Section 6.2: Oral Care, Perineal Care, & Catheter Support

Oral Care, Perineal Care, & Catheter Support

Daily oral hygiene, perineal care, and proper catheter maintenance are essential components of basic nursing care. These procedures are critical for preventing infection, preserving skin and mucosal integrity, and maintaining resident comfort and dignity. Because these tasks involve highly sensitive areas of the body, the Certified Nursing Assistant (CNA) must maintain professional boundaries, explain each step, and adhere to strict infection control protocols.

Oral Care for the Unconscious Resident

An unconscious resident is unable to perform oral hygiene or swallow. However, they still require frequent oral care—usually every two hours—because they often breathe through their mouths, leading to extremely dry, cracked, and sticky oral membranes. Additionally, bacteria build up rapidly, putting them at risk for systemic infections and tooth decay.

Prevention of Aspiration

The single most critical safety concern when performing oral care on an unconscious resident is aspiration (inhaling fluids, saliva, or toothpaste into the trachea and lungs). Aspiration can block the airway or lead to aspiration pneumonia, a severe and potentially fatal lung infection.

• Positioning: The resident must be placed in a lateral (side-lying) position with their head turned to the side facing the CNA. If the head of the bed can be elevated slightly, it should be, but the side-lying position is the primary defense against aspiration.
• Equipment and Fluids:
  • Do not use standard toothpaste and a cup of water, as these produce foam and liquid that are easily aspirated.
  • Use sponge swabs (toothettes) dampened with water or an approved mouthwash.
  • Squeeze out all excess fluid from the swab before introducing it into the resident's mouth. The swab should be damp, not dripping.
  • Use a padded tongue depressor to gently hold the mouth open. Never place your fingers inside the resident's mouth, as they may bite down reflexively, causing serious injury.
  • Clean all areas of the mouth: the teeth, gums, tongue, roof of the mouth, and inside the cheeks.
  • Apply water-soluble lip moisturizer to prevent dry, cracked lips.

Perineal Care Guidelines

Perineal care (pericare) is the cleansing of the genital and anal areas. It is performed daily during bathing, and immediately following any episode of incontinence. The water temperature must be maintained between 105°F and 110°F to prevent burns while ensuring comfort. The CNA must wear clean gloves and change them if they become soiled.

The Cleanest-to-Dirtiest Standard

For both male and female residents, the perineum must be washed from the cleanest area to the dirtiest area. The urethral opening is the cleanest, and the anus is the dirtiest.

Female Perineal Care

• Wiping Direction: Always wipe from front-to-back (anterior to posterior), moving from the urethra and vagina toward the anus. Wiping back-to-front introduces fecal bacteria (such as Escherichia coli) directly into the short female urethra, leading to a urinary tract infection (UTI).
• Technique:
  1. Separate the labia gently with one gloved hand.
  2. Use a clean washcloth with soap and warm water.
  3. Wipe downward on one side of the labia, then fold the washcloth to a clean area, wipe downward on the other side, and use another clean area to wipe down the center.
  4. Rinse the area using the same front-to-back technique with a clean, wet washcloth.
  5. Pat the area dry thoroughly, as moisture trapped in skin folds promotes yeast growth.

Male Perineal Care

• The Uncircumcised Male: If the resident is uncircumcised, the CNA must gently retract the foreskin to expose the glans (head of the penis). Wash the glans using a circular motion starting at the meatus (urethral opening) and spiraling outward/downward toward the base of the shaft. Rinse and pat dry.
• Foreskin Return: The CNA must immediately return the retracted foreskin to its natural position after washing, rinsing, and drying. Failure to do so can cause constriction, swelling, and severe tissue damage (paraphimosis), which is a medical emergency.
• Shaft and Scrotum: Wash the shaft of the penis downward toward the pubic area. Wash the scrotum, lifting it gently to clean the skin folds underneath, which are prone to sweat and friction.

Daily Indwelling Catheter Care

An indwelling urinary catheter (Foley catheter) is a sterile tube inserted into the bladder to drain urine. The presence of a catheter significantly increases the risk of a Catheter-Associated Urinary Tract Infection (CAUTI). Daily catheter care is a critical CNA duty to prevent these infections.

Catheter Cleaning Technique

1. Put on clean gloves.
2. Expose only the perineal area and place a protective pad under the resident.
3. Anchor the Tubing: Hold the catheter tube firmly at the meatus (where it enters the body) with one hand. This prevents pulling or tugging on the catheter, which causes severe bladder spasms, mucosal trauma, and pain.
4. Wipe Downward: Using a clean, soapy washcloth, wipe away from the meatus down the tubing for at least 4 inches. Never wipe upward toward the body, as this forces bacteria into the urinary tract.
5. Use a clean portion of the washcloth for each stroke. Rinse and pat dry.

Catheter Maintenance and Safety Rules

• Position of the Drainage Bag: The collection bag must always be kept below the level of the bladder. If the bag is lifted above the bladder (such as during transfers or turning), urine will flow backward (reflux) from the bag or tube into the bladder. Because urine in the bag is non-sterile and contaminated with bacteria, reflux causes immediate bladder infection.
• Tubing Safety: Ensure the tubing is free of kinks, loops, or twists. Obstruction of urine flow causes urine to back up, leading to bladder distention and pain.
• Attachment: Attach the bag to the bed frame (a non-movable part of the bed), never to the side rails. If attached to side rails, lowering or raising the rails will pull on the catheter.
• Floor Clearance: The drainage bag must never touch the floor, as the floor is a major reservoir for pathogens.
• Emptying the Bag: Empty the bag at least once per shift or when it is half full. Place a clean graduate container on the floor (on a paper barrier), open the drain spigot, and empty the urine. The spigot must never touch the graduate container or any other surface to maintain the closed sterile system.