July 2012 Vol. 10, No. 7 ADL assistance Helping residents with their ADLs is the largest part of a CNA s workday. It is important to be able to devote time to each resident and his or her particular needs. These tasks must not be pushed aside, as neglecting ADLs can create serious health problems in the future. In addition, it is imperative to make residents feel as if they are able to care for themselves with as little assistance as possible, while assuring each individual of his or her own safety, health, and privacy. This issue will define and explain the importance of the four late-loss ADLs. It will cover how CNAs can best assist residents with eating, including techniques and communication. It will also highlight elderly residents nutritional and dietary needs. One of the more intimate and difficult ADLs is bathing, which this lesson will address by explaining general guidelines, care benefits, and the effect of bathing on residents skin. Have a good day of training, and stay tuned for next month s issue of CNA Training Advisor, which will cover infection control and bloodborne pathogens. Program time Approximately 30 minutes Program Prep Learning objectives Participants in this activity will learn how to: Identify the four late-loss ADLs Properly assist residents before, during, and after meals Describe elderly residents nutritional needs Properly assist residents with washing and bathing Preparation Review the material on pp. 2 4 Duplicate the CNA Professor insert for participants Gather equipment for participants (e.g., an attendance sheet, pencils, etc.) Method 1. Place a copy of CNA Professor and a pencil at each participant s seat 2. Conduct the questionnaire as a pretest or, if participants reading skills are limited, as an oral posttest 3. Present the program material 4. Review the questionnaire 5. Discuss the answers Resistant to bathing Bathing is a highly personal routine. It is a good idea to determine individual preferences for each resident and to do your best to accommodate them. Some residents are resistant to bathing. Never force these residents to bathe. Instead, report the resistance to your supervisor. Often, a simple change in staff members, bathing time, or day will make a resident more agreeable and cooperative. Quiz answer key Breaking the ADL Code Use HCPro s comprehensive video, Breaking the ADL Code: A Team Approach to MDS 3.0 Documentation, to train your entire nursing team on the ADL documentation requirements under the MDS 3.0. Familiar scenarios provide concrete examples of each level of scoring, and walk CNAs and RNs through the correct ways to code the four late-loss ADLs. In addition, MDS coordinators will discover how to tabulate the ADL scores of each resident to come up with the final ADL codes. 1. b 2. c 3. d 4. a 5. d 6. c 7. a 8. b 9. d 10. c For more information or to order, call 800-650-6787 or visit www.hcmarketplace.com/prod-8756.
Page 2 CNA Training Advisor July 2012 The four late-loss ADLs are those that residents tend to be able to perform the longest during their lives. These are the most basic activities and are usually the last to disappear. Their decline could indicate that a resident s health is failing. The four late-loss ADLs are as follows: 1. Transfer. This describes how the resident moves between surfaces (e.g., to and from the bed, a chair, a wheelchair, or the standing position). This does not include moving to and from the bath or toilet, which is covered under other ADL categories. CNAs should document as soon as possible after care delivery. This will help ensure accurate documentation of how the resident performed on his or her own and what the CNA had to assist with. 2. Bed mobility. This refers to how the resident moves to and from a lying position, turns from side to side, and positions his or her body while in a bed, recliner, or other type of furniture in which he or she sleeps. 3. Eating. This describes how the resident eats and drinks, regardless of skill (although it does not include eating or drinking during a medication pass). Eating also includes the intake of nourishment by other means, such as tube feeding or total parenteral nutrition. Even a resident who receives tube feedings and does not consume food or fluids by mouth is engaged in eating and receiving nourishment. 4. Toilet use. This refers to how the resident uses the bathroom, commode, bedpan, or urinal; transfers on and off the toilet; cleanses him- or herself; changes his or her pad; manages an ostomy or catheter; and adjusts his or her clothes. Don t limit the assessment to bathroom use only; elimination occurs in many settings. Helping residents eat Hunger, taste, and socialization are all reasons why eating can be an enjoyable event. However, sometimes residents need assistance to experience these pleasures. The first thing you should do before helping a resident eat is wash your hands. When assisting residents as necessary with eating, you should also: Identify the resident, introduce yourself, and explain what you ll be doing Make certain that the resident s teeth are in and glasses are on Check the meal tray to ensure that the resident s diet is correct for example, that he or she has pureed foods or thickened liquids, if specified in the care plan Place the tray within the resident s reach Make sure the resident is in a comfortable position to eat Position yourself comfortably Place the napkin under the resident s chin Test any hot liquids on your wrist Tell the resident what is being served, especially if he or she has difficulty seeing Ask the resident in what order he or she would like the food served Name each food as you serve it if the resident cannot see Place only a small amount of food on the spoon or fork Do not rush, and allow the resident time to chew Provide liquids intermittently Wipe the resident s mouth as needed After assisting a resident with eating, you should, when the resident is unable to do so on his or her own: Remove the napkin from under the resident s chin Clean the resident s mouth and hands Make the resident comfortable Leave the eating area neat and clean Return the tray to its proper place Wash your hands Report amounts of food and liquids eaten according to facility policy Report anything significant, such as the resident eating less than half of the meal, choking, or having difficulty swallowing Residents nutritional needs Sick or elderly residents have different food requirements than younger, healthy residents. They are also more likely to suffer harm from not eating the proper foods. After age 50, chemical and physical changes take place in the body that affect nutritional needs. These changes include the following: The metabolic rate, or metabolism, slows down. The metabolic rate is the speed at which the body uses energy. Older bodies burn less Editorial Board Editorial Director: Lauren McLeod Assoc. Editorial Director: Elizabeth Petersen Editor: Justin Veiga jveiga@hcpro.com CNA Training Advisor (ISSN: 1545-7028 [print]; 1937-7487 [online]) is published monthly by HCPro, Inc., 75 Sylvan Street, Suite A-101, Danvers, MA 01923. Subscription rate: $149/year; back issues are available at $15 each. Copyright 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email customerservice@hcpro.com. Visit our website at www.hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CTA. Mention of products and serv ices does not constitute en dorse ment. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.
