Hygiene and Grooming Skill Tasks

The Universal Opening and Closing

Almost every Montana hygiene checklist opens and closes with the same scored steps. Drill them until they are automatic, because they are free points on every task you draw:

Opening: perform hand hygiene, explain the procedure to the resident, provide for the resident's privacy, gather and set up equipment, and put on gloves whenever you will contact body fluids, mucous membranes, or non-intact skin.

Closing: place soiled linen in the linen hamper; empty, rinse, dry, and return equipment to storage; remove gloves by turning them inside out and discard them in a trash container; perform hand hygiene; leave the resident in a position of comfort; and leave the call light or signaling device within easy reach. One more step runs the length of every checklist: maintain respectful, courteous interpersonal interactions at all times.

On the randomly selected tasks, 'perform hand hygiene' means alcohol-based hand sanitizer — cover all surfaces of the hands and rub them together until they are completely dry. On the four mandatory tasks, a full soap-and-water wash is embedded at the end.

The Embedded Soap-and-Water Hand Wash

Montana no longer scores hand washing as a standalone first task. Instead it appears as a long block of steps at the end of each mandatory task — bedpan, urinary drainage bag, and both perineal care tasks — and it is worth more scored steps than most whole tasks. The sequence:

1. Turn on the water and thoroughly wet your hands.
2. Apply soap and rub your hands together using friction.
3. Keep that friction going for at least twenty seconds with soap.
4. Rub interlaced fingers together while pointing downward, still with soap.
5. Wash all surfaces of your hands with soap, then wash your wrists with soap.
6. Rinse your hands and then your wrists thoroughly under running water with fingers pointed downward.
7. Dry your hands with clean paper towels and discard each towel as it is used.
8. Turn off the faucet with a clean, dry paper towel, then discard it.
9. Do not re-contaminate your hands at any time by touching the faucet or sink during or after the procedure.

The downward-pointing fingers matter twice — once during the interlaced-finger scrub and again during the rinse — because water must run from the cleaner wrists off the dirtier fingertips, not back up your arms.

Partial Bed Bath: Face, One Underarm, One Hand

Cover the resident with a bath blanket, fan-fold the top linens to the bottom of the bed or set them aside, remove the gown, and place it in the hamper. Then follow Montana's order:

• Face first, with water and no soap, then dry the face.
• Place a towel under one arm; wash the hand with water and soap, rinse it, and dry it.
• Wash the underarm with water and soap, rinse it, and dry it.

Finish by putting a clean gown on the resident, clearing the linen, returning the basin, lowering the bed, and placing the call light in reach.

Perineal Care for a Female Resident (Mandatory Task, on a Manikin)

Fill a basin with comfortably warm water, adjust the bed to a working height, glove up, and place a waterproof pad under the resident's buttocks. Expose the perineum only. Separate the labia — and verbalize that you are separating them while you actually do it, so the observer can see the step. Clean one side of the labia from top to bottom, using a clean portion of the washcloth or a fresh disposable wipe for each stroke, then repeat on the other side the same way. Pat the perineum dry, re-cover with the bath blanket, and turn the manikin onto her side away from you. Clean the rectal area with single strokes running from the vagina toward the rectum, again with a clean portion for every stroke, and pat dry in the same direction. Remove the waterproof pad, clear the linen, remove gloves — then the embedded hand wash.

Perineal Care for an Uncircumcised Male + Adult Brief (Mandatory Task, on a Manikin)

Montana adds one step at the very start that candidates forget: choose the correct brief and size per facility instructions before you set up. Then privacy, warm water, working height, gloves, waterproof pad.

Gently grasp the penis and demonstrate retracting the foreskin. Clean the tip using single strokes starting at the urethral opening and working outward in a circular motion, a clean portion of the washcloth each stroke. Clean the shaft with single firm downward strokes from the tip toward the base, then the scrotum, always with a clean portion each time. Pat dry — and then demonstrate replacement of the foreskin. Both the retraction and the replacement are scored; leaving a foreskin retracted can constrict blood flow.

