Introduction to The Patient’s Environment

Beds should be made on a daily basis, usually in the morning after providing morning care. Having clean, dry sheets promotes comfort, prevents skin breakdown, and helps to promote a sense of well-being for the patient. Home Health Aides/Personal Care Aides should always ensure linens are wrinkle-free as this helps to prevent skin breakdown and pressure sore formation. Linens should be changed when they are wet, soiled, or if the patient requests. The Care Plan will direct Home Health Aides/Personal Care Aides as to how often linens should be changed. For patients who are bedridden, Home Health Aides/Personal Care Aides will have to make the bed or change the linens while the patient is in the bed. This is called Making an Occupied Bed and instructions are provided on how to do this in this section. While making an occupied bed, patients are turned to the opposite side the HHA/PCA is working.

Procedure: Making an Unoccupied Bed

1. Explain to the patient you are going to make their bed.
2. Wash and dry your hands. Always apply gloves when working with soiled linens.
3. Assemble equipment and supplies (e.g. clean linens and pillows). Assemble supplies in the order they will be used: Bottom or fitted sheet, bed pad, top or flat sheet, blanket, bedspread, pillow cases(s). Carry linens away from your body to prevent bacteria from your clothes getting on the clean linens. Turn the pile of linens upside down and place on a clean surface which will be within your reach.
4. Raise the bed to waist level. Remember to use good body mechanics. Never lean over the bed. Work on one side of the bed at a time. Move to the other side of the bed as needed. Lower the bed rails on the side you are working.
5. Remove and fold any bedding to be re-used (such as blankets and comforters or quilts). Place them on a clean surface.
6. Remove soiled linens and place in the appropriate receptacle (e.g. hamper). Roll soiled linens away from you inside out. Do not shake linens as this will release microorganisms in the air. Discard in the appropriate container.
7. Discard gloves and wash your hands.
8. Smooth mattress pad, if using, and remove wrinkles.
9. Place the bottom or fitted sheet in the middle of the bed lengthwise. The fold/crease should be in the center of the bed.
10. Unfold ½ the sheet on the side you are working and tuck into corners under the mattress.
11. Fanfold (accordion style) the other half of the sheet and leave in the center of the bed.
12. Place the bed pad in the center of the bed. Open it on the side you are working. Fanfold it to the other side of the bed.
13. Place top sheet in center of the bed lengthwise. Fanfold it to the other side of the bed.
14. Go to the opposite side of the bed.
15. Repeat steps 8-12, opening the fitted sheet and tucking it under the edges of the bed. Unfold the remaining half of the top sheet and bed pad.
16. Add blankets and bedspreads.
17. Miter corners of the bedding: To miter corners, grasp the edge of the bedding about 18 inches away from the end of the bed. Bring it up to the top of the bed. Hold it taut (tight) at about a 45 degree angle. It will look to be a triangular shape. Tuck the loose sheet hanging below underneath the mattress. Pick up the triangular shaped piece you made, place it over the side of the mattress, and tuck it under.Bring the top sheet and blankets down over the bedspread, forming a cuff. Smooth out any wrinkles. Remove the soiled pillowcase by turning it down and placing it inside out.
18. Putting a pillowcase on a pillow:
19. Method 1: Grasp the pillow in one hand and fold it in half so that it makes a V shape. Guide the pillow into the open end of the pillowcase, which is in your other hand. Smooth out the pillow inside the case. Method 2: Grasp the end of a pillowcase at the center of bottom seams. With your other hand, gather up the pillowcase so it is covering your hand. Grasp the pillow with the hand that is covered by the pillowcase. Pull the pillowcase down and over the pillow.
20. Lower bed to lowest height. Raise bed rails.
21. Remove and dispose of your gloves. Wash and dry your hands.
22. Document completion of task.