July 2012 CNA Training Advisor Page 3 fuel for daily operations. This means seniors, and people who are not active or are confined to bed, need fewer calories for normal everyday activities. Lean tissue and muscle mass decrease. There is less bone mass, and body fat increases. Stomach acid may decrease, and the stomach might not empty as quickly. Also, the intestines may absorb less nutrition from food. Tooth and gum problems increase, sometimes making it difficult to chew. Some people have trouble swallowing, especially those who have had strokes. There is a loss of taste and smell. This causes people to be less interested in food. People are sometimes too tired or weak to eat an entire meal. Bodies will break down if they do not get the amount and type of fuel they need. Malnutrition means badly nourished and is another way of saying that a resident isn t getting enough of the proper nutrients the body needs to stay healthy. It can be caused by not eating enough nutritious foods or by not adequately digesting and absorbing nutrients from food. Getting too much food is harmful as well; this is also called malnutrition. Someone who meets one or more of the following criteria might be headed for malnutrition: Doesn t eat from the major food groups most of the time Eats less than half of two meals per day Eats less than one hot meal per day Changes from solid foods to pureed foods, or experiences other dietary changes Drinks a lot of alcohol Is socially isolated or depressed Has cognitive problems (the person might not remember to eat) Uses laxatives excessively (this hinders digestion of nutrients by causing food to pass through the intestines too quickly) Has had recent surgery or illness, or has chronic or multiple diseases Feeding techniques When assisting residents with meals, it is important to only help them when necessary you should encourage them to do as much as possible by themselves. Although you may aid residents with tasks such as cutting food, it is important to encourage residents to keep trying on their own. Repeat eating instructions as often as necessary, and be sure to speak directly and simply. Provide only one instruction at a time. If a resident does not respond to verbal cues, use the hand-over-hand technique to help him or her eat. Residents will sometimes have difficulties communicating their dining needs. No matter what the cause, you should help your residents communicate to the best of their ability. There are several types of communication problems. For example, residents can have difficulty understanding written or verbal information, or they may have trouble communicating their wants and needs. Never turn your back on a resident who might need assistance while eating. That way, the resident is never at risk of causing an accident, such as spilling food or drink. It is important to recognize when your residents need assistance with feeding and to be there to assist when necessary. It is also necessary to know what methods of assistance work best with each resident. Helping residents bathe Remember that it is better to assist your residents, rather than doing the entire bath for them. If they are able to move their arms, they should at least wash their own face. This helps prevent residents from being totally dependent on you and provides them with needed exercise. Bathing is important to a resident s overall health and plays a role in maintaining healthy skin. Bathing is also good for: Enhancing relaxation and comfort Removing dead skin cells Controlling infection by removing microorganisms Providing muscle and tissue stimulation through gentle rubbing Eliminating body odor that develops due to the interaction of harmless microorganisms on the skin with odorless secretions of the sweat glands Bathing also provides an opportunity for the caregiver to inspect the resident for potential skin problems. Remember to look under the breasts and in the folds of the groin. Early detection and treatment of skin problems can prevent the resident from developing pressure ulcers. It also reduces resident discomfort, as well as the time and costs involved in wound care. To help compensate for changes to the skin due to the aging process, do the following: Use a moisturizing liquid cleanser Pat the skin dry; do not rub Apply lotion to dry areas Provide ample clothing/blankets to keep residents warm Questions? Comments? Ideas? Contact Editor Justin Veiga Email jveiga@hcpro.com Phone 781-639-1872, Ext. 3933
