to self-feed. Assess the

patient’s physical motor skills, such as the ability to grasp utensils,
hold a cup, and move it to the mouth. Evaluate the patient’s level of
consciousness, visual acuity and peripheral vision, and mood.
 Assess the patient’s appetite, food tolerance, recent fluid intake,

cultural and religious preferences, and food preferences.
 Ensure that the patient is comfortable and will not be interrupted

during the meal.
 Collaborate with an occupational therapist (OT) to assess the

patient’s ability to self-feed and to obtain recommendations on
adaptive equipment and self-feeding supplies.
DELEGATION
The skill of assisting a patient with oral nutrition can be delegated to
nursing assistive personnel (NAP). However, the nurse is responsible for
determining whether the patient is able to receive oral nutrition, which
includes assessing the patient's ability to swallow and identifying any
other oral intake restrictions. Be sure to inform NAP of the following:
 Any specific swallowing strategies/techniques unique to the patient.
 When to stop feeding; direct NAP to report immediately to you any

incidents of coughing, gagging, or difficulty swallowing.
PROCEDURE
7. Assess the patient for nausea, the ability to pass gas, and an intact
gag reflex.
8. Check the condition of the patient's teeth, or that dentures (if

present) fit properly.
9. Check for bowel sounds in all four quadrants.
10. Assess the patient for the ability to feed himself/herself and
what his/her appetite has been like.
11. Prepare the patient's room for mealtime:
a. Clear the overbed table to make room for the meal tray.
b. Help the patient into a comfortable sitting position in a chair,

or place the patient's bed in the high-Fowler's position. If the
patient is unable to sit, turn the patient onto his or her side,
with the head of the bed elevated.
12. Prepare the patient for the meal:
a. Help the patient with elimination needs, if necessary.
b. Help the patient put in dentures and put on eyeglasses or

insert contact lenses if used.
c. Help the patient with hand hygiene.

13. Verify the meal is the patient's.
14. Ask the patient in what order he or she would like to eat the
meal. Ask the patient about desired seasonings. Help the patient cut
food into bite-size pieces if he or she is unable to do so
independently. Patients with dementia may manage better with
finger foods that may be easily picked up and put in their mouths as
they may have difficulty using silverware.2
15. Use adaptive eating and drinking aids for the patient as
needed, according to your assessment, such as a two-handled cup
with lid, a plate with plate guard, utensils with splints, or utensils
with oversized handles.
16. If the patient is disoriented, visually impaired, or easily

fatigued, identify food placement by locating the food items as if the
plate were a clock face.
17. If the patient needs assistance, feed the patient in a way that
facilitates chewing and swallowing.
a. For the older adult, provide small amounts of food at a time.

Watch the patient bite, chew, and swallow, and be aware of
his or her level of fatigue. Be sure the patient swallows the
food between bites.
b. For the neurologically impaired patient, provide small amounts

of food at a time. Assess the patient's ability to chew,
manipulate the tongue to form a bolus, and swallow. Check
the patient's mouth for food left inside the cheeks, known as
"pocketing."
18. Provide fluids as requested. Encourage the patient not to drink

all of the liquid at the beginning of the meal.
19. Talk with the patient during the meal. Use the meal as an
opportunity to educate the patient about topics such as those
related to nutrition, postoperative exercises, and discharge
planning.
20. Assist the patient with hand hygiene and mouth care after the
meal has ended.
21. Ask the seated patient their preference for staying in the chair
or being assisted into bed.
22. If the patient is still in bed, help the patient into a resting
position, leaving the head of the bed elevated at 30 to 45 degrees
for 30 to 60 minutes after the meal. To ensure the patient's safety,
raise the appropriate number of side rails and lower the bed to the
lowest position.
24. Return the patient's tray to the appropriate place, and perform
hand hygiene.
25. Document the procedure in the patient’s record. If necessary,

record the calorie count. If monitoring intake and output (I&O),
record the fluid intake. Document any swallowing difficulties or
refusal to eat.
MONITORING AND CARE
 Monitor the patient’s body weight in kilograms daily or weekly.
 Monitor the patient’s laboratory values as indicated.
 Monitor the patient’s I&O and the percentage of food remaining on

the tray after each meal.
 Observe the patient’s ongoing ability to self-feed, including the

ability to feed certain items, and part or all of the meal, and provide
assistance to optimize oral intake if additional assistance is needed.
 Observe the patient for choking, coughing, or gagging, and for food
left in the mouth while eating.
EXPECTED OUTCOMES
 Patient denies biting, chewing, and swallowing problem, or food

intolerances.
 Patient's weight is maintained or changes according to the

nutritional care plan.
 Patient meets caloric intake goal.
 Patient meets goals for nutrition independence.
UNEXPECTED OUTCOMES
 Patient is unable to meet caloric goals through oral nutrition.
 Patient chokes on or aspirates food or fluids.
 Patient's weight increases or decreases beyond goals.
 Patient is unable to maintain fluid restriction.
DOCUMENTATION
 Document in the patient’s chart his or her tolerance of the

prescribed diet. Record the percentage of each meal eaten by the
patient (for example, 25% of food consumed at breakfast).
 If the patient is on a calorie count, record the caloric intake. If the

patient’s I&O is being evaluated, record the fluid intake.
 If the patient is receiving oral nutritional supplements, such as

Ensure or Boost, record the amount of the supplement taken and
communicate the patient’s tolerance to the health care team. For
example, report whether the patient likes or dislikes the supplement
and if the supplement is to fill in or replace any meals.
 Report if the patient experienced any swallowing difficulties or

disliked any foods. Report the patient’s refusal to eat.
 Record patient’s progress toward goals.
0800 Patient sitting up in chair for breakfast. Able to feed self five bites
with encouragement. Reported, “That's all I can do.” Remaining meal fed
to patient. No coughing or difficulty swallowing noted. Consumed 70% of
meal. —S.Boneventure, RN 9/5/13
 Human milk is the most desirable complete diet for infants during
the first 6 months. Infants who are breastfed or bottle-fed do not
require additional fluids, especially water or juice, during the first 4
months of life. Excessive intake of water causes water intoxication,
failure to thrive, and hyponatremia. Typically infants do not consume
solid foods until 6 months of age. Iron-fortified infant cereal is
usually the first solid food to offer. A common sequence for
introducing solid food is one new food every 5 to 7 days. Strained
fruits followed by vegetables and finally meats is the usual pattern. 5
 Do not mix solid foods in a bottle and feed through a nipple with a
larger hole.5
 Food consistency should be assessed and provided based on

developmental milestones.
 Some older adults tire quickly and need assistance.
 Some older adults have diminished appetite because of loss of taste

and smell and decreased number of taste buds. 1
 Interactions between nutrients and medications affect taste of foods

or metabolism, absorption, digestion, or excretion of drugs.
 Older adults with dementia may do best with finger foods as they
may have difficulty using silverware even though their hand or arm
movements may be not affected.2
 Assess financial resources of patient and family to determine if they

are able to purchase nutritionally complete foods for patient.
 Help patient and family identify ways to make meals in the home
pleasant and enjoyable experiences.
15. Taking aspiration Precaution
ALERT
 Assess the patient’s level of consciousness before feeding

him or her.
 Identify obstructions and medication side effects that cause

difficulty swallowing.
 Suspect dysphagia or aspiration if the patient complains of

having the sensation of food sticking in the throat and
makes repeated attempts to swallow.
 Place any patient at risk of dysphagia or aspiration on NPO

status until a swallowing evaluation determines that the
dysphagia poses no substantial risk to the patient.
 Comply with the mandate of The Joint Commission that any

patient admitted with a stroke diagnosis be screened for
aspiration before he or she ingests an oral diet.
 To evaluate for silent aspiration, use pulse oximetry when

administering oral fluids. A drop in oxygen saturation of
greater than or equal to 2% from the patient’s baseline is
diagnostic of aspiration.
 The inability to coordinate the complex, sequential

swallowing mechanism results in food being left in the
mouth and may lead to failure to protect the airway.
Aspiration pneumonia is a potentially fatal complication of
dysphagia, especially in older adults.


