2.2 Activities of Daily Living

ADLs Are Care Skills, Rights Questions, and Safety Questions

Activities of Daily Living (ADLs) are the routine self-care tasks a person normally does independently. On the 2024 NNAAP written outline they make up 22% of the exam, which is 13 of the 60 scored items. The listed sub-topics are hygiene/dressing/grooming, nutrition and hydration, elimination, and rest/sleep/comfort. Maryland's skills evaluation keeps ADLs concrete: bedpan use, denture care, dressing an affected side, a modified (partial) bed bath, feeding a dependent resident, mouth care, foot care, and perineal care are all testable hands-on skills.

A strong ADL answer respects the resident as a person before the task begins. Knock, identify the resident, explain what you will do, offer realistic choices, close the curtain or door, and expose only the area being cared for. If the resident can safely do part of the task, let them. Promoting independence is not slower care; under the Omnibus Budget Reconciliation Act of 1987 (OBRA), which governs nursing-home resident rights, maintaining the highest practicable level of function is a legal expectation, not a courtesy.

ADL Decision Table

A Safe ADL Sequence

1. Check the care plan. Mobility limits, diet texture, fluid restriction, the side affected by a stroke, catheter instructions, and skin precautions all come from the plan, not from habit.
2. Set up before starting. Gather linens, clothing, basin, gloves, trash bag, hygiene supplies, and any assistive device so the resident is never left exposed or unsafe mid-task.
3. Work clean before dirty. Wash eyes (inner to outer corner) and face before the rest of the body, use a clean section of the washcloth for each stroke, and save perineal care for last.
4. Support alignment and comfort. Move limbs slowly through their range, never force a joint, support above and below it, and stop if pain appears.
5. Finish with safety and reporting. Remove contaminated supplies, perform hand hygiene, lower and lock the bed, place the call signal within reach, and report any change to the nurse.

Nutrition, Refusals, and Elimination Traps

Aspiration, the entry of food or liquid into the airway, is the dominant feeding trap. The resident should sit upright at 75-90 degrees during the meal and stay upright for 30-60 minutes afterward if the plan requires. Offer small bites, alternate solids and liquids when appropriate, and watch for coughing, a wet or gurgly voice, food held in the cheek (pocketing), drooling, or sudden fatigue. Dysphagia is difficulty swallowing; if the plan orders thickened (nectar-, honey-, or pudding-thick) liquids, you must never substitute thin water, even if the resident asks.

Worked example: Mrs. Akin is on a mechanical-soft diet and coughs after two sips of juice, then holds rice in her left cheek. The correct action is to stop feeding, keep her upright and safe, and report the swallowing difficulty to the nurse. Larger bites or thin water would increase aspiration risk, and charting only the percentage eaten would hide a dangerous change.

Refusal is another frequent trap. A resident has the right to refuse a bath, a meal, or a clothing choice. The CNA does not threaten, force, bribe, or punish. Acknowledge the refusal, try to understand the concern, offer a reasonable alternative within the care plan (a different time, a shower instead of a tub), document per facility policy, and report to the nurse. Forcing care can constitute abuse.

Elimination and Skin Protection

Elimination care is both dignity care and infection prevention:

• Provide privacy, position the resident safely, and keep the call signal within reach during and after use.
• Perform female perineal care front to back, from the cleanest area (urinary opening) toward the rectum, using a clean section of cloth for each stroke.
• For catheter care, clean from the insertion site outward along the tubing for about 4 inches, never tugging the catheter, and keep the drainage bag below the level of the bladder so urine does not flow back.
• Change soiled briefs or linens promptly; do not wait for a convenient round when skin breakdown is a risk. Prolonged moisture and pressure cause pressure injuries, areas of skin and tissue damage over bony points.

Mouth, Denture, and Comfort Details

Provide oral care at least twice daily and after meals; for an unconscious resident, turn the head to the side and use minimal moisture to prevent aspiration. Clean dentures over a padded or water-filled basin so a dropped denture does not crack, and store them labeled in cool water (hot water warps them). For the exam, ADL excellence looks simple: talk to the resident, protect privacy, follow the plan, use clean technique, promote independence, observe skin and intake, and leave the resident safe with the call signal in reach.