Section 6.3: Dressing & Toileting

Dressing & Toileting

Assisting residents with dressing and toileting is a core responsibility of the Certified Nursing Assistant (CNA). These activities are deeply personal and directly affect a resident's sense of dignity, independence, and physical safety. Proper techniques in dressing prevent joint injury and pain, while safe toileting support reduces the risk of falls and prevents skin breakdown associated with incontinence.

Dressing and Undressing a Resident with a Weaker Side

Many residents in long-term care suffer from one-sided weakness or paralysis (hemiplegia), often due to a stroke (cerebrovascular accident or CVA), brain injury, or joint surgery. When assisting these residents, the CNA must follow a strict sequence to prevent pain, muscle strain, and joint dislocation.

The DAF / USF Rule

The CNA must remember two critical acronyms for dressing and undressing a resident with physical limitations:

• Dress Affected First (DAF): When putting clothes on, always begin with the affected (weaker) limb. Because the clothes are loose at the start, you can easily slide the sleeve or pant leg over the restricted limb and guide it into place without forcing the joint. Once the weaker limb is dressed, the resident can easily use their stronger, flexible limb to slide into the remaining side of the garment.
• Undress Stronger First (USF): When taking clothes off, always begin with the stronger (unaffected) limb. Removing the clothing from the fully functional side first creates extra space and fabric slack. You can then gently slide the garment off the weaker, stiffer limb without pulling, twisting, or putting pressure on the compromised joints.

Step-by-Step Dressing Procedure

1. Resident Choice: Offer the resident a choice between at least two outfits. Choosing their own clothing promotes autonomy and cognitive engagement.
2. Privacy: Keep the resident covered with a bath blanket, exposing only the body parts being dressed.
3. Sleeve/Pant Application:
   • To dress the upper body: Gather the sleeve of the shirt/gown, support the resident's weaker arm at the joints, and slide the sleeve onto the weaker arm first (DAF). Guide the garment over the head/back, and then dress the stronger arm.
   • To undress: Remove the sleeve from the stronger arm first (USF). Slide the garment off the head/back, and then gently slide the sleeve off the weaker arm.
4. Footwear: Always assist the resident with putting on non-skid footwear (such as rubber-soled shoes or slip-resistant socks) before they get out of bed. This is a critical fall-prevention measure.

Toileting: Bedpans, Urinals, and Bedside Commodes

Promptly assisting with elimination is vital. Delayed care causes extreme distress, increases the risk of urinary tract infections (UTIs), and frequently causes falls when residents attempt to walk to the bathroom unsupervised.

Types of Bedpans

For bedbound residents, the CNA must select the appropriate bedpan:

• Standard Bedpan: A deep, contoured plastic pan. It is placed under the resident with the wide, curved rim pointing toward the resident's upper back/buttocks and the narrow, tapered end pointing toward the feet.
• Fracture Bedpan: A flatter, wedge-shaped pan designed for residents who cannot lift their hips easily (e.g., those with hip fractures, hip replacements, spinal injuries, or severe arthritis). The thin, flat edge is placed under the resident's buttocks (toward the head), and the handle points toward the feet.

Assisting with a Bedpan or Urinal

• Placement: If the resident can lift their hips, have them bend their knees and push up. Slide the bedpan under. If they cannot lift their hips, turn the resident onto their side, align the bedpan against their buttocks, and roll them back onto the pan.
• Safety Positioning: Once the bedpan is in place, raise the head of the bed to a sitting or semi-Fowler's position (30 to 45 degrees, or up to 90 degrees if tolerated). Lying flat makes elimination difficult, increases the risk of spilling, and is highly uncomfortable.
• Urinals: Male residents use urinals for urination. If the resident is able, let them position the urinal themselves to promote independence. Ensure the cap is closed tightly after use to prevent spills.
• Hygiene and Clean Up: Provide toilet paper and the call light. Leave the room to give the resident privacy if safe. When removing the bedpan/urinal, lower the head of the bed slightly to prevent spills, slide the pan out, cover it immediately, and take it to the bathroom to inspect, measure (if on I&O), and empty. Always assist the resident with perineal care and hand hygiene afterward.

Incontinence Care

Incontinence is the inability to control bowel or bladder function. It is a distressing condition that can lead to moisture-associated skin damage (MASD), chemical irritation from ammonia in urine, and rapid skin breakdown (pressure injuries).

Guidelines for Managing Incontinence

• Prompt Attention: Check incontinent residents at least every two hours or immediately when the call light is activated. Cleanse the skin immediately.
• Friction and Shearing Prevention: When changing wet linens or disposable briefs, never drag the resident across the sheets. Lift or roll them side-to-side. Dragging causes shearing, which tears the outer layers of fragile skin.
• Brief Disposal: Roll the soiled brief or underpad inward (soiled side inside) to contain the waste and prevent the spread of pathogens. Place it directly into a designated waste container. Never place soiled briefs on the floor or bedside tables.
• Skin Barrier: Apply a thin layer of barrier cream (e.g., zinc oxide) to the clean, dry skin if specified in the care plan to protect the skin from corrosive body fluids.