6. Determine if the patient is at risk for aspiration:
a. Assess nutritional status and ability to chew or swallow.
b. Assess for mental status by seeing if the patient can follow

simple commands.
c. Apply gloves and inspect mouth and cheeks with penlight and
tongue blade. Pocketing of food suggests patient has difficulty
swallowing.
d. Ask the patient to tuck chin at a 45-degree angle. Ask him or

her to swallow twice or several times, and monitor the
patient’s swallowing and any associated respiratory difficulty.
7. Position the patient at a 90-degree angle, or place at the most

upright position the patient’s medical condition allows.
8. Apply the pulse oximeter to the patient’s finger (or other

appropriate site) to monitor oxygenation during the feeding.
9. Add a thickener to thin liquids to achieve the desired consistency, as

determined by the health care provider or SLP’s evaluation. Always
read the label when modifying liquids to prepare the proper
thickness.
10. Encourage the patient to feed himself or herself.

11. Remind the patient not to tilt his or her head backward while
eating or drinking.
12. If the patient is unable to feed himself or herself, direct ½ to 1

teaspoon of food into the unaffected side of the patient’s mouth,
allowing the utensil to touch the mouth or tongue.
13. Offer verbal cues as you feed the patient. Remind him or her
to focus on chewing and to think about swallowing.
14. If necessary, use sauces, condiments, and gravies to form a

cohesive food bolus.
15. Avoid mixing foods that have different textures in the same
mouthful. Alternate between offering liquids and giving bites of
food.
16. Minimize distractions, and do not rush the patient. Allow

plenty of time for him or her to adequately chew and swallow the
food.
17. Monitor for any signs and symptoms of fatigue, dysphagia, or

aspiration.
18. If needed, suction patient’s orapharyngeal airway and check

mouth periodically with penlight to make sure patient is not
pocketing food.
19. If coughing, choking, or other signs of aspiration occur,

remove the tray until the patient is evaluated by the practitioner or
speech therapist.
20. Ask the patient to remain sitting in the upright position for at
least 30 to 60 minutes after the meal.
21. Remove pulse oximeter and help the patient with hand
hygiene.
22. Provide thorough oral hygiene to the patient after meals.

27. Report any signs or symptoms of dysphagia or aspiration to
the health care provider.
28. Weigh the patient daily or weekly. Document I&O, calorie

intake, food intake, and pulse oximeter readings during meals.
29. Consult the health care provider about any modification of the
patient’s diet.
ALERT
 Assess the patient’s level of consciousness before feeding

him or her.
 Identify obstructions and medication side effects that cause

difficulty swallowing.
 Suspect dysphagia or aspiration if the patient complains of

having the sensation of food sticking in the throat and
makes repeated attempts to swallow.
 Place any patient at risk of dysphagia or aspiration on NPO

status until a swallowing evaluation determines that the
dysphagia poses no substantial risk to the patient.
 Comply with the mandate of The Joint Commission that any

patient admitted with a stroke diagnosis be screened for
aspiration before he or she ingests an oral diet.
 To evaluate for silent aspiration, use pulse oximetry when

administering oral fluids. A drop in oxygen saturation of
greater than or equal to 2% from the patient’s baseline is
diagnostic of aspiration.
 The inability to coordinate the complex, sequential

swallowing mechanism results in food being left in the
mouth and may lead to failure to protect the airway.
Aspiration pneumonia is a potentially fatal complication of
dysphagia, especially in older adults.1
OVERVIEW
The ability to swallow effectively and safely is a basic human need. Safe
transport of food and fluid through the mouth, pharynx, and esophagus to
the stomach requires a complex and fine coordination of cranial nerves
and the muscles of the tongue, pharynx, larynx, and jaw. Any alteration or
delay in the swallowing process causes dysphagia (difficulty swallowing).
People with dysphagia have difficulty holding food and fluid in their
mouths or experience difficulty in the movement of food and fluids into
the esophagus. Dysphagia can occur at any age, but is most common in
the elderly because the likelihood of diseases associated with swallowing
alterations increases with age. The prevalence of oropharyngeal
dysphagia is high in older adult patients and this prevalence leads to
multiple diseases. Studies conducted on healthy older adults more than
80 years of age revealed that natural aging delayed and prolonged the
swallowing response and increased oropharyngeal residue. 2 Studies of the
older adult population have revealed that oropharyngeal dysphagia is an
independent risk factor for the development of respiratory infections and
community-acquired pneumonia.2
Dysphagia is a symptom or complication of certain medical conditions,

particularly stroke. Stroke is more common in older adults. Age-related
swallowing problems can compound stroke-related dysphagia. The
dysphagia that occurs with stroke can cause decreased appetite, weight
loss, malnutrition, dehydration, pneumonia, depression, and poor quality
of life.3 Because the swallowing centers in the central nervous system
(CNS) are located bilaterally and act interdependently, the hemisphere in
which a CNS lesion occurs during a stroke is critically important to the
recovery of swallowing function.
A patient’s risk for dysphagia and aspiration is increased in the presence

of preexisting conditions or factors that produce general muscle
weakness, altered mental status, and structural obstructions as well as
side effects from medications used for treatment.3 Examples of these
preexisting conditions and factors include presence of a tracheostomy
tube, presence of an orogastric or a nasogastric tube, tube feedings,
decreased gastrointestinal motility, facial or head trauma, traumatic brain
injury, head or neck surgery, CPAP (continuous positive airway pressure)
or BiPAP (bilevel positive airway pressure) machine use, history of seizures
and history of recent extubation.7 Patients with neurologic conditions such
as Parkinson disease and patients who have had recent head and neck
surgery are at greater risk for dysphagia.
In some patients, aspiration related to dysphagia occurs silently. The

patient aspirates food or liquid into the trachea and lungs without outward
signs of a swallowing difficulty. Pharyngeal muscle weakness can affect
the coughing reflex and inhibit a productive cough. 7,8 Characteristics of
dysphagia that are predictive of an aspiration risk and warrant further
evaluation include a wet-sounding voice; a weak, voluntary cough;
coughing or choking during or after meals; a prolonged swallow; frequent
drooling; and dropping food out of the mouth when eating. 6 Additional
characteristics of dysphagia include voice changes that occur after
swallowing, hoarseness, difficulty or pain when speaking, slurred speech,
an abnormal gag reflex, regurgitating food, pain when swallowing, food
sticking in the throat, and the need for multiple attempts to swallow food.
If any of these signs or symptoms are detected during dysphagia
screening, an order should be obtained for a speech therapist to perform a
detailed dysphagia assessment.6
A comprehensive oral care protocol that includes toothbrushing and

tongue brushing is the best approach to minimize the harboring of
microorganisms in plaque, mucosa, saliva, and tongue, which may
contribute to hospital-acquired pneumonia. 7
SUPPLIES
 Provide an explanation of the procedure and the equipment.
 Advise the patient not to use a straw when drinking fluids.
 Assess the patient’s knowledge of aspiration risk.
 Perform a nutritional assessment.
 Assess the patient’s mental status, including alertness, orientation,

and ability to follow simple commands, such as opening the mouth
and sticking out the tongue.
 Determine if the patient is at increased risk for aspiration, and

assess for signs and symptoms of dysphagia. Use a dysphagia
screening tool for this assessment if one is available.
 Formally refer any patient at risk for aspiration to a speech and

language pathologist (SLP) for a dysphagia evaluation.
 Assess the patient’s oral health. Check the patient’s level of dental
hygiene, missing teeth, or poorly fitting dentures. Apply clean
gloves to make this oral health assessment if needed.
 Observe the patient during mealtime for signs of dysphagia, such as

coughing, dyspnea, or drooling. Note if the patient is fatigued during
and at the end of a meal.
DELEGATION
Assessment of a patient’s risk for aspiration and determination of the

patient’s position to prevent aspiration cannot be delegated to nursing
assistive personnel (NAP). However, NAP may feed patients after receiving
instruction on aspiration precautions. Be sure to inform NAP of the
following:
 Explain that the patient must be positioned upright or in the high-

