2.2 Fundamentals of Nursing Care & Activities of Daily Living
Key Takeaways
- RCSI lists Fundamentals of nursing care as an OSCE station group with current examples of falls, intake including MUST, skincare including pressure areas, urinary elimination including related clinical procedures, and wound dressing using ANTT.
- Activities of daily living divide into basic ADLs - bathing, dressing, toileting, transferring, continence and feeding - and instrumental ADLs such as medication management, shopping, finances and transport.
- Fundamental care is the care most often rationed when a ward is busy, and omitted fundamental care is a recognised route to pressure injury, malnutrition, falls, incontinence-associated dermatitis and hospital-acquired infection.
- Every fundamental care episode carries an assessment opportunity: assisting with a wash is also a skin inspection, a mobility assessment and a cognitive assessment.
- Dignity, privacy, consent and choice are scored at these stations as heavily as technique, because NMBI Domain 1 requires the nurse to practise safely, compassionately and accountably.
Fundamentals of Nursing Care & Activities of Daily Living
RCSI names Fundamentals of nursing care as an OSCE station group and publishes its current examples: falls; intake including MUST; skincare including pressure areas; urinary elimination including related clinical procedures; and wound dressing using ANTT. Its reading list also points to material on activities of daily living and on what "fundamentals of care" means.
It is tempting to treat this as the easy chapter. It is not. Fundamental care is the care that gets rationed when a ward is short-staffed, and the harms that follow - pressure injuries, malnutrition, falls, incontinence-associated dermatitis, catheter-associated infection, dehydration and delirium - are precisely the harms Irish national standards, HIQA inspections and NMBI's Domain 1 are most concerned with. The RGN is accountable for this care whether or not the task itself was delegated.
What Counts as Fundamental Care
Fundamental care is the set of physical, psychosocial and relational needs that must be met for a person to be safe and comfortable, delivered in a way that respects the person. Three strands run through it:
- Relationship - trust, respect, dignity, being known by name, having choices honoured.
- Integration of care - the physical acts: nutrition and hydration, elimination, personal hygiene, mobility, comfort, rest and sleep, safety, skin integrity, communication.
- Context - the systems, staffing, leadership and culture that make it possible.
None of this is separable from the clinical task. Assisting someone to wash is a skin inspection; helping someone eat is a swallow and appetite assessment; walking someone to the toilet is a mobility and continence assessment.
Activities of Daily Living
The ADL framework is the assessment scaffolding for fundamental care.
| Basic ADLs (self-care) | Instrumental ADLs (independent living) |
|---|---|
| Bathing and showering | Managing medications |
| Dressing | Managing money and bills |
| Toileting and continence | Shopping for groceries |
| Transferring (bed to chair) | Preparing meals |
| Mobility and walking | Housekeeping and laundry |
| Feeding (the act of eating) | Using the telephone or technology |
| Personal hygiene and grooming | Using transport |
Why the distinction matters clinically: instrumental ADLs fail first. An older adult who has stopped managing their own medication or shopping is showing early functional decline long before they need help to wash. Discharge planning that only checks basic ADLs will send a person home who cannot collect a prescription or cook a meal.
Assess against the person's usual baseline, not against an abstract normal. "Independent" means independent for this person before this admission. A patient who normally walks with a stick and now needs two people has deteriorated, even though "walks with assistance" sounds unremarkable on its own.
Fundamental Care as Continuous Assessment
Build the assessment into the care rather than bolting it on afterwards.
| While you are... | You are also assessing... | Which feeds... |
|---|---|---|
| Assisting with a wash or shower | Skin integrity over the sacrum, heels, elbows and under devices; bruising; oedema; wounds; continence-related skin damage | The SSKIN bundle and the Waterlow score |
| Assisting at mealtimes | Appetite, swallow, dentition, how much was actually eaten, ability to use cutlery | The MUST score and the food and fluid chart |
| Assisting to the toilet | Gait, balance, urgency, frequency, dysuria, stool type on the Bristol chart, continence aids | Falls risk assessment and bowel or bladder care |
| Assisting with dressing | Upper limb function, dexterity, cognition, mood, fatigue | Discharge planning and occupational therapy referral |
| Repositioning | Pain on movement, skin, device pressure points, tolerance of activity | Pressure injury prevention and mobility planning |
Documentation Is Part of the Care
RCSI is explicit that candidates must be able to complete and interpret the documentation. For fundamental care that means the food and fluid chart, the MUST score, the repositioning or SSKIN chart, the bowel record, the falls risk assessment and the fluid balance chart. A nurse who gave excellent care and documented none of it has produced no evidence that the care happened - and in an OSCE, unwitnessed and unrecorded care is uncredited care.
Dignity, Privacy and Consent
These are scored, and they are easy marks to lose.
- Introduce yourself and your role. Use the person's preferred name, not "love" or "dear".
- Explain and gain consent before every element, including exposing a body area. Consent is ongoing, not a single permission at the start.
- Protect privacy: curtains fully closed, door closed, the person covered except for the area being cared for, visitors asked to step out.
- Offer choice wherever a real choice exists - wash or shower, now or after breakfast, which clothes, which hand.
- Preserve independence: do with, not for. Handing someone the flannel for their own face is better care than washing it for them, and it is also a functional assessment.
- Communicate throughout, particularly with a person who has dementia or delirium: short sentences, one instruction at a time, face them, allow time.
- Attend to the small things that mark whether care is person-centred: glasses and hearing aids in place, dentures in, mouth care done, hair brushed, call bell within reach, water within reach, the person left comfortable.
The Five Current Examples
| Example | The fundamental care task | The trap |
|---|---|---|
| Falls | Complete a falls risk assessment, address modifiable risks, orientate the patient, lower the bed, call bell in reach, appropriate footwear | Completing the assessment form and then changing nothing in the environment |
| Intake including MUST | Weigh and measure, calculate BMI, score unplanned weight loss and acute disease effect, total the score, act on the risk category, record intake accurately | Recording "diet taken" instead of what was actually eaten, or leaving a MUST score of 2 without a referral |
| Skincare including pressure areas | Inspect all pressure points, distinguish blanching from non-blanching erythema, stage any damage, apply the SSKIN bundle, reposition and document | Rubbing reddened skin, or treating non-blanching erythema as transient |
| Urinary elimination | Offer toileting, maintain dignity, measure and chart output, obtain specimens correctly, care for a catheter with a closed system and the bag below bladder level | Sampling from the drainage bag rather than the sampling port; leaving the bag resting on the floor |
| Wound dressing using ANTT | Clean the trolley, prepare the field, identify and protect key parts and key sites, use a non-touch technique, assess the wound, dress, dispose and document | Touching a key part and continuing; failing to declare and remedy a breach |
Delegation and Accountability
Much fundamental care is delivered with or by Healthcare Assistants. Under the NMBI Code and its scope of practice guidance, the registered nurse remains accountable for the decision to delegate: for judging that the task is appropriate to delegate, that the person is competent to perform it, that they have been given clear instruction, that supervision is available, and that the nurse evaluates what was recorded. Delegating the task never delegates the accountability, and "the HCA said she ate well" is not an intake assessment.
An 84-year-old man is admitted from home. He can wash and dress himself slowly but his daughter reports he stopped managing his tablets and shopping about four months ago. How should the nurse interpret this?
During a fundamentals of care station a candidate assists a patient with a bed bath. Which combination best demonstrates the standard expected?
A healthcare assistant records that a patient 'ate well' at lunch. The patient has a MUST score of 2. What is the registered nurse's responsibility?