4.1 Activities of Daily Living & Personal Care
Key Takeaways
Wash from cleanest to dirtiest: eyes first (inner to outer canthus, no soap, new cloth area per eye), perineal area last during a complete bed bath
Dressing rule: put clothing onto the weak (affected) side first, remove from the strong (unaffected) side first ('weak goes in first, strong comes out first')
Perineal care for females is always front to back (clean to dirty) to prevent urinary tract infection; for males clean from the tip outward and return a retracted foreskin
For an unconscious resident, give oral care every 2 hours with the head turned to the side, a padded tongue blade, and a small amount of solution to prevent aspiration
Reposition at least every 2 hours in bed; in a wheelchair, shift weight more often (MedlinePlus says every 15 to 20 minutes); the earliest pressure-injury sign is a reddened area that does not fade (Stage 1) — report it
What ADLs Are and Why They Matter
Activities of daily living (ADLs) are the routine self-care tasks a person normally performs without help: bathing, dressing, grooming, oral care, toileting, and eating (transferring and mobility are sometimes added). New Jersey CNAs assist with ADLs while protecting the resident's dignity, privacy, and independence — the federal Nursing Home Reform Act and NJ's resident-rights rules require that residents do as much for themselves as they safely can. The CNA's job is to assist, not take over.
ADL concepts support nurse aide care and preparation. For the official test assignment, use the current NJ bulletin: hand washing first, then four random tasks from its 22-task list. Use the task-specific scoring rules; a NNAAP 23-skill list, mandatory measurement assignment and 30-minute timer are not asserted here.
Bathing
Bathing cleans the skin, improves circulation, and gives the CNA a chance to observe the whole body for bruising, rashes, or breakdown. The two common methods are the complete bed bath (for fully dependent residents) and the partial bath (face, hands, axillae, and perineal area).
The Clean-to-Dirty Rule
Always wash from the cleanest area to the dirtiest. This prevents spreading microorganisms.
| Order | Body Area | Key Point |
|---|---|---|
| 1 | Eyes | Inner to outer corner, no soap, new section of cloth per eye |
| 2 | Face, neck, ears | Ask whether the resident wants soap on the face; the New Jersey partial bed bath task washes the face without soap |
| 3 | Arms, hands, axillae | Wash the farthest part first; support the joint |
| 4 | Chest and abdomen | Keep the resident covered with a bath blanket |
| 5 | Legs and feet | Check between the toes; do not massage the calves |
| 6 | Back and buttocks | A good time to inspect for skin breakdown |
| 7 | Perineal area | Always last — cleanest to dirtiest |
Keep water at about 105°F (40.5°C), test it before use, change it when it becomes cool or soapy, and dry the skin thoroughly, especially in skin folds where moisture causes breakdown. Do not massage the legs — this can dislodge a blood clot (thrombus).
Oral Care
Oral hygiene prevents tooth decay, gum disease, and aspiration pneumonia. Provide it at least twice daily and after meals.
- Dentures: Hold them over a towel or a water-filled basin while cleaning so they do not break if dropped, use cool or tepid water (the New Jersey denture task says tepid), and store them in a labeled cup of cool or tepid water or denture solution — never hot water, which warps them.
- Unconscious resident: Turn the head to the side so fluid drains out, use only a small amount of solution on swabs, and use a padded tongue blade — never your fingers — to keep the mouth open. Because the mouth dries out, provide care every 2 hours.
Grooming and Dressing
Grooming includes hair care, shaving, and nail care. Shave in the direction of hair growth with a safety razor; an electric razor is required for a resident on blood thinners (anticoagulants) because of bleeding risk. Never use an electric razor near oxygen.
The Affected-Side Rule
For a resident with weakness or paralysis on one side (for example, hemiplegia after a stroke):
- Dressing: put clothing on the weak (affected) side first.
- Undressing: remove clothing from the strong (unaffected) side first.