Fowler’s position during and after feeding, according to medical
restrictions.
 Instruct NAP to use aspiration precautions while feeding patients

who need assistance.
 Instruct NAP to report to you immediately if the patient has any

onset of coughing or gagging, a wet voice, or pocketing of food.
PROCEDURE


6. Determine if the patient is at risk for aspiration:
a. Assess nutritional status and ability to chew or swallow.
b. Assess for mental status by seeing if the patient can follow

simple commands.
c. Apply gloves and inspect mouth and cheeks with penlight and
tongue blade. Pocketing of food suggests patient has difficulty
swallowing.
d. Ask the patient to tuck chin at a 45-degree angle. Ask him or

her to swallow twice or several times, and monitor the
patient’s swallowing and any associated respiratory difficulty.
7. Position the patient at a 90-degree angle, or place at the most

upright position the patient’s medical condition allows.
8. Apply the pulse oximeter to the patient’s finger (or other
appropriate site) to monitor oxygenation during the feeding.
9. Add a thickener to thin liquids to achieve the desired consistency, as

determined by the health care provider or SLP’s evaluation. Always
read the label when modifying liquids to prepare the proper
thickness.
10. Encourage the patient to feed himself or herself.
11. Remind the patient not to tilt his or her head backward while
eating or drinking.
12. If the patient is unable to feed himself or herself, direct ½ to 1

teaspoon of food into the unaffected side of the patient’s mouth,
allowing the utensil to touch the mouth or tongue.
13. Offer verbal cues as you feed the patient. Remind him or her
to focus on chewing and to think about swallowing.
14. If necessary, use sauces, condiments, and gravies to form a

cohesive food bolus.
15. Avoid mixing foods that have different textures in the same
mouthful. Alternate between offering liquids and giving bites of
food.
16. Minimize distractions, and do not rush the patient. Allow

plenty of time for him or her to adequately chew and swallow the
food.
17. Monitor for any signs and symptoms of fatigue, dysphagia, or

aspiration.
18. If needed, suction patient’s orapharyngeal airway and check

mouth periodically with penlight to make sure patient is not
pocketing food.
19. If coughing, choking, or other signs of aspiration occur,

remove the tray until the patient is evaluated by the practitioner or
speech therapist.
20. Ask the patient to remain sitting in the upright position for at
least 30 to 60 minutes after the meal.
21. Remove pulse oximeter and help the patient with hand
hygiene.
22. Provide thorough oral hygiene to the patient after meals.


27. Report any signs or symptoms of dysphagia or aspiration to

the health care provider.
28. Weigh the patient daily or weekly. Document intake and

output (I&O), calorie intake, food intake, and pulse oximeter
readings during meals.
29. Consult the health care provider about any modification of the
patient’s diet.
MONITORING AND CARE
 Continually evaluate the at-risk patient’s ability to cough and

manage oral secretions. Monitor the patient’s ability to swallow
foods and fluids of different textures and viscosities without choking.
 Weigh the patient daily or weekly.
 Monitor the patient’s I&O, calorie count, and food intake per the
health care provider’s order.
 Monitor the pulse oximetry readings for high-risk patients while they
are eating.
EXPECTED OUTCOMES
 Patient does not exhibit signs or symptoms of aspiration or

respiratory compromise.
 Patient maintains stable weight.
UNEXPECTED OUTCOMES
 Patient coughs, gags, reports food “stuck in throat,” or has pockets

of food in mouth.
 Patient develops respiratory compromise from aspiration

pneumonia.
 Patient develops nutrient deficiencies from avoiding certain food

textures.
 Patient loses weight.
DOCUMENTATION
 Document assessment findings, patient’s tolerance of liquids and

food textures, amount of assistance required, position during the
meal, absence or presence of any symptoms of dysphagia during
the meal, fluid intake, and amount eaten.
 Report any patient coughing, gagging, choking, or swallowing

difficulties to the health care provider.
 Document pulse oximeter readings during the meal.
 Document unexpected outcomes and related nursing interventions.
1200 With much encouragement, patient ate half of pureed diet and 4 oz
juice thickened to consistency of honey. Patient refused additional food.
Tolerated diet with no coughing or aspiration noted. Patient unable to
assist with meal. Consumed 70% of food on tray. –T. Jacobi, RN 8/24/19
 Monitor growth, hydration, and nutritional status in children with

dysphagia.
 Families and caregivers caring for children with dysphagia require

support, information, reassurance, and appreciation for their efforts.
 Be aware that silent aspiration has been reported in children with

dysphagia before, during, and after swallowing.
 The risk for aspiration pneumonia is higher in older adults because

of an increased incidence of dysphagia and gastroesophageal reflux.
Older adults with stroke, Parkinson disease, or dementia are
particularly at risk.7
 Malnutrition occurs rapidly in older adults with dysphagia. Enteral

feedings are sometimes necessary, but there is still a risk for
aspiration.
 Educate patient and family caregivers about aspiration precautions

used to prevent pneumonia.
 Determine patient’s and family caregiver’s knowledge of
appropriate food choices, strategies to increase caloric intake, and
food and liquid texture modifications.
 Dysphagia in home care is best managed with a multidisciplinary

approach that includes patient, family caregivers, health care
provider, nurse occupational therapist, and speech therapist.
18. Measuring Intake and output record
PROCEDURE:
Measuring Intake and Output
1. Put on gloves.
2. Measure intake.
a. Pour liquid remaining in the container into the graduate. Avoid

spills and splashes on the outside of the graduate.
b. Measure the amount at eye level on a flat surface. Keep the

graduate level.
c. Check the serving amount on the I&O record. Or check the

serving size of each container.
d. Subtract the remaining amount from the full serving amount.

Note the amount. (For example, a cup holds 250 mL. The
amount in the graduate is 50 mL. 250 mL − 50 mL = 200 mL.)
e. Pour fluid in the graduate back into the container.
f. Repeat step 2, a–e for each liquid.
g. Add the amounts from each liquid together.
h. Record the time and amount on the I&O record.
3. Measure output as follows.
a. Pour the fluid into the graduate used to measure output. Avoid

graduate level.
c. Dispose of fluid into the toilet. Avoid splashes.
4. Clean and rinse the graduates. Dispose of rinse into the toilet and
flush. Return the graduates to their proper place.
5. Clean, rinse, and disinfect the voiding receptacle or drainage
container. Dispose of the rinse into the toilet and flush. Return the
item to its proper place.
6. Remove and discard the gloves. Practice hand hygiene.
7. Record the output amount on the person’s I&O record.
ALERT
 Urine may contain microbes and blood. Microbes can grow in

urinals, commodes, bedpans, specimen pans, and drainage
systems. Follow Standard Precautions and the Bloodborne
Pathogen Standard when handling such equipment.
Thoroughly clean the item with a disinfectant after it is
used.
OVERVIEW
 The doctor or nurse may order intake and output (I&O)

measurements.
o Intake is the amount of fluid taken in. All oral fluids are
measured and recorded. So are foods that melt at room
temperature, such as ice cream. The nurse measures and
records intravenous (IV) fluids and tube feedings.
o Output is the amount of fluid lost. Output includes urine,

vomitus, diarrhea, and wound drainage.
 I&O records are kept. They are used to evaluate fluid balance and
kidney function. They also are kept when the person has special
fluid orders.
 Intake and output are measured in milliliters (mL).
o You need to know that 1 ounce (oz) equals 30 mL, 1 pint is

about 500 mL, and 1 quart is about 1,000 mL.
o You need to know the serving sizes of bowls, dishes, cups,

pitchers, glasses, and other containers. This information may
be on the I&O record or on the container. You may need to
convert the amount into milliliters. To do this, multiply the
number of oz by 30 (the number of mL in each oz).
 A measuring container for fluid is called a graduate. It is used to

measure left-over fluids, urine, vomitus, and drainage from suction.
It is marked in ounces and milliliters. Plastic urinals and kidney
basins also have amounts marked. Hold the measuring device on a
flat surface at eye level to read the amount.
 An I&O record is kept at the bedside. When I&O is measured, the

amount is recorded in the correct column. Amounts are totaled at
the end of the shift. The totals are recorded in the person’s chart.
 The urinal, commode, bedpan, or specimen pan is used for voiding.

