7.3 Dressing, Bedmaking & Elimination Assistance
Key Takeaways
For unilateral weakness, dress the affected side first and undress the unaffected side first while supporting vulnerable joints.
Separate clean and soiled linens, use the required turning assistance, smooth wrinkles, and leave comfortable space for feet.
Choose the assigned bedpan or commode and follow movement restrictions; remove a bedpan promptly when the resident is finished.
Keep a catheter system closed, tubing free of traction/kinks, and the drainage bag below the bladder and off the floor.
7.3 Dressing, Bedmaking & Elimination Assistance
Assisting residents with dressing, bedmaking, and elimination are core certified nursing assistant (CNA) duties that safeguard physical comfort, skin integrity, and dignity. Residents in long-term care frequently cope with hemiparesis, contractures, or incontinence. By mastering specialized mobilization techniques—such as dressing affected limbs first, executing occupied linen changes with pressure-relieving comfortable loose top linens, and maintaining closed catheter systems—the CNA actively prevents musculoskeletal trauma, pressure injuries, and infections.
Dressing and Undressing Principles for Hemiplegia
A stroke or injury often causes hemiplegia (paralysis) or hemiparesis (unilateral weakness). Attempting to dress or undress a compromised extremity without proper biomechanics risks joint dislocation, severe pain, and skin tears.
Cardinal Dressing Mnemonics
- DAF — Dress Affected First: When dressing, slide garment sleeves or pant legs onto the affected (weak/paralyzed) extremity first, then guide the unaffected (strong) extremity into the garment. The weak limb has restricted mobility; dressing it first requires minimal joint manipulation. The mobile, unaffected arm easily flexes into the remaining sleeve without strain.
- UAF — Undress Unaffected First: When undressing, remove clothing from the unaffected (strong) extremity first, and slip the sleeve off the affected extremity last. Removing clothing from the strong limb first creates maximum slack in the fabric, allowing the CNA to slide the garment off the paralyzed arm gently without traction.
Resident Choice and Adaptive Aids
Federal OBRA regulations require honoring resident choice in clothing selection. Always encourage residents to select daily attire. Incorporate adaptive dressing devices to foster independence:
- Button Hooks & Zipper Pulls: Assist residents with arthritis or tremors to manipulate fasteners.
- Sock Aids & Long-Handled Shoehorns: Enable residents to put on socks and shoes without bending hips past 90 degrees or losing balance.
Occupied Bedmaking Procedure & Pressure Relief
An occupied bed must be changed when linens are soiled, wet, or wrinkled to prevent skin breakdown.
Occupied Linen Change Protocol
- Preparation: Explain procedure, provide privacy, lock casters, and raise bed to waist level. Lower near side rail; use the care-plan fall-prevention method on the far side, with a second worker or permitted rail as appropriate; never leave the resident unsupported.
- Bath Blanket: Place clean bath blanket over top sheet; slide soiled sheet out from underneath to preserve warmth and modesty.
- Lateral Turning & Linen Removal: Turn resident to lateral position facing away. Loosen bottom linens on working side. Roll soiled linens inward toward resident back, tucking roll snugly against body.
- Clean Bottom Linens: Apply clean bottom fitted sheet on working side. Fanfold clean draw sheet and underpad toward center, tucking under soiled roll.
- Rolling Across Linens: Assist resident to roll over linen roll onto clean side.
- Removing Soiled Linens: Move to opposite side, lower rail, roll soiled linens inward, and place immediately into laundry hamper. Never place soiled linens on floors or chairs.
- Smoothing Foundation: Pull clean linens across mattress, pulling every layer completely taut to eliminate wrinkles, and secure corners.
- Pressure-Relieving Toe Pleat: Return resident to supine position. Place clean top sheet and blanket over resident. At foot of bed, pull top linens upward 2 to 3 inches over toes to create a toe pleat (or foot pleat) before tucking corners.
- Clinical Rationale: Tight sheets press downward continuously on feet, causing heel excoriation, toe pressure sores, and discomfort or restricted ankle movement; persistent plantar-flexion positioning can contribute to contracture.