Turn the manikin onto his side away from you and clean away from the scrotum toward the rectal area with single strokes, then pat dry in that direction. Apply the brief: place it under the buttocks with the top of the absorbent pad aligned just above the buttocks crease, stretch the leg portion of the front panel to extend the elastic into the groin, roll the ruffles away from the groin, fasten the bottom tabs angled toward the abdomen, then the top tabs angled toward the bottom tabs. Two closing steps are verbal: state that the brief should be checked every two hours, and that it is changed as needed following facility toileting and bowel-and-bladder protocol. Then the embedded hand wash.

Denture Care

Line the sink with a washcloth or towel — Montana's checklist says in so many words that no paper towels are allowed for this. Glove up, remove the denture from its cup, handle it carefully, and rinse the denture cup while the denture is out. Apply denture cleanser or cream to the brush and thoroughly brush the inner, outer, chewing, and upper/lower surfaces in turn. Rinse the denture with clean, cool water, place it in the rinsed cup, and add cool, clean water to the cup. Cool water throughout: hot water warps denture material.

Mouth Care (Brushing Teeth)

Privacy, towel across the chest, gloves. Wet the toothbrush, apply toothpaste, and brush the inner surfaces, outer surfaces, and chewing surfaces of the upper and lower teeth — then gently brush the tongue, a step candidates routinely miss. Assist the resident in rinsing, wipe the mouth, clear the linen, empty and rinse the emesis basin (or discard disposables), rinse the toothbrush, and return the equipment.

Mouth Care for a Comatose Resident

There is no 'explain the procedure' greeting in this checklist, but there is a hard safety step: position the resident in a side-lying position to avoid choking or aspiration. Drape the chest, glove up, and use toothettes with prepared mouthwash solution or water, squeezing out the excess. Clean the inner, outer, and chewing surfaces, then the gums, then the tongue and the roof (palate) of the mouth. Dip a new toothette in clean water, rinse the mouth with it, wipe the mouth, and return the resident to a position of comfort and safety.

Nail Care (One Hand)

After privacy, Montana scores locking the wheelchair brakes for safety. Obtain comfortably warm water and immerse the nails of one hand for at least five minutes — then verbalize the five-minute soak time to the RN Test Observer once the soak has begun, because the observer cannot score a clock you keep in your head. Clean under the nails with a file, orange stick, or nail brush; dry the hand thoroughly and specifically dry between the fingers; gently push the cuticle back with a washcloth, towel, or orange stick. Two closing steps are purely verbal: state the technique you would use to cut the resident's nails, and state the technique you would use to file them. You are not asked to cut them on the manikin-free hand of a live actor — but you must say how you would.

Foot Care (One Foot)

Fill a basin with comfortably warm water, remove the sock from one foot, and immerse the foot for 10 to 20 minutes — then verbalize the 10-to-20-minute soaking time to the observer. Remove the foot from the water, and with a soapy washcloth wash the entire foot and between the toes, then rinse the entire foot and between the toes. Dry thoroughly, being careful to dry between the toes, where trapped moisture breeds fungal infection. Warm the lotion by rubbing it between your hands, massage it over the entire foot, wipe any excess with a towel, and replace the sock. Leave the resident in proper alignment in the chair.

Dressing a Resident with an Affected (Weak) Side

Keep the resident covered at all times while you work. Remove the gown from the unaffected (strong) side first and place it in the hamper. Then, starting from the affected (weak) side, dress the resident in a shirt or blouse by putting your hand through the sleeve and grasping the resident's hand to guide it through. For pants, again starting from the weak side, help the resident raise the buttocks or rock side to side and draw the pants over the buttocks up to the waist. Draw socks up until they are smooth. Memory aid: weak first on, strong first off.