Remind the person not to void into the toilet and not to put toilet
tissue in the receptacle.
SUPPLIES
PREPARATION
 Observe quality-of-life measures.
 Review the information under Delegation and Safety and Comfort.
 Collect the equipment.
DELEGATION
Follow delegation guidelines. Before measuring intake and output, obtain

this information from the nurse and care plan:
 If the person has a special fluid order
 When to report measurements—hourly or end-of-shift
 What the person uses for voiding—urinal, bedpan, commode, or

specimen pan
 If the person has a catheter
 What patient or resident concerns to report at once
 What observations to report and record
 When to report observations
PROCEDURE
Measuring Intake and Output
1. Put on gloves.
2. Measure intake.
a. Pour liquid remaining in the container into the graduate. Avoid

graduate level.
c. Check the serving amount on the I&O record. Or check the

serving size of each container.
d. Subtract the remaining amount from the full serving amount.

Note the amount. (For example, a cup holds 250 mL. The
amount in the graduate is 50 mL. 250 mL – 50 mL = 200 mL.)
e. Pour fluid in the graduate back into the container.
f. Repeat step 2, a–e for each liquid.
g. Add the amounts from each liquid together.
h. Record the time and amount on the I&O record.
3. Measure output as follows.
a. Pour the fluid into the graduate used to measure output. Avoid

graduate level.
c. Dispose of fluid into the toilet. Avoid splashes.
4. Clean and rinse the graduates. Dispose of rinse into the toilet and
flush. Return the graduates to their proper place.
5. Clean, rinse, and disinfect the voiding receptacle or drainage

container. Dispose of the rinse into the toilet and flush. Return the
item to its proper place.
6. Remove and discard the gloves. Practice hand hygiene.
7. Record the output amount on the person’s I&O record.
MONITORING AND CARE
 Provide for comfort.
 Place the call light within reach.
 Complete a safety check of the room.
REPORTING/RECORDING
Report and record your observations, including:
 Urinary frequency, amount of urine, and habits when voiding
 Urinary incontinence or dribbling

