6.3 Dressing, Undressing & Bedmaking
Key Takeaways
- When dressing a resident with hemiplegia, paralysis, or an affected side, the nursing assistant must always dress the AFFECTED (weak) side first and undress the UNAFFECTED (strong) side first (Mnemonic: DAF – Dress Affected First; TOW – Take Off Well first).
- Anti-embolic stockings (TED hose) must be applied while the resident is in the supine position in bed before rising, prior to the accumulation of dependent lower extremity venous pooling and edema.
- Correct TED hose application requires turning the stocking inside out down to the heel, easing it smoothly over the foot and leg without twists or bunched wrinkles, and strictly avoiding rolling or folding down the top band.
- Bedmaking procedures must distinguish between an occupied bed (made with the resident in it using side-lying turns and raised side rails) and an unoccupied bed (open bed with fan-folded linens vs. closed bed with bedspread pulled to the headboard).
- Infection control standards require rolling soiled linens inward with the contaminated side facing in, holding linens away from the CNA uniform, never placing linens on the floor or furniture, and immediately depositing them into a hamper.
Dressing, Undressing & Bedmaking
Assisting residents with dressing and maintaining clean, wrinkle-free bed linens are fundamental nursing assistant responsibilities that directly safeguard physical comfort, prevent hospital-acquired complications, and promote resident self-worth. Dressing allows individuals to express personal identity, autonomy, and cultural dignity, while proper bedmaking prevents shear forces, friction, and moisture accumulation that lead to debilitating pressure injuries.
To pass the Arizona Headmaster clinical evaluation and deliver high-standard care, the CNA must master the biomechanics of dressing residents with unilateral weakness (hemiplegia/stroke), the proper application and neurovascular monitoring of anti-embolic stockings, and rigorous infection-control protocols for soiled linen management.
1. Dressing & Undressing Residents with Hemiplegia
Residents who have suffered a Cerebrovascular Accident (CVA/stroke), traumatic brain injury, hip fracture, or neurological disorder frequently present with hemiplegia (total paralysis of one side of the body) or hemiparesis (unilateral weakness). Manipulating stiff, spastic, or flaccid limbs requires careful biomechanical technique to avoid joint dislocation, skin tears, or pain.
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| THE DRESSING / UNDRESSING CORE PRINCIPLES |
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| | DRESSING A RESIDENT | |
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| | Rule: DRESS THE AFFECTED (WEAK) SIDE FIRST | |
| | Mnemonic: DAF (Dress Affected First) | |
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| | [Step 1: Gather sleeve/pant leg] | |
| | [Step 2: Slip over AFFECTED (weak/stiff) limb gently] | |
| | [Step 3: Pull garment around back/torso] | |
| | [Step 4: Resident easily moves UNAFFECTED (strong) limb into hole] | |
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| | UNDRESSING A RESIDENT | |
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| | Rule: UNDRESS THE UNAFFECTED (STRONG) SIDE FIRST | |
| | Mnemonic: TOW (Take Off Well first / Take Off Weakest last) | |
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| | [Step 1: Remove garment from UNAFFECTED (strong/mobile) limb] | |
| | [Step 2: Creates slack in the garment across shoulders/chest] | |
| | [Step 3: Gently slide garment off AFFECTED (weak/stiff) limb] | |
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Clinical Rationale for DAF and TOW
- Why Undress Strong First (TOW)? The resident retains full range of motion and muscular control in their strong (unaffected) limb. Removing the sleeve or pant leg from the strong side first provides excess slack and fabric mobility across the torso. The CNA can then gently slide the garment off the stiff or paralyzed weak limb without pulling, twisting, or forcing the compromised joint.
- Why Dress Weak First (DAF)? Dressing requires threading an extremity through a narrow sleeve or pant opening. Putting the garment onto the paralyzed, stiff, or contracted weak limb first allows the CNA to support the limb at the joints and guide the fabric without resistance. Once the weak limb is positioned, the resident can easily bend, reach, and maneuver their mobile, strong limb into the remaining opening.
Procedural Protocol for Upper Body Dressing
- Choice & Dignity: Present two appropriate, weather-suitable clothing options and invite the resident to select what they wish to wear. Maintain privacy with a bath blanket.