Memory aid: "weak goes in first, strong comes out first." This reduces strain on the impaired limb and protects the joint, and dressing a resident with a weak arm should be practised using the applicable current New Jersey task instructions.
Perineal Care
Perineal (peri) care cleans the genital and anal area and reduces infection. For females, always wipe front to back (urethra toward anus), using a clean section of cloth with each stroke, to prevent a urinary tract infection (UTI). For males, clean in a circular motion from the tip of the penis outward; on an uncircumcised resident retract the foreskin, clean, then return it to prevent swelling. Peri care is given daily, after every incontinence episode, and as part of catheter care.
Nail and Foot Care
Clean under the nails and file straight across to prevent ingrown nails. Do not cut the toenails of a resident with diabetes or poor circulation — a small nick can become a serious, slow-healing wound. Nurse aide training teaches this (Indiana's state curriculum says only a nurse or physician should do so), and New Jersey's curriculum leaves nail care to facility policy, so report long nails to the nurse.
Skin Care and Pressure-Injury Prevention
A pressure injury (pressure ulcer, decubitus ulcer, or bedsore) forms over a bony prominence — sacrum, heels, hips, elbows, shoulder blades, back of the head — when prolonged pressure cuts off blood flow. Prevention is a core CNA duty:
- Reposition at least every 2 hours in bed (New Jersey's rule for nonambulatory residents). In a wheelchair, shift weight more often; MedlinePlus says every 15 to 20 minutes. Follow the posted turning schedule.
- Keep skin clean and dry; change wet or soiled linens promptly.
- Reduce friction and shearing — lift the resident with a draw sheet, never drag.
- Use pillows, heel protectors, and padding to keep bony areas off the bed; keep linens wrinkle-free.
- Encourage fluids and good nutrition, which keep skin healthy.
- Report the earliest sign immediately: a reddened area that does not fade (blanch) after pressure is relieved — this is a Stage 1 pressure injury. Catching it early prevents an open Stage 2-4 wound.
AM and PM Care
Routine care is grouped by time of day:
- Early AM care (before breakfast): toileting, washing the face and hands, oral care.
- AM (morning) care: a bath or partial bath, grooming, dressing, and bed-making.
- PM (HS / evening) care (bedtime): oral care, washing, a back rub for circulation and comfort, fresh linens, and a comfortable, safe position with the call light within reach.
Throughout all care, knock, address the resident by their preferred name, explain each step, keep the body covered except the area being washed, and let the resident make choices — use the current task-specific checklist to identify which actions are scored or designated key steps on the skills exam.
A New Jersey CNA is dressing a resident who had a left-side stroke and has left arm weakness. The resident is putting on a button-up shirt. Which arm should the CNA place into the sleeve first?
The right (strong) arm first, because it has full movement
The left (weak) arm first, then the right arm
Whichever arm the resident points to
Both arms at the same time to save time
During a complete bed bath for a New Jersey nursing home resident, the CNA notices the water has become cool and slightly soapy halfway through. The resident's perineal area has not yet been washed. What is the BEST action?
Finish quickly with the same water so the resident does not get chilled
Skip the perineal area and let the next shift complete it
Change the water before continuing, then wash the perineal area last
Use the cool water only for the perineal area to save time
A resident with diabetes asks the CNA to trim his thickened, overgrown toenails. What is the correct response?
Explain that you don't cut a diabetic resident's toenails and report it to the nurse, following facility policy
Trim them carefully with clean nail clippers since the resident requested it
File them straight across but do not cut, then document only
Soak the feet and cut the nails after they soften
While giving mouth care to an unconscious resident, which action BEST protects the resident from aspiration?
Lay the resident flat on the back and use plenty of fluid
Hold the mouth open with a gloved finger to work faster
Skip oral care because the resident cannot eat or drink
Turn the resident's head to the side and use only a small amount of solution
Sections you finish are checked off in the contents.