 Burning sensation when voiding
 Cloudy, bloody, or foul-smelling urine
 Urine retention or voiding of small amounts
19. Performing Blood glucose testing
ALERT
 Failure to follow manufacturer guidelines pertaining to
glucose meter use may cause inaccurate results.
 Do not milk finger or wick blood onto the reagent strips as
this may cause inaccurate results.
 Failure to recognize inaccurate results can lead to errors in
management and death.
 Be aware that abnormal clotting mechanisms increase the
risk of local ecchymosis and bleeding.
 Never reuse a lancet because of the risk for infection.
 Do not use the hand on the side on which a mastectomy was
performed as a puncture site.
3. Ensure patient privacy. Perform hand hygiene and don gloves. Don
appropriate personal protective equipment (PPE) based on the
patient’s need for isolation precautions or the risk of exposure to
bodily fluids.
5. Identify the patient using two identifiers, such as the patient’s name
and birth date or name and account number, according to your
agency’s policy. Compare the identifiers in the MAR/medical record
with the information on the patient’s identification bracelet, and/or
have the patient state his or her name.
6. To perform a blood glucose test, begin by assessing your patient.
Note in particular the condition of the skin and possible puncture
sites, such as the fingers or forearm. Look for edema, inflammation,
cuts, and sores. Avoid bruised areas and open lesions.
7. Position the patient comfortably in a chair or in the semi-Fowler’s
position in bed.
8. Instruct the adult patient to perform hand hygiene, including the
forearm, if applicable, with soap and water. Rinse and dry.
9. Explain the procedure and ensure that the patient agrees to
treatment. Keep in mind that many types of blood glucose meters
are available. You must follow the manufacturer’s specific
instructions for the model you are using.
10. Clean and disinfect the meter per the manufacturer’s
instructions. Remove gloves, perform hand hygiene, and don clean
gloves. Remove the reagent strip from the vial, and tightly reseal
the cap. Insert the test strip into the meter according to the
manufacturer’s directions. Do not bend the strip. The meter will turn
on automatically.
11. Check the code and expiration date on the test strip vial. Use
only test strips that are recommended for the glucose meter you are
using. Some newer meters do not require a code and/or are
equipped with a disk or drum containing 10 or more test strips. The
code displayed on the screen of the meter must match the code on
the test strip vial. Press the proper button on the meter to confirm
that the codes match. The meter is now ready for use.
12. Prepare a single- or multiple-use lancet device. Note: Some
meters recommend that this step be completed before preparing
the test strip. Ensure that the blood glucose meter is calibrated
correctly per the manufacturer’s instructions.
a. Remove the cap from the lancet device, and insert a new
lancet. Some lancet devices contain a disk or cylinder that
rotates to a new lancet.
b. Twist off the protective cover on the tip of the lancet. Replace
the cap of the lancet device.
c. Cock the lancet device, adjusting for proper puncture depth.
13. Obtain a blood sample:
a. Select a puncture site in a vascular area. In a stable adult, the
lateral side of the finger is usually a good choice. Be sure to
avoid the central portion of the tip of the finger, because of its
denser nerve supply. Pricking the skin there can be painful. If
the meter allows, also consider using the forearm, thigh, or
fleshy part of the hand.
b. Wipe the puncture site, either patient’s finger or other
selected site, lightly with an antiseptic swab. Allow it to dry.
c. Hold the area to be punctured in a dependent position. Do not
milk or massage the finger site.
d. Hold the tip of the lancet device against the skin at the
intended puncture site. Press the release button on the
device.
e. With some devices, a blood sample begins to appear. Remove
the device.
f. If you do not see a drop of blood, gently squeeze or massage
the fingertip until a blood drop forms. If indicated by the
manufacturer’s instructions, wipe away the first droplet of
blood with a cotton ball or gauze.
14. Obtain test results:
a. Bring the meter with the test strip already in place to the
finger (or site of blood).
b. Blood will be wicked onto the test strip. Follow the specific
meter instructions you are using to be sure that you obtain an
adequate sample of blood.
c. The blood glucose test result will appear on the screen of the
meter. Some devices will beep when the measurement has
been completed.
d. If the glucose meter displays “low” or “high” instead of a
numeric result, repeat testing. If the meter again displays
“low” or “high,” notify the practitioner immediately.
15. Turn off the meter if it does not do so automatically. Dispose of
the test strip and lancet in the proper receptacles.
17. As part of your follow-up care, assess the puncture site for any
bleeding.
18. Discuss the test results with the patient. Allow the patient to
ask questions. If the patient has a new diagnosis of diabetes
mellitus, encourage the patient to become an active participant in
care as soon as the patient feels ready.
unexpected outcomes as per agency policy. Document test results
where appropriate according to agency policy.
ALERT
 Failure to follow manufacturer guidelines pertaining to
glucose meter use may cause inaccurate results.
 Do not milk finger or wick blood onto the reagent strips as
this may cause inaccurate results.
 Failure to recognize inaccurate results can lead to errors in
management and death.
 Be aware that abnormal clotting mechanisms increase the
risk of local ecchymosis and bleeding.
 Never reuse a lancet because of the risk for infection.
 Do not use the hand on the side on which a mastectomy was
performed as a puncture site.
OVERVIEW
Blood glucose monitoring allows patients with diabetes mellitus to
self-manage their disease. Obtaining capillary blood by skin
puncture is an alternative to reduce the frequency of needlesticks
when you cannot perform venipuncture. The procedure is less
painful than venipuncture, and the ease of the skin puncture
method makes it possible for patients to perform this procedure. The
development of reagent strips, home glucose monitors, and the skin
puncture method has revolutionized home management care of
patients with diabetes mellitus.
Glucose levels can be evaluated by performing a skin puncture and
using either a visually read test (e.g., Chemstrip bG, Glucostix) or a
reflectance meter. The visually read test does not require an
expensive machine, but the patient must be able to visually
interpret the results. A single drop of blood is applied to a
specifically prepared reagent strip; the strip is read, and the results
are compared to the color chart on the container. Measurement by a
visually read test may not be accurate but can be useful for
screening.
Blood glucose reflectance meters are lightweight and run on
batteries (e.g., AccuChek III, OneTouch). After a drop of blood from
the skin puncture is dropped or wicked onto a reagent strip, the
meter provides an accurate measurement of blood glucose level in 5
to 50 seconds. Point-of-care (POC) blood glucose testing meters
should be dedicated for single-patient use. If single-patient use is
not possible, meters must be cleaned and disinfected.
Reflectance meters use a wet-wash or dry-wipe method of testing.
To perform a wet wash, the user flushes the blood-coated reagent
strip with water before inserting the strip into the glucose meter.
The dry-wipe method requires the user to wipe off the blood-coated
reagent strip with a dry cotton ball before making a reading. Some
products do not require blood to be flushed or wiped before a
reading. The various methods allow measurement of blood glucose
between 20 and 800 mg/dL, thus providing a sensitive measurement
of blood glucose level.
The meters differ in several ways, including amount of blood needed
for each test, testing speed, overall size, ability to store test results
in memory, cost of the meter, and cost of test strips. 1 Some meters
recommend wiping away the first drop of blood with a gauze and
using the second drop for the test while others recommend using
the first drop of blood. For accurate results, it is imperative that the
user follow the manufacturer’s instructions. Some larger meters are
voice activated, which provides support for the older adult or patient
with visual impairments. The amount of time to complete the
glucose testing with the current glucose meters varies from 5 to 50
seconds. You can program some meters to monitor the glucose
levels for a continuous 72 hours.
Additionally, alternative blood glucose monitoring devices are
available. Some meters allow for an alternative puncture site,
including the forearm, palm, and thigh. Continuous interstitial
glucose meters use a very small, fine biosensor inserted through the
abdomen or the back of the arm that transmits continuous readings
of interstitial glucose levels to a monitor or a computer. These
systems support the patient with diabetes mellitus who requires
assessment of glucose trends and patterns.1 Testing of glycosylated
hemoglobin (HbA1c) evaluates the amount of glucose available in the
bloodstream over the 120-day life span of a red blood cell.
HbA1c provides an accurate long-term index of a patient’s average
blood glucose level drawn by venous puncture. 2
SUPPLIES
EDUCATION
 Provide information about blood glucose monitoring, including the
reason for the test, an explanation of each step involved in
obtaining the blood glucose measurement, and a description of the
sensations the patient may feel during the test.
 Provide information on where patient with diabetes mellitus can
obtain testing supplies. When possible, teach with the same meter
that patient will use at home.
 Provide patient with information on where to obtain assistance if
glucose meter has malfunctioned.
 Instruct the patient on what to do and whom to contact if the
glucose reading is out of range or if the meter malfunctions.
 Stress importance of the timing of blood glucose levels, particularly
in patients with diabetes mellitus.
 Assess the patient’s understanding of the procedure and the
purpose of blood glucose monitoring. Determine if the patient knows
how to perform the test and understands its importance in glucose
control.
 Review the health care provider’s orders to see how often the
patient’s blood glucose level must be measured and whether the
procedure must be completed at a specific time. For example, the
sample might need to be collected before insulin is administered,
while the patient is fasting, after he or she has had a meal, or after
certain medications have been administered.
 Determine if any risks exist for performing skin puncture, including
the patient’s being on anticoagulant therapy or having a low platelet
count or a bleeding disorder.
 Assess the area of the skin to be used as a puncture site. Inspect
the fingers or forearms for edema, inflammation, cuts, and sores.
Avoid selecting as a puncture site any bruised area or open lesion.
DELEGATION
Assessment of the patient’s condition may not be delegated. When
the patient’s condition is stable, the skill of obtaining and testing a
sample of blood to measure the blood glucose level may be
delegated to nursing assistive personnel (NAP). Be sure to inform
NAP of the following:
 Explain the appropriate sites to use for the puncture, and review
when to test the patient’s blood glucose level.
 Specify the expected blood glucose level and when to report an
unexpected result to you.
PROCEDURE
3. Ensure patient privacy. Perform hand hygiene and don gloves. Don
appropriate personal protective equipment (PPE) based on the
patient’s need for isolation precautions or the risk of exposure to
bodily fluids.
5. Identify the patient using two identifiers, such as the patient’s name
and birth date or name and account number, according to your
agency’s policy. Compare the identifiers in the MAR/medical record
with the information on the patient’s identification bracelet, and/or
have the patient state his or her name.
6. To perform a blood glucose test, begin by assessing your patient.
Note in particular the condition of the skin and possible puncture
sites, such as the fingers or forearm. Look for edema, inflammation,
cuts, and sores. Avoid bruised areas and open lesions.
7. Position the patient comfortably in a chair or in the semi-Fowler’s
position in bed.
8. Instruct the adult patient to perform hand hygiene, including the
forearm, if applicable, with soap and water. Rinse and dry.
9. Explain the procedure and ensure that the patient agrees to
treatment. Keep in mind that many types of blood glucose meters
are available. You must follow the manufacturer’s specific
instructions for the model you are using.
10. Clean and disinfect the meter per the manufacturer’s
instructions. Remove gloves, perform hand hygiene, and don clean
gloves. Remove the reagent strip from the vial, and tightly reseal
the cap. Insert the test strip into the meter according to the
manufacturer’s directions. Do not bend the strip. The meter will turn
on automatically.
11. Check the code and expiration date on the test strip vial. Use
only test strips that are recommended for the glucose meter you are
using. Some newer meters do not require a code and/or are
equipped with a disk or drum containing 10 or more test strips. The
code displayed on the screen of the meter must match the code on
the test strip vial. Press the proper button on the meter to confirm
that the codes match. The meter is now ready for use.
12. Prepare a single- or multiple-use lancet device. Note: Some
meters recommend that this step be completed before preparing
the test strip. Ensure that the blood glucose meter is calibrated
correctly per the manufacturer’s instructions.
a. Remove the cap from the lancet device, and insert a new
lancet. Some lancet devices contain a disk or cylinder that
rotates to a new lancet.
b. Twist off the protective cover on the tip of the lancet. Replace
the cap of the lancet device.
c. Cock the lancet device, adjusting for proper puncture depth.
13. Obtain a blood sample:
a. Select a puncture site in a vascular area. In a stable adult, the
lateral side of the finger is usually a good choice. Be sure to
avoid the central portion of the tip of the finger, because of its
denser nerve supply. Pricking the skin there can be painful. If
the meter allows, also consider using the forearm, thigh, or
fleshy part of the hand.
b. Wipe the puncture site, either patient’s finger or other
selected site, lightly with an antiseptic swab. Allow it to dry.
c. Hold the area to be punctured in a dependent position. Do not
milk or massage the finger site.
d. Hold the tip of the lancet device against the skin at the
intended puncture site. Press the release button on the
device.
e. With some devices, a blood sample begins to appear. Remove
the device.
f. If you do not see a drop of blood, gently squeeze or massage
the fingertip until a blood drop forms. If indicated by the
manufacturer’s instructions, wipe away the first droplet of
blood with a cotton ball or gauze.
14. Obtain test results:
a. Bring the meter with the test strip already in place to the
finger (or site of blood).
b. Blood will be wicked onto the test strip. Follow the specific
meter instructions you are using to be sure that you obtain an
adequate sample of blood.
c. The blood glucose test result will appear on the screen of the
meter. Some devices will beep when the measurement has
been completed.
d. If the glucose meter displays “low” or “high” instead of a
numeric result, repeat testing. If the meter again displays
“low” or “high,” notify the practitioner immediately.
15. Turn off the meter if it does not do so automatically. Dispose of
the test strip and lancet in the proper receptacles.
17. As part of your follow-up care, assess the puncture site for any
bleeding.
18. Discuss the test results with the patient. Allow the patient to
ask questions. If the patient has a new diagnosis of diabetes
mellitus, encourage the patient to become an active participant in
care as soon as the patient feels ready.
unexpected outcomes as per agency policy. Document test results
where appropriate according to agency policy.
MONITORING AND CARE
 Reinspect the puncture site for any bleeding or tissue injury.
 Compare the glucose meter reading with the patient’s normal blood
glucose levels and previous test results.
 Ask the patient to discuss any concerns about the procedure.
EXPECTED OUTCOMES
 Puncture site shows no evidence of bleeding or tissue damage.
 Blood glucose level is normal or in expected range for specific
patient.
 Sample collected from and results documented for correct patient.
 Patient meets education goals for demonstrating procedure.
 Patient explains meaning of test results.
UNEXPECTED OUTCOMES
 Puncture site is bruised or continues to bleed.
 Inability to obtain adequate blood sample for testing.
 Blood glucose level is above or below target range.
 Glucose meter malfunctions.
 Patient expresses misunderstanding of procedure and results.
DOCUMENTATION
 Record and report any abnormal blood glucose level.
 Describe the patient’s response, including the appearance of the
puncture site.
 Describe any explanations or teaching that you provided to the
patient.
 Record the procedure used and the resulting blood glucose level
measured.
 Document any action taken to correct abnormal values.
 Document unexpected outcomes and related nursing interventions.
0730 Finger stick blood glucose 110 mg/dL. No sliding-scale insulin
administered. —T. Priceman, RN 1/23/20
1200 Finger stick blood glucose 240 mg/dL. Regular insulin (4 units)
administered subcutaneously as prescribed, per sliding scale.
Denies pain at puncture site. Verbalized importance of blood glucose
testing in managing his diabetes. —T. Priceman, RN 1/23/20
 Allow young children to choose puncture site; heel and great toe are
common puncture sites in infants.
 Heel warming helps to obtain specimen from a neonate.
 Infection or abscess of the heel and necrotizing osteochondritis are
the most serious complications of heelstick puncture in infants. To
avoid osteochondritis make sure that puncture is not deeper than 2
mm and is made at the outer aspect of the heel. 3
 Allow young child with parent to demonstrate technique; incorporate
a play activity for further understanding.
 Warming fingertips may facilitate obtaining specimen.
 Some older adults have vision or dexterity problems that interfere
with performing self-fingersticks.
 Provide information on correct disposal of sharps in nonpermeable
and puncture-resistant container.
 Suggest that patient attend diabetic support group if needed.
 Be sure that patient’s family caregiver can perform test when
patient is ill or is unable to manipulate devices.
Measuring Height and weight
 Determine the patient’s ability to bear his or her own weight