- Undressing:
- Release all buttons, zippers, or fasteners.
- Slip the sleeve off the unaffected (strong) arm first.
- Slide the garment around the resident's back and gently ease it off the affected (weak) arm.
- Dressing:
- Bunch up the sleeve of the clean shirt.
- Support the resident's affected (weak) arm at the wrist and elbow, and slide the sleeve up the weak arm onto the shoulder.
- Assist the resident to lean forward or roll slightly, smoothly pulling the garment across the back.
- Instruct or assist the resident to insert their unaffected (strong) arm into the opposite sleeve.
- Fasten all buttons or closures, adjust the neckline, and ensure the garment is smooth and comfortable.
2. Anti-Embolic Stockings (TED Hose) Application & Assessment
Anti-embolic stockings (frequently referred to as TED hose — Thromboembolic Deterrent stockings) are specialized elastic garments designed to exert graded, graduated compression on the lower extremities. By compressing superficial veins, they increase venous blood flow velocity, enhance deep venous return to the heart, prevent venous stasis, and dramatically reduce the incidence of Deep Vein Thrombosis (DVT) and life-threatening Pulmonary Embolisms (PE) in immobile or surgical residents.
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| TED HOSE APPLICATION STEP-BY-STEP |
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| [Step 1: Verify Resident is Supine in Bed (Before Dependent Edema)] |
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| [Step 2: Inspect Skin for Redness, Open Sores, Warmth, Edema] |
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| [Step 3: Turn Stocking Inside Out Down to the Heel Pocket] |
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| [Step 4: Ease Foot Section Over Toes & Position Heel Pocket Under Heel] |
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| [Step 5: Gather & Smoothly Unroll Stocking Up Leg Over Calf/Thigh] |
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| [Step 6: Check: NO Wrinkles, NO Rolled Band, Toe Opening Clear] |
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Application Technique & Headmaster Checkpoints
- Timing of Application: TED hose MUST be applied early in the morning while the resident is resting supine in bed, before the resident dangles, stands, or sits in a chair. If the resident has already been upright, they must lie flat in bed with legs elevated for 15–20 minutes prior to application to allow pooled venous blood and edema to subside.
- Inversion Method:
- Reach inside the stocking and grasp the center of the heel pocket.
- Turn the stocking inside out down to the heel pocket, creating an easy pocket for the foot.
- Slip the foot portion smoothly over the resident's toes, instep, and heel, ensuring the heel pocket is centered precisely over the calcaneus (heel).
- Unrolling & Smoothing:
- Gently gather the remaining leg portion and smoothly unroll/slide the stocking up over the ankle, calf, and lower knee (or thigh, depending on length).
- ELIMINATE ALL WRINKLES: The stocking must be completely smooth and taut. Wrinkles create localized high-pressure ridges that can cut off microcirculation and induce pressure necrosis.
- The Top Band Warning:
[!CAUTION] Never Fold or Roll Down the Top Band: If a stocking is slightly long, NEVER fold, roll, or bunch down the top elastic cuff. Rolling the band creates a tight, constrictive elastic ring that functions like a tourniquet, cutting off arterial perfusion, obstructing venous return, and causing severe tissue ischemia.
- Neurovascular & Skin Circulation Checks:
- TED hose feature an inspection opening located under or over the toes.
- Assess the exposed toes at least once per shift for the 5 P's of neurovascular compromise: Pain, Pallor (pale/cyanotic color), Paresthesia (numbness/tingling), Poikilothermia (cool skin temperature), and Pulselessness/delayed capillary refill (> 3 seconds).
- Remove stockings at least once daily (or per care plan) during bathing to wash, dry, inspect the skin, and allow tissue reperfusion.
3. Bedmaking Protocols: Occupied vs. Unoccupied Beds
Bedmaking is not merely aesthetic; clean, tightly stretched, dry linens prevent shear forces, reduce bacterial reservoirs, and protect fragile skin from friction-induced breakdown.