Procedure: Making an Occupied Bed

1. Explain the procedure to the patient.
2. Wash and dry your hands. Don gloves.
3. Assemble equipment and supplies (e.g. clean linens and pillows).
4. Assemble supplies in the order they will be used: Bottom or fitted sheet, bed pad, top or flat sheet, blanket, bedspread, pillow cases(s). Carry linens away from your body to prevent bacteria from your clothes getting on the clean linens. Turn the pile of linens upside down and place on a clean surface which will be within your reach.
5. Raise the bed to waist level. Remember to use good body mechanics. Never lean over the bed. Work on one side of the bed at a time. Move to the other side of the bed as needed. Lower the bed rails on the side you are working.
6. Remove and fold any bedding to be re-used (such as blankets and comforters or quilts). Place them on a clean surface. Do not shake linens as this will release microorganisms in the air.
7. Loosen bedding on the side you are working. Loosen top sheet at foot and bottom or flat sheet at the foot and top of the bed. Leave top sheet or a bath blanket on the patient for warmth and privacy.
8. Leave the pillow under patient’s head for comfort.
9. Turn the patient to the opposite side from which you are working. Position for safety and comfort.
10. Roll the soiled bottom sheet and bed pad toward patient. The soiled sheet and mattress pad should be rolled inward so the soiled part is not touching the patient.
11. Gently tuck the soiled sheets under the patient.
12. Position the clean bottom or fitted sheet lengthwise along the length of the patient. Tuck the clean bottom sheet next to and under the soiled sheets underneath the patient. Be sure the clean sheet is underneath the soiled sheet. This will ensure the new sheet stays clean and that it will be easy to move to the other side after you turn the patient onto their opposite side. Tuck the bottom sheet in at the head and foot, under the mattress. Smooth out any wrinkles.
13. Open ½ the bed pad on your side. Fanfold (fold it up accordion style) the remaining half. Tuck this under the patient, over the clean sheet but under the soiled sheet.
14. Turn the patient to the clean side of the bed. Let them know that they will feel a “bump” as they roll over the linens underneath them. Position the patient for safety and comfort. If the bed has rails, ensure the bed rails are positioned up before you move to the opposite side of the bed.
15. Go to the opposite side of the bed.
16. Loosen the bottom sheet at the head and foot of the bed. Roll the soiled bottom sheet and bed pad into a ball so that the soiled part of the linen is inside, and away from clean areas. Place soiled linen in the appropriate receptacle.
17. Remove your gloves and wash your hands. If you move away from the bed, ensure that the bed rails are up.
18. Roll the clean bottom sheet and bed pad out from under the patient. Tuck in corners and smooth out wrinkles.
19. Re-position the patient back to the center of the bed.
20. Remove the soiled top sheet and replace with the clean top sheet. Replace blankets and top bedding over the patient.
21. Bring the top sheet and blanket down over the top bedding to form a cuff.
22. Remove soiled pillow cases and replace with clean pillow cases as outlined in Making an Unoccupied Bed Procedure.
23. At the foot of the bed, make a toe pleat by lifting all linens with pinched fingers. This allows the patient to have room to move their feet and prevents deformities of the feet from pressure made by tight linens.
24. Position the patient for comfort.
25. Lower the bed to its lowest setting. Ensure side rails are up.
26. Remove gloves, wash and dry your hands.
27. Observe, record, and report any changes in condition or behavior.

Introduction to Special Equipment used by Home Care Patients

Patients may have a number of special types of equipment that have been prescribed for them to use in order to be as independent as possible. Home Health Aides/Personal Care Aides should always be sure they know how to use the equipment correctly prior to using it with a patient.

Bed Equipment:

Patients may be using their own bed or they may have a prescribed hospital bed. Learn how to properly use a hospital bed by practicing using the buttons to raise and lower the bed prior to using it with a patient.

Mobility Equipment:

Patients may have any number of equipment to help them with mobility. Learn which types have been prescribed to the patient and how to correctly use them. An important task of the HHA/PCA is to use and teach patients how to properly use mobility devices.

Types of mobility equipment include:

• Canes
• Walkers
• Wheelchairs
• Transfer/sliding board
• Hydraulic Lift (e.g. Hoyer Lift)
• Electric Lift Chair
• Gait belts
• Braces, splints, slings
• Prosthetic limbs
• Special shoes or boot

Toileting Equipment:

Patients may have special equipment to use which will assist them with toileting if they have problems with mobility. These types of equipment help to meet the patient’s elimination needs and maintain as much independence as possible. Remember to offer toileting at least every two hours, or more frequently if the patient requires. Use proper safety procedures for transferring a patient to a toilet or bedside commode.

Types of Toileting Equipment:

• Bedpan
• Urinal
• Bedside commode
• Catheters

Scales:

One of the tasks of the Home Health Aide/Personal Care Aide may be to measure the patient’s weight on a regular basis. This helps to determine if the patient is maintaining an adequate weight. Some patients may be on a special diet to lose weight, while others are prescribed diets to help them gain weight. Patients with conditions such as kidney or heart failure may have to be weighed on a daily basis in order to measure if the patient is retaining fluid. Retaining fluid can lead to a worsening of their health condition.