and stand safely on a scale. Use a chair or bed scale, if
needed.
3. Provide for the patient's privacy, perform hand hygiene and apply
gloves as needed. Don appropriate personal protective equipment
(PPE) based on the patient’s need for isolation precautions or the
5. Verify the correct patient using two identifiers. Compare identifiers
to the patient’s identification band.
6. Explain the procedure to the patient and ensure he or she agrees to
treatment.
7. Ask the patient to void and remove or empty any fluid drainage
bags that would impede movement and will not be included in the
weight measurement.
8. Weigh the patient on the same scale at the same time of day,
wearing the same type of clothing each time, such as a patient
gown and agency approved footwear.
9. Determine if the patient can bear his own weight and can stand
safely on a scale. Initiate fall prevention measures, per the agency’s
practice, before mobilizing a patient. If the patient is unable to
stand, select a scale suited to the patient’s level of mobility such as
a wheelchair or bed scale.
10. Enlist the assistance of other health care team members, if
needed, and use ergonomic principles for patient moving and
handling.
11. To measure an ambulatory patient's weight on a digital
standing scale:
a. Turn the scale on and check that the display on the scale
reads zero. If necessary, reset, or “zero”, the scale.
b. Help the patient onto the platform. Have the patient stand still
on the scale, evenly distributing body weight on both feet.
c. Listen for an audible beep or note the display of a word such
as “locked” once weight is measured, per the manufacturer’s
instructions.
d. Press the lock, hold, or recall button to keep or view the
weight in the scale’s memory. If there is no lock, hold or recall
option, note the patient’s weight according to the display.
e. Assist the patient off the scale.
12. To measure an ambulatory patient's weight on an eye-level
weight adjustment standing scale:
a. Estimate the patient’s weight or ask the patient his or her
most recent known weight.
b. Make sure the patient is wearing light-weight clothing. Provide
assistance with removing the patient's shoes and socks if
needed. Have the patient put on skid proof socks.
c. To obtain an accurate weight, make sure the beam scale has
been calibrated. Before you begin, slide each weight over to 0.
d. Help the patient onto the platform. Have the patient stand still
e. Slide the lower counterweight along the bar until the number
displayed is close to the patient’s weight, but still below the
expected measurement.
f. Move the top counterweight along the bar until the scale is
balanced. The scale is balanced when the indicator hovers in
the middle of the frame and does not touch the top or bottom
of the frame. Note the patient’s weight.
g. Assist the patient off the scale.
h. Record the patient's weight to the nearest 0.1 kg (1/4 lb).
13. To measure the patient's height:
a. Ask the patient stand up straight, with body weight evenly
distributed on both feet, arms at the patient’s sides, and
palms facing the thighs.
b. Ask the patient to look straight ahead, take a deep breath,
and hold the position as you bring the horizontal bar down
firmly on top of the patient's head.
c. Measure the patient's height to the nearest 0.1 cm (1/8 inch).
To read the measurement accurately, your eyes must be level
with the bar.
14. To measure the weight of a patient who is alert and mobile but
unable to stand for long, a digital chair scale may be used.
a. Bring the chair scale to the patient and lock and lock the
wheels. Raise the armrests and footrests if applicable.
b. Turn the scale on and check that the display on the scale
c. Help the patient into the scale’s seat and secure the patient, if
needed, according to the manufacturer’s directions and facility
policy.
15. To measure the weight of a patient who is alert but unable to
stand, a wheelchair can be rolled onto a platform scale.
a. If the scale is digital, begin with a reading of 0 and select the
unit of measurement.
b. Establish the weight of the wheelchair and cushions prior to
weighing the patient. For consistency, always weigh the
patient in the same chair.
c. Position the wheelchair on the scale and lock the wheels to
keep it from rolling.
d. Wait for the trigger or watch for the reading to appear on the
digital display.
16. To weigh a patient who cannot stand using a sling or lift scale:
a. Attach the sling to the lift according to the manufacturer’s
instructions for use.
b. Turn the scale on and note the weight of the sling and any
linens used so it is not included in the patient’s weight
measurement.
c. Detach the sling from the scale.
d. Tare the scale to subtract the weight of the sling.
e. Place the patient into a supine position and raise the bed to a
comfortable working height. Remove any blankets or pillows.
Have the patient cross his or her arms and ankles.
f. With help from an assistant and using good body mechanics,
roll the patient onto one side and place the sling beneath the
patient. Explain to the patient that he or she will be rolling
over the edge of the sling. Roll the patient onto the other side
to finish placing the sling. Center the patient on the sling.
g. Position the scale at the bedside and lock the wheels for
safety.
h. Lower the arm of the scale and attach the sling to the scale
according to the manufacturer’s directions. Raise the arm of
the scale slowly until the patient is lifted completely off the
surface of the bed or stretcher. Ask the patient to stay still
while you read the digital weight.
i. Note the patient’s weight.
j. Lower the patient gently onto the bed.
k. Detach the sling from the scale.
l. With help from an assistant and using good body mechanics,
roll the patient onto one side and roll the sling toward the
patient’s back. Explain to the patient that he or she will be
rolling over the edge of the sling. Roll the patient onto the
other side to finish removing the sling. Place the sling with the
scale.
m. Assist the patient to a comfortable position and replace any
pillows and blankets.
17. To weigh a patient who cannot stand using a bed scale:
a. Before weighing a patient with the bed scale, account for the
weight of all items placed on the surface of the bed or
stretcher. These items include sheets, a pillow, and other
linens or equipment necessary for patient care. By accounting
for the weight of items on the bed or stretcher surface, a more
accurate weight will be obtained. This is usually done before
the patient is placed in the bed for the first time.
i. Ensure that the mattress and bed frame are level.
ii. Raise or lower the bed or stretcher to the maximum or
minimum height according to the manufacturer’s
instructions for use with all applicable items to be used,
but without the patient.
iii. Zero the scale on the bed or stretcher.
b. Assist the patient onto the bed or stretcher and into the center
of the surface.
c. Weigh the patient using the bed controls and note the
patient’s weight according to the display.
18. Determine the patient’s BMI using a chart or formula per
agency policy.
19. Reattach or replace any fluid drainage bags that were present
prior to obtaining the patient’s weight, if applicable.
room tidy.
unexpected outcomes. Always compare the current height and
weight with his or her previous measurements.
ALERT
 Determine the patient’s ability to bear his or her own weight
and stand safely on a scale. Use a chair or bed scale, if
needed.
OVERVIEW
Assessment of nutritional status is an essential part of patient care
and is the foundation for diagnosing nutritional problems. It may
lead to recommendations such as change in diet, need for
alternative mode of nutrition intake, or improvement in a patient’s
nutritional status. There are four basic components of a holistic
nutritional assessment: patient history (psychological and social);
dietary history; physical examination and anthropometric
measurements; and biochemical indices.
Body weight measurement is a necessary component of physical
assessment. Body weight is used to determine correct medication
doses as well as shed light on a patient’s nutritional status and fluid
volume status. Estimating, asking a patient’s weight, or using a
documented weight from a previous encounter has been shown to
be significantly inaccurate;1 it is necessary to weight the patient for
accuracy. Medical errors that can be traced to inaccurate or
erroneous weights include confusing pounds and kilograms. 1,2 A
weight in pounds is more than double the same number in
kilograms. Follow agency policy with regards to whether pounds or
kilograms are recorded in the medical record. Kilograms are needed
for calculations related to weight.
Scales available for weight measurement include standing scales,
bed and chair scales, and sling scales. Use the available scale that is
most appropriate for the patient’s condition. Scales for patients with
limited mobility include bed scales, stretcher scales, and sling or lift
scales.
Patient weight should be taken at the same time each day and
patients should be weighed in the same clothes each time. If a chair
or bed scale is used, take care to use the same cushions or linens
each time. Understand your agency’s process for scale calibration. If
a scale is not calibrated regularly, it can lead to errors in
measurement.
Body mass index (BMI) is a value that estimates body fat based on
weight and height using a standardized BMI chart. BMI is a
screening tool used to assess a patient’s risk of obesity-related
diseases, such as heart disease, diabetes, and some cancers; it is
not a diagnostic test.3 BMI can be inaccurate if the patient has
edema, ascites, increased muscle mass, or other conditions that