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| BEDMAKING CLASSIFICATIONS |
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| | OCCUPIED BED | | UNOCCUPIED BED | |
| | - Resident remains in the bed | | - Resident out of bed | |
| | - Side-lying turning protocol | | - Complete linen overhaul | |
| | - Side rail raised on turn side | | - Mitered corners on bottom | |
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| | OPEN BED | | CLOSED BED | |
| | - Top linen fan-folded down | | - Bedspread pulled to | |
| | to foot of mattress | | headboard over pillow | |
| | - Ready for resident return | | - Ready for new admit | |
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Occupied Bedmaking Step-by-Step
- Preparation & Safety: Ensure resident privacy. Raise the bed to waist-working height. Lower the head of the bed flat (if tolerated). Keep the side rail UP on the side toward which the resident will turn.
- Turning the Resident: Assist the resident to turn onto their side facing the raised side rail. Drape with a bath blanket.
- Loosening & Rolling Soiled Linen:
- Loosen the bottom sheets on your working side.
- Roll the soiled bottom sheet, draw sheet, and incontinence pad inward toward the resident's back, tucking the roll snugly against their spine.
- Placing Clean Bottom Linens:
- Apply the clean fitted sheet (or mitered flat sheet) to the mattress corners on your side.
- Fan-fold or roll the remaining clean linen lengthwise toward the resident, tucking it under the soiled roll.
- Rolling Over the Hump:
- Raise the side rail on your side. Move to the opposite side of the bed.
- Assist the resident to roll over the central linen roll onto the clean side, facing the newly raised side rail.
- Lower the side rail on your new working side. Carefully remove the soiled linen roll, rolling it inward, and deposit it immediately into the linen hamper.
- Pull the clean bottom linens smoothly through from under the resident, stretching them taut, and secure the remaining mattress corners.
- Top Linens & Toe Pleat:
- Assist the resident back onto their spine. Place clean top sheet and blanket over the resident while withdrawing the bath blanket from underneath.
- Miter the bottom corners of the top sheet.
- Toe Pleat (Slack): Grasp the top covers over the resident's toes and pull upward 2 to 3 inches to create a loose pleat. A tight top sheet exerts constant downward pressure on the toes, leading to skin breakdown on the heels/toes and contributing to permanent foot drop (plantar flexion contracture).
- Pillowcase Replacement: Remove soiled pillowcase by turning it inside out. Hold clean pillowcase bunched in one hand, grasp center of pillow end, and pull pillowcase smoothly over pillow. Never hold a pillow under your chin or against your uniform.
4. Linen Handling & Infection Control Standards
Linen management in healthcare facilities is strictly governed by CDC and OSHA infection-control standards to prevent the transmission of nosocomial pathogens (such as Clostridioides difficile, MRSA, and Norovirus).
| Infection Control Rule | Procedural Standard | Clinical Rationale |
|---|---|---|
| Carrying Technique | Always hold clean and soiled linens away from your body and uniform (arms extended). | Uniforms act as vectors; hugging linens transfers pathogenic microorganisms from clothing to clean linen or from dirty linen to clothing. |
| Soiled Linen Rolling | Always roll soiled linen inward, with the most contaminated/dirty side facing inward inside the roll. | Traps body fluids, excretions, shed skin cells, and microorganisms inside the bundle, preventing environmental contamination. |
| Prohibited Placements | NEVER place soiled linen on the floor, on overbed tables, or on clean chairs. | Placing linen on the floor spreads pathogens to flooring and footwear; placing on furniture contaminates eating and dressing surfaces. |
| Disposal & Agitation | Place soiled linen directly into the laundry hamper bag inside the room. NEVER shake linens in the air. | Shaking linens aerosolizes dust, skin flakes, and pathogenic spores into the air, causing airborne microbial dispersal. |
| Excess Linen Rule | Never return unused clean linen taken into a resident's room back to the clean linen supply closet. | Once clean linen enters a resident's room, it is deemed biologically exposed/contaminated and must be laundered. |
A nursing assistant is assisting a resident who is recovering from a left-hemisphere stroke with resultant right-sided hemiparesis to change into daytime clothing. Which sequence must the CNA follow?
When applying knee-high anti-embolic stockings (TED hose) to an immobile resident, which clinical action represents the correct standard of care?
During occupied bedmaking, how must the nursing assistant handle soiled bed sheets to adhere to CDC and OSHA infection-control standards?