Accuracy is important when weighing a patient. Always ensure the scale is balanced to zero before weighing a patient.When weighing a patient, Home Health Aides/Personal Care Aides should encourage them to empty their bladder and bowels first. Weigh them first thing in the morning, and while they are wearing light clothing, such as pajamas.

Depending on the patient’s mobility, they may have a bed scale, chair scale, balance scale, or bathroom scale. Learn how to properly use each type of scale. It is important to ensure the safety of the patient while weighing them. If a patient appears unsteady and unable to stand in order to be weighed, inform the supervisor.

Remember too that people may be sensitive about their weight. Never chastise (scold) or be judgmental toward a person about their weight. Maintain privacy while weighing a patient and do not disclose a patient’s weight to others outside of the healthcare team, unless the patient states it is okay.

Types of Scales:

• Bed scale (the patient is weighed while in bed)
• Chair scale (the patient sits while being weighed)
• Balance scale (the type found in a doctor’s office)
• Bathroom scale (digital or standard)

This section will provide instruction about how to properly weigh a patient, use a hydraulic lift, and a slide board. The Home Health Aide/Personal Care Aide should always seek training from their agency to ensure they can correctly complete any procedure.

Procedure: Weighing a Patient

1. Explain the procedure to the patient.
2. Wash your hands. Don gloves as needed.
3. Check that the scale is at “0”. Readjust if it is not.
4. Assist the patient to the scale.
5. Provide support while the patient steadies themselves.
6. Note the weight once the dial stops moving.
7. Assist the patient off the scale and safely back into a chair or bed.
8. Wash hands.
9. Record weight and any problems observed that the patient may have had getting onto or off of the scale.
10. Report any changes in condition or behavior (such as an increase or decrease in weight).
11. Store the scale in a safe place.

Procedure: Assisting with the Use of a Hydraulic Lift

At least two people should assist during patient transfer with a hydraulic lift. This provides for patient safety. One person can operate the mechanical lift while the other ensures the patient moves on the lift safely by guiding and protecting their body as the lift moves them.

1. Explain the procedure to the patient.
2. Wash your hands and apply gloves, as needed.
3. Provide for patient privacy. Keep the patient covered with a blanket for warmth and privacy.
4. Raise the height of the bed to a safe working height.
5. Lock bed wheels. Lower the head of the bed so that the patient is lying flat. One staff person should be on either side of the bed. Lower bed rails.
6. To position the sling under the patient: Have the patient turn on their side, facing away from you. Position the sling folded accordion style along the length of their body, pushing it under the patient. Repeat this process to position the other half of the sling under the patient by having them turn the opposite way. The staff person on the other side of the bed finishes unfolding the sling and smoothing any wrinkles. Reposition as necessary for proper fit.
7. Position the patient into a Semi-Fowler’s position. Place wheelchair or chair to which you are transferring the patient next to the bed, about 12 inches away from the bed. Place a cushion or blanket to be used for patient comfort on the chair.
8. Position the mechanical lift next to the bed, opening the base to its widest point and push the base under the bed. Position the frame of the hydraulic lift so that it is centered over the patient.
9. Attach straps to the sling according to the manufacturer’s directions.
10. Instruct the patient to cross their arms to prevent injury during the transfer.
11. Raise the patient with the hydraulic lift, following the manufacturer’s instructions, about 2 inches above the bed.
12. Roll the mechanical lift to position the patient over the chair or wheelchair. The patient’s back should be toward the chair. Your partner should support the patient’s head and guide the patient’s body.
13. Slowly lower the patient to the chair, using the mechanical lift.
14. Once the patient is in the chair, undo straps from the overhead bar to the sling. Leave the sling in place. This will allow for ease of transfer of the patient back to the bed later.
15. Move the mechanical lift away from the patient.
16. Position the patient comfortably. Ensure their body is properly aligned. Cover them with a blanket, per preference. Lock wheelchair or chair locks.
17. Safely store the mechanical lift for later use.
18. The sling can be left under the patient for ease of transfer back to the bed later.
19. Remove gloves and wash hands.
20. Document the procedure and any observations or changes in condition.