Elimination Assistance: Bedpan Selection & Commode Use
Prompt toileting assistance preserves continence, protects skin, and prevents falls.
| Equipment Type | Physical Design | Clinical Indications & Placement |
|---|---|---|
| Standard Bedpan | Deep, contoured bowl with a wide seat. | For residents who can safely flex knees and raise hips. Placed with wide end under buttocks and narrow end toward feet. |
| Fracture Pan | Shallow, flat wedge with thin, beveled rim and handle. | Often selected for residents unable to lift their hips, according to the care plan and movement restrictions. Placed with flat, low edge under buttocks and handle pointing toward foot of the bed. Reduces the need to raise the hips; it does not by itself guarantee compliance with surgical restrictions. |
Urinals & Bedside Commodes
- Urinals: Position between thighs with penis inside opening. Close cap after voiding, check urine clarity, empty into graduate, and never place urinals on overbed tables.
- Bedside Commode: A portable chair frame with toilet seat and bucket. Position alongside bed, lock wheels, ensure non-skid footwear, and transfer using a gait belt. Never leave an unsteady resident unattended.
Indwelling Foley Catheter Care & CAUTI Prevention
An indwelling urethral (Foley) catheter creates an open conduit for bacteria, representing the primary cause of Catheter-Associated Urinary Tract Infections (CAUTIs).
Cleansing Protocol
- Perform catheter care during morning hygiene, after bowel movements, or when soiled. Don gloves.
- Expose perineum. Stabilize catheter tubing with non-dominant hand at urinary meatus to prevent tension on retention balloon.
- Using a warm soapy washcloth, cleanse gently downward away from urinary meatus along tubing for at least 4 inches (10 centimeters).
- Use a clean cloth surface per stroke. Never push tubing backward toward meatus or wash toward body, which can carry contamination toward the urinary opening. Rinse downward and pat dry.
Closed System Maintenance & Positioning Rules
- Continuous Gravity Drainage: Drainage bag must remain below level of bladder at all times. Raising it above bladder level can cause backflow and increase infection risk; report an accidental disconnection or other system breach.
- Bed Frame Attachment: Suspend drainage bag from designated support on the bed frame. Never attach bag to movable side rail, where rail movement can pull catheter or elevate bag above bladder.
- Tubing Security & Patency: Secure tubing to upper inner thigh (or lower abdomen in males) with anchor device, leaving slack for leg movement. Route tubing over thigh, never under legs where weight occludes flow. Ensure tubing is free of kinks.
- Emptying Technique: Empty drainage bag at shift end or when two-thirds full into calibrated graduate without allowing spout to touch container rim. Wipe spout with alcohol swab before reclamping. Measure urine at eye level and document output.
Sources checked October 16, 2026
South Dakota required care skills; CDC oral health toolkit; NIDDK bladder training.
A certified nursing assistant is assisting a resident who has residual right-sided hemiplegia from a cerebrovascular accident to get dressed for the day. Which procedure must the CNA implement when changing the resident's shirt?
Remove the soiled shirt from the paralyzed right arm first, and put the clean shirt onto the strong left arm first
Pull the soiled shirt over both arms simultaneously, and force the clean sleeves onto both wrists while extending the elbows
Remove the shirt from the unaffected left arm first (UAF), and put the clean shirt onto the affected right arm first (DAF)
Instruct the resident that clothing cannot be changed until full motor strength returns to the hemiplegic extremity
A resident's postoperative care plan specifies a low-profile fracture pan and assisted rolling for bed toileting. How should the CNA position the pan?
A standard deep bedpan placed with the high contoured end under the lower thighs and the narrow end toward the head of the bed
A standard metal bedpan placed while instructing the resident to pull their left knee tightly against their chest
A bedside commode placed across the room, requiring the resident to bear full weight on the unhealed hip joint
A fracture pan placed with the shallow, flat edge under the buttocks and the handle pointing toward the foot of the bed
A nurse aide is providing morning hygiene and bed care for a resident with an indwelling Foley catheter. Which catheter maintenance practice is essential to prevent catheter-associated urinary tract infections (CAUTIs)?
Cleanse the catheter tubing at least four inches downward away from the urinary meatus with soap and water, and maintain the drainage bag below bladder level on the bed frame
Hang the urinary drainage bag on the highest point of the movable side rail to facilitate fast drainage into the graduate
Disconnect the catheter tubing from the drainage bag every two hours to flush the bladder with sterile tap water
Wipe the catheter tubing vigorously toward the urinary meatus using a single unrinsed washcloth surface
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