alter body composition.
SUPPLIES
EDUCATION
 Explain the procedure for weight measurement, the steps involved,
and the rationale for obtaining an accurate weight.
 Determine if the patient can bear his own weight and can stand
safely on a scale.
 Initiate fall prevention measures, per the agency’s practice, before
mobilizing the patient.
 If the patient is unable to stand, use a device suited to the patient’s
level of mobility such as a wheelchair or bed scale, to weigh the
patient.
 Weigh the patient on the same scale at the same time of day,
DELEGATION
Measurement of a patient’s height and weight can be delegated to
nursing assistive personnel (NAP). Be sure to inform NAP of the
following:
 Measure the patient’s weight after he or she voids. Weigh the
patient on the same scale, at the same time of day, and wearing the
same type of clothing each time.
 Use the internal bed scale to measure a patient’s weight, if
applicable.
 Report the inability to measure height if a patient is nonambulatory.
PROCEDURE
3. Provide for the patient's privacy, perform hand hygiene and apply
gloves as needed. Don appropriate personal protective equipment
(PPE) based on the patient’s need for isolation precautions or the
5. Verify the correct patient using two identifiers. Compare identifiers
to the patient’s identification band.
6. Explain the procedure to the patient and ensure he or she agrees to
treatment.
7. Ask the patient to void and remove or empty any fluid drainage
bags that would impede movement and will not be included in the
weight measurement.
8. Weigh the patient on the same scale at the same time of day,
9. Determine if the patient can bear his own weight and can stand
safely on a scale. Initiate fall prevention measures, per the agency’s
practice, before mobilizing a patient. If the patient is unable to
stand, select a scale suited to the patient’s level of mobility such as
a wheelchair or bed scale.
10. Enlist the assistance of other health care team members, if
needed, and use ergonomic principles for patient moving and
handling.
11. To measure an ambulatory patient's weight on a digital
standing scale:
a. Turn the scale on and check that the display on the scale
b. Help the patient onto the platform. Have the patient stand still
c. Listen for an audible beep or note the display of a word such
as “locked” once weight is measured, per the manufacturer’s
instructions.
12. To measure an ambulatory patient's weight on an eye-level
weight adjustment standing scale:
a. Estimate the patient’s weight or ask the patient his or her
most recent known weight.
b. Make sure the patient is wearing light-weight clothing. Provide
assistance with removing the patient's shoes and socks if
needed. Have the patient put on skid proof socks.
c. To obtain an accurate weight, make sure the beam scale has
been calibrated. Before you begin, slide each weight over to 0.
d. Help the patient onto the platform. Have the patient stand still
e. Slide the lower counterweight along the bar until the number
displayed is close to the patient’s weight, but still below the
expected measurement.
f. Move the top counterweight along the bar until the scale is
balanced. The scale is balanced when the indicator hovers in
the middle of the frame and does not touch the top or bottom
of the frame. Note the patient’s weight.
g. Assist the patient off the scale.
h. Record the patient's weight to the nearest 0.1 kg (1/4 lb).
13. To measure the patient's height:
a. Ask the patient stand up straight, with body weight evenly
distributed on both feet, arms at the patient’s sides, and
palms facing the thighs.
b. Ask the patient to look straight ahead, take a deep breath,
and hold the position as you bring the horizontal bar down
firmly on top of the patient's head.
c. Measure the patient's height to the nearest 0.1 cm (1/8 inch).
To read the measurement accurately, your eyes must be level
with the bar.
14. To measure the weight of a patient who is alert and mobile but
unable to stand for long, a digital chair scale may be used.
a. Bring the chair scale to the patient and lock and lock the
wheels. Raise the armrests and footrests if applicable.
b. Turn the scale on and check that the display on the scale
c. Help the patient into the scale’s seat and secure the patient, if
needed, according to the manufacturer’s directions and facility
policy.
15. To measure the weight of a patient who is alert but unable to
stand, a wheelchair can be rolled onto a platform scale.
a. If the scale is digital, begin with a reading of 0 and select the
unit of measurement.
b. Establish the weight of the wheelchair and cushions prior to
weighing the patient. For consistency, always weigh the
patient in the same chair.
c. Position the wheelchair on the scale and lock the wheels to
keep it from rolling.
d. Wait for the trigger or watch for the reading to appear on the
digital display.
16. To weigh a patient who cannot stand using a sling or lift scale:
a. Attach the sling to the lift according to the manufacturer’s
instructions for use.
b. Turn the scale on and note the weight of the sling and any
linens used so it is not included in the patient’s weight
measurement.
c. Detach the sling from the scale.
d. Tare the scale to subtract the weight of the sling.
e. Place the patient into a supine position and raise the bed to a
comfortable working height. Remove any blankets or pillows.
Have the patient cross his or her arms and ankles.
f. With help from an assistant and using good body mechanics,
roll the patient onto one side and place the sling beneath the
patient. Explain to the patient that he or she will be rolling
over the edge of the sling. Roll the patient onto the other side
to finish placing the sling. Center the patient on the sling.
g. Position the scale at the bedside and lock the wheels for
safety.
h. Lower the arm of the scale and attach the sling to the scale
according to the manufacturer’s directions. Raise the arm of
the scale slowly until the patient is lifted completely off the
surface of the bed or stretcher. Ask the patient to stay still
while you read the digital weight.
i. Note the patient’s weight.
j. Lower the patient gently onto the bed.
k. Detach the sling from the scale.
l. With help from an assistant and using good body mechanics,
roll the patient onto one side and roll the sling toward the
patient’s back. Explain to the patient that he or she will be
rolling over the edge of the sling. Roll the patient onto the
other side to finish removing the sling. Place the sling with the
scale.
m. Assist the patient to a comfortable position and replace any
pillows and blankets.
17. To weigh a patient who cannot stand using a bed scale:
a. Before weighing a patient with the bed scale, account for the
weight of all items placed on the surface of the bed or
stretcher. These items include sheets, a pillow, and other
linens or equipment necessary for patient care. By accounting
for the weight of items on the bed or stretcher surface, a more
accurate weight will be obtained. This is usually done before
the patient is placed in the bed for the first time.
i. Ensure that the mattress and bed frame are level.
ii. Raise or lower the bed or stretcher to the maximum or
minimum height according to the manufacturer’s
instructions for use with all applicable items to be used,
but without the patient.
iii. Zero the scale on the bed or stretcher.
b. Assist the patient onto the bed or stretcher and into the center
of the surface.
c. Weigh the patient using the bed controls and note the
patient’s weight according to the display.
18. Determine the patient’s BMI using a chart or formula per
agency policy.
19. Reattach or replace any fluid drainage bags that were present
prior to obtaining the patient’s weight, if applicable.
room tidy.
unexpected outcomes. Always compare the current height and
weight with his or her previous measurements.
MONITORING AND CARE
 Monitor the patient's body weight daily during inpatient stay. Note
any changes and report to health care provider if there is a sudden
increase or decrease in weight.
 Monitor input and output per the healthcare provider’s order and the
organization’s practice.
EXPECTED OUTCOMES
 Patient weight is recorded in the expected units (pounds or
kilograms).
 Patient weight correlates with physical presentation and previous
patient weight assessments.
UNEXPECTED OUTCOMES
 Patient weight is recorded in unexpected units (pounds or
kilograms).
 Patient weight is significantly increased or decreased from previous
weight assessments.
DOCUMENTATION
 Document patient and family education.
 Record the method of calculating patient weight (type of scale, use
of linens, etc.).
 Document the patient’s weight in the correct units per the
organization’s practice.
 Report unexpected outcomes and related interventions.
1030 5'8" 170 lb. —T. Winkelmann, RN 12/8/20
 Anthropometric data include measurement of length, weight, and
head circumference in children. Compare these measurements with
standard growth charts to determine percentiles. The most
commonly used growth charts are from the National Center for
Health Statistics. These charts now include BMI for age and weight
for stature percentiles.
 Change the child’s diaper before weighing, if the child is wearing
one. A soiled diaper will artificially increase weight.
 BMI charts may not be accurate for older adults. Healthy BMI ranges
in older adult patients remain an area of research.
 A home scale may not be as accurate as a professional grade scale.
 Teach patients to weight themselves in the same clothes, at the
same time of day each time and record weight in a journal or log.
 Explain that a home scale should be placed on a hard surface.