Procedure: Slide Board Transfer

A slide board, or transfer board, is sometimes used to help a patient transfer to a bed, chair, or bath stool when they are unable to walk or bear weight on their legs. Home Health Aides/Personal Care Aides should always ensure that the patient has clothing on so that the slide board does not touch bare skin. Rubbing against the slide board with bare skin can cause injury to the patient’s skin. A slide board should only be used for patients who have the strength to move themselves across it. Never drag a patient across the slide board. Always use a series of small movements to assist them cross the slide board.

1. Explain the procedure to the patient.
2. Wash your hands and apply gloves, as needed.
3. Place wheelchair or chair at a 20 degree angle, facing the chair to which they are moving.
4. Lock brakes on the wheelchair and remove armrest and raise footrests.
5. Place slide board like a bridge between the two chairs or between the bed and wheelchair.
6. Instruct the patient to lean away from the slide board, lifting their hip closest to the slide board slightly.
7. Gently slide the slide board under the patient’s buttocks. The other end should be placed on the surface to which the patient is moving (such as on the chair).
8. Ensure the slide board is secure before proceeding.
9. Instruct the patient to place both of their hands on the slide board at their sides next to their thighs.
10. Instruct them to take a series of small push-ups across the board, or to use a scooting movement, using their hands to press down, and lifting up their buttocks, until they reach the other end of the slide board.
11. You may use a gait belt during this and assist the patient with moving along the slide board by grasping under the gait belt and helping the patient move across the slide board.
12. Remember to use proper body mechanics. Keep a wide stance with your knees slightly bent. Use the weight of your thighs and not your back to assist with pulling the patient up.
13. Once the transfer is complete, clean and store the slide board.
14. Remove gloves and wash your hands.
15. Document the procedure and any observations or changes in condition.

Procedure: Handling the Infant

Home Health Aides/Personal Care Aides may work with families who have an infant whom they must help care for. Sometimes, a mother or other caretaker may not be available to help care for the infant. They may also have health issues which prevent them from caring for the infant at that time. Always keep in mind family, cultural, religious, and social differences. Be respectful of the family’s beliefs, customs, and wishes. Remember, it is their child. The Home Health Aide/Personal Care Aide is there to provide support and to help care for the infant.

When caring for a baby, it is very important for Home Health Aides/Personal Care Aides to be conscious of ensuring they prevent the spread of bacteria. Infants do not have a fully developed immune system. They are at very high risk for getting an infection. Home Health Aides/Personal Care Aides should always wash their hands before and after handling a baby, their clothing, bottles, and equipment. Wear gloves when providing diaper and bath care.

Infants require constant supervision. They are not able to protect or care for themselves. Never leave a baby unattended, especially when providing a bath. The only safe place to leave a baby is in their crib lying on their back with their face up or with an adult holding them. Home Health Aides/Personal Care Aides should always ensure they lift and hold a baby safely. The head, neck, and back must always be supported. When traveling with a baby, the HHA/PCA must ensure the infant travels in a car seat specific to the baby’s weight. The infant should be secured in the car seat prior to the car being started.

When feeding a baby, remember to keep their head higher than their body to prevent choking. Babies must be burped in between and after feedings. This helps to prevent choking and aids with digestion. Follow the feeding schedule as directed by the caretaker and Care Plan. When they are finished feeding and burping the baby, they should change his/her diaper. Concerns about the well-being or safety of the baby should be documented and brought to the attention of the supervisor.

Procedure: Picking up the Infant

Wash your hands. Put on gloves, as needed.Put one hand under the infant’s buttocks.Put the other hand under the head, neck, and shoulders of the baby. This provides support so that the baby’s head stays stable and does not roll backward. Place the baby in the appropriate position as outlined below.Wash your hands when finished handling the baby. Document the procedure and any observations or changes in the baby’s condition.

Cradle Hold

1. Always ensure that the baby’s head and neck are cradled. Rest the baby’s head and neck in the crook of your elbow. Hold the baby close to your body.
2. Support the baby’s back with one or both hands. With the arm that is not cradling the baby’s head and back, hold the baby’s legs securely and gently close to you.

Shifting to a “Football” Hold

1. While supporting the baby’s head, neck, and buttocks, swing the baby gently to the side of your body. The baby will be in a resting position against your hips, while your arm and hand cradle the infant, providing support.
2. To do this, hold the baby’s head in one hand and support the baby’s back with the forearm of the same hand supporting the head. The baby’s body will lie along the side of your body. This provides protection and support to the baby.