Page 4 CNA Training Advisor July 2012 Take necessary precautions to prevent damage to the skin when moving or transferring residents to the bathing area For most, daily bathing is considered routine. However, for the elderly, daily bathing may be damaging to the skin. Nevertheless, the face, hands, underarms, and perianal area must be cleansed daily. Basinless or bag bath When a resident is unable to bathe using a tub or shower, a bed bath is usually provided. The disadvantages associated with the bed bath are potential contamination of the bathwater and cross-contamination to the immediate environment and to staff members. As a result, many facilities now use the basinless bath, which eliminates the need to reuse dirty bathwater. There are two types of basinless baths, also known as bag baths. The first type is the commercial bag bath, which is made up of premoistened disposable washcloths, similar to thick, soft baby wipes. The second type is prepared in the facility and usually consists of 10 washcloths. When administering a basinless bath, one washcloth is used for each major body part. The solution used in both commercial and facility-prepared basinless baths contains moisturizers and evaporates without the need to rinse or dry the body. This type of bath reduces the time staff members spend bathing residents, and it prevents residents from becoming cold and tired during bath time. As with any type of bed bath, it is important to protect the resident s privacy at all times by using a bath blanket to cover the areas you are not washing. Remember, also, to keep the resident as warm as possible. Studies show that residents prefer the bag bath because their skin feels softer compared to the traditional bed bath. Furthermore, 99% of residents admitted with skin problems show an improvement in their skin after a period of bag baths. Guidelines for showers and tub baths There are general guidelines you should follow when administering tub baths or showers to residents. Be aware of maintaining the resident s privacy. In addition, ensure the resident s safety, as well as your own. Often, you may be rushed and feel overwhelmed when completing your assignments. If your mind is focused on other things when bathing a resident, it s easy to overlook the following important guidelines: Wipe up any water on the floor that may cause a fall Ensure that residents are wearing the proper nonslip footwear when standing or walking Use proper body mechanics Close the door to the bathing area while the resident is being bathed Never leave the resident unattended in the tub or shower Use a bath blanket to ensure the resident s privacy and to keep him or her warm Make sure the bathwater is at the correct temperature To prevent skin breakdown, pat the skin dry carefully, especially under the breasts, in the groin area, and between the toes It is also important to bathe the resident in a calm, unhurried manner. This is much more relaxing for the resident and reduces the chance of resistance. n Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving CNA Training Advisor, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at 800-650-6787. CTA Subscriber Services Coupon q Start my subscription to CTA immediately. Options No. of issues Cost Shipping Total q Electronic 12 issues $149 (CTAE) N/A q Print & Electronic 12 issues of each $149 (CTAPE) $24.00 Sales tax Order online at (see tax information below)* www.hcmarketplace.com. Be sure to enter source code Grand total N0001 at checkout! For discount bulk rates, call toll-free at 888-209-6554. *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax Email address (Required for electronic subscriptions) q Payment enclosed. q Please bill me. q Please bill my organization using PO # q Charge my: q AmEx q MasterCard q VISA q Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge from HCPro, the publisher of CTA.) Mail to: HCPro, P.O. Box 3049, Peabody, MA 01961-3049 Tel: 800-650-6787 Fax: 800-639-8511 Email: customerservice@hcpro.com Web: www.hcmarketplace.com
July 2012 Vol. 10, No. 7 ADL assistance Mark the correct response. Name: Date: 1. Which of the following is not one of the four late-loss ADLs? a. Transfer b. Bathing c. Bed mobility d. Eating 2. The first thing a CNA should do before helping a resident eat is. a. introduce him- or herself b. make certain the resident s teeth are in c. wash his or her hands d. place a napkin under the resident s chin 3. After assisting a resident with eating, CNAs should, when the resident is unable to do so on his or her own,. a. remove the napkin from under the resident s chin b. clean the resident s mouth and hands c. report amounts of food and liquids eaten according to facility policy d. all of the above 4. Sick or elderly residents have different food requirements than younger, healthy residents. a. True b. False 5. After age 50, the rate, which is the speed at which the body uses energy, slows down. a. caloric b. energy conversion c. processing d. metabolic 6. Which of the following is not a sign of malnutrition? a. Eating less than one hot meal per day b. Drinking a lot of alcohol c. Presence of more than one pressure ulcer d. Excessive laxative use 7. Bathing helps do all of the following for residents, except. a. improve skin integrity b. enhance relaxation and comfort c. control infection by removing microorganisms d. eliminate body odor 8. It is inappropriate to inspect the resident for potential skin problems during bathing. a. True b. False 9. A basinless bath, also known as a bag bath, consists of a series of. a. water and soap rinses b. various chemical cleansing solutions c. moisturizers d. disposable washcloths 10. When assisting residents with bathing, CNAs should do all of the following, except. a. wipe up any water on the floor that may cause a fall b. close the door to the bathing area c. rub the skin dry d. use a bathing blanket to ensure privacy and warmth A supplement to CNA Training Advisor