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1. Performing Hand Hygiene

1. Review the information under Safety and Comfort.

5. Turn on and adjust the water until it feels warm.

7. Apply about 1 teaspoon of soap to your hands.

8. Rub your palms together and interlace your fingers to work up a

11. Clean under the fingernails with a nail file or orangewood

13. Repeat steps 7 through 12, if needed.

17. Discard the paper towels into the wastebasket.

Using an Alcohol-Based Hand Rub ABHR

1. Review the information under Safety and Comfort.

2. Apply a palmful of an alcohol-based hand rub into a cupped hand.

3. Rub your palms together.

5. Rub your palms together with your fingers interlaced.

6. Interlock your fingers. Rub your fingers back and forth.

9. Continue rubbing your hands until they are dry.

Always practice hand hygiene before and after giving care or

The nursing assistant can perform hand hygiene by:

 Washing with soap and water.

 Using an alcohol-based hand rub.

See Supplies tab at the top of the page.

Plan to wash your hands with soap and water:

 After using the restroom.

 If exposure to anthrax spore is suspected or proven.

 If an alcohol-based hand rub is not available.

 Before direct contact with a person.

 After contact with the person’s intact skin.

 After contact with body fluids or excretions, mucous membranes,

 When moving from a contaminated body site to a clean body site

 After contact with objects in the care setting.

 After removing gloves.

1. Review the information under Safety and Comfort.

5. Turn on and adjust the water until it feels warm.

7. Apply about 1 teaspoon of soap to your hands.

11. Clean under the fingernails with a nail file or orangewood

13. Repeat steps 7 through 12, if needed.

15. Discard the paper towels into the wastebasket.

17. Discard the paper towels into the wastebasket.

Using an Alcohol-Based Hand Rub

1. Review the information under Safety and Comfort.

2. Apply a palmful of an alcohol-based hand rub into a cupped hand.

3. Rub your palms together.

5. Rub your palms together with your fingers interlaced.

6. Interlock your fingers. Rub your fingers back and forth.

9. Continue rubbing your hands until they are dry.

 Don appropriate PPE based on the patient’s signs and

o Determine whether the patient has a known or

o Wear PPE when the anticipated patient interaction

o Remove your gloves and perform hand hygiene

o Perform hand hygiene with soap and water or use an

o Use synthetic nonlatex gloves with patients at high risk

o Hypoallergenic, low-powder, and low-protein latex

o Protect fellow health care workers from exposure to

o If an AIIR is not available, place a surgical mask on the

 The door to the isolation room and the anteroom should

1. Assess the patient and review the patient's history.

2. Verify the health care provider's orders to determine which isolation

3. Gather the necessary equipment and supplies.

4. Perform hand hygiene.

5. Prepare to enter the isolation room. Your choice of barrier protection