Section 6.2: Dressing & Oral Hygiene (including Unconscious Care)

Assisting residents with dressing and oral hygiene are core direct care responsibilities that significantly impact physical health, infection prevention, self-esteem, and legal rights. Certified Nursing Assistants (CNAs) in Iowa must execute these tasks with clinical precision, utilizing techniques designed to prevent injury and aspiration, while complying with federal and state regulations regarding resident dignity and autonomy.

Dressing and Undressing: Clinical Principles and Resident Rights

Assisting a resident with dressing is not merely a task of putting on clothes; it requires understanding musculoskeletal limitations and respecting personal choice. Many residents in long-term care facilities suffer from hemiparesis (weakness on one side) or hemiplegia (paralysis on one side) due to cerebrovascular accidents (strokes), arthritis, or fractures.

The Affected vs. Unaffected Side Rules

To prevent pain, joint strain, and skin tears, CNAs must follow two critical clinical rules when dressing and undressing residents with one-sided weakness:

1. Dressing - Dress Affected First (DAF): When putting on clothing, always dress the affected (weak) limb first. Because the affected limb has limited range of motion and strength, dressing it first allows the CNA to gently guide the sleeve or pant leg over the restricted joints without overextending them. Once the weak side is dressed, the resident can easily assist in moving the strong (unaffected) side into the garment.
2. Undressing - Remove Unaffected First (RUA): When taking off clothing, always remove the garment from the strong (unaffected) side first. Removing the clothing from the strong side creates maximum slack in the material. This extra fabric makes it simple to slide the garment off the weak side without pulling, tugging, or causing discomfort to the restricted joints.

Promoting Independence and Iowa Legal Mandates

Under Iowa Administrative Code 441 Chapter 81, residents have a legal right to self-determination and choice.

• Resident Choice: The CNA must offer the resident a choice between at least two outfits. Choosing their own clothing promotes cognitive engagement and self-esteem.
• Encouraging Autonomy: Allow the resident to do as much as possible for themselves, such as pulling up sleeves, fastening Velcro closures, or choosing accessories. CNAs must resist the urge to rush the resident, as promoting independence helps maintain joint mobility and cognitive function.
• Privacy and Dignity: Always pull the privacy curtain, close the door, and keep the resident covered with a bath blanket or towel during the process, exposing only the parts of the body necessary to complete the task.

Oral Hygiene for the Conscious Resident

Oral hygiene is vital for preventing periodontal disease, systemic infections, and promoting nutritional intake. Neglecting oral care can lead to painful cavities, gum infections (gingivitis), and can even impact blood glucose control in diabetic residents. Oral care should be performed at least twice daily (morning and night), and after meals if preferred by the resident.

• Brushing Technique: Place the toothbrush at a 45-degree angle to the gum line. Brush in short, circular strokes from the gums to the crown of the teeth. Clean all outer, inner, and chewing surfaces. Gently brush the tongue to remove bacteria and food particles that cause halitosis (bad breath).
• Equipment: Provide water for rinsing, an emesis basin to spit into, and a towel to protect the resident's clothing.

Denture Care and Protection

Dentures are expensive, custom-fitted prosthetic devices. If they are broken, a resident may be unable to eat a regular diet, leading to nutritional deficiencies.

1. Basin Protection: Before handling dentures, place a clean washcloth or paper towel at the bottom of the sink basin and fill the sink with a few inches of cool water. If the dentures slip out of the CNA's hands, the water and washcloth act as a cushion to prevent them from cracking.
2. Water Temperature: Always wash and rinse dentures in cool or tepid water. Never use hot water, as it can warp the acrylic structure of the dentures, permanently ruining their fit and causing oral pain or ulcers when worn.
3. Storage: When not in the resident’s mouth (typically overnight), dentures must be stored in a labeled denture cup filled with cool water or a denture cleaning solution. Allowing dentures to dry out causes them to warp and crack.

Oral Hygiene for the Unconscious Resident

Unconscious residents are at extreme risk for oral infections and aspiration. Because they cannot swallow, saliva and oral secretions can pool in the back of the throat. If these fluids enter the lungs, they can cause aspiration pneumonia, a life-threatening infection.

Positioning and Safety Protocols

Oral care for an unconscious resident must be performed at least every two hours to keep the oral mucosa moist and clean.

• Lateral Positioning: The resident must be placed in a lateral (side-lying) position with their head turned toward the side facing the CNA. If permitted by the care plan, the head of the bed should be flat or slightly elevated. This positioning uses gravity to drain fluids out of the mouth and into an emesis basin placed under the cheek, preventing fluid from flowing back into the trachea.
• Minimal Moisture: Use pre-moistened oral swabs (tootlettes). Squeeze out all excess fluid before introducing the swab into the mouth. The swab must be damp, not dripping. Never use a standard toothbrush or pour water into an unconscious resident’s mouth.
• Technique: Gently wipe all oral surfaces, including the teeth, gums, tongue, inner cheeks, and roof of the mouth. Apply a water-soluble lubricant to the lips to prevent cracking.
• Safety Trap: Never place your fingers inside an unconscious resident's mouth. Unconscious individuals can exhibit a reflexive bite reflex, which can result in severe injury to the CNA. Use a padded tongue blade or swab to hold the mouth open if necessary.