Basic Care and ComfortLesson 5.1
Activities of Daily Living (ADLs) and Personal Hygiene
Bathing, dressing, eating, toileting: the most personal care you give. Measure function, build independence, protect dignity, and finish with postmortem care.
By the end you can
- Tell basic from instrumental ADLs and pick the right assessment tool
- Assist with bathing, dressing, oral care, feeding, and toileting while promoting independence
- Protect dignity and culture, and give postmortem care, including medical examiner cases
Your case
Med-surg · day 3 · pneumonia
Mrs. A, 78. Old stroke with left-sided weakness. She feeds herself, is continent, and gets to the toilet and back to bed with her quad cane.
She needs help to bathe and dress. She is Muslim and asked that only women help her bathe. Today her bath is assigned to a male nursing assistant.
Left arm weakFeeding independentTransfers with caneBathing needs help
Hold that thought
- What is her Katz score?
- Which arm goes into her gown first?
- Who should give her bath today?
You will answer all three at the end of the lesson.
Concept 1 · Two kinds of ADLs
Body or beyond
- Basic ADLs (body): bathing, dressing, eating, toileting, grooming, walking and transferring
- Instrumental ADLs (beyond): cooking, cleaning, shopping, money, medications, transport, phone
- Can't do basic ADLs: can't live alone. Can't do IADLs: needs community support
Basic ADL or IADL?
Tap a task, then tap the box it belongs in.
Concept 2 · Katz Index
Six functions, one point each
Katz Index of Independence in ADLs
- Gold standard for basic ADLs
- Six functions: bathing, dressing, toileting, transferring, continence, feeding
- Scoring: independent = 1, dependent = 0. Needing help or supervision counts as dependent
- Total: 6 is fully independent, 0 is fully dependent
Work it out
Mrs. A feeds herself, is continent, and toilets and transfers on her own with a cane. She needs help to bathe and dress. What is her Katz score?
of 6
Worked answer: feeding 1 + continence 1 + toileting 1 + transferring 1 = 4. Bathing and dressing score 0. A cane or walker still counts as independent.
Concept 3 · Order of loss
IADLs go first, then bathing
- IADLs decline first, before any basic ADL
- Basic ADLs fall in a set order, starting with bathing
- Recovery runs in reverse: feeding is the last lost and the first back
Put the basic ADLs in the order they are lost
Pearl: because IADLs slip first, the Lawton IADL Scale catches early dementia before basic self-care fails.
Concept 4 · Assessment tools
Match the tool to the question
Match each tool to what it measures
- FIM 1
- Total assist
- FIM 5
- Supervision or setup
- FIM 7
- Complete independence
- Barthel dressing
- 0, 5, or 10 (10 is independent)
Concept 5 · Levels of help
Never do what the client can do
- Independent
- Does it alone. You monitor and document
- Setup or supervision
- You set out supplies, cue, or stand by. The client does the task
- Partial assist
- You do part: the client washes the front, you do the back and feet
- Total assist
- You do it all, and still involve the client in choices
Pearl: document the level of help and reassess every day. Today's total assist can be next week's supervision.
Quick check 1 of 4
After hip surgery, a client can wash her face, arms, and chest but tires before finishing. Best approach?
Partial assistance keeps her doing what she can, which preserves strength and independence. A complete bed bath does for her what she can do herself, and delaying hygiene or handing it to family leaves the need unmet.
Concept 6 · Bathing and toileting
Check the water, clean to dirty
Bathing
- Water: 105 to 110 F. Check with a thermometer or your inner wrist
- Never trust the client's touch, especially with neuropathy
- Order: cleanest to dirtiest. Face first, perineum last
- Expose only the part you are washing
- Strokes: long, distal to proximal, for venous return
Toileting
- Offer the toilet, bedpan, or urinal every 2 hours
- Answer call lights fast to prevent accidents
- Perineal care: front to back for females
- Bedpan: warm it, raise the head of the bed 30 degrees if allowed, give privacy
- Record I&O every time
Watch out: never leave a client with altered LOC, seizure risk, or fall risk alone in the shower or tub. Use a shower chair, grab bars, and non-slip mats.
Concept 7 · Dressing
Weak side in first, strong side out first
Fill in the rule
Putting on a shirt: the arm goes in first.
Taking it off: the arm comes out first.
Why: the weak arm goes in while the garment is and needs the least range of motion.
Clothes that build independence
- Velcro in place of buttons
- Elastic waistbands and front-opening shirts
- Slip-on shoes
- Let the client choose what to wear: self-image matters
Concept 8 · Oral care
Unconscious? Position before anything
Conscious client
- Brush at least twice a day and after meals
- Sit upright in high Fowler's
- On oxygen: mouth care every 2 hours. Mouth breathing dries the mucosa
- Dentures: remove, clean separately, inspect the mucosa underneath
Unconscious client
- Position first: side-lying, head of the bed about 30 degrees
- Never your fingers in the mouth. Use a padded tongue blade
- Moist foam swab and small amounts of fluid. Suction ready
- Intubated: frequent oral care (often every 2 hours) helps prevent VAP
Quick check 2 of 4
The nurse is about to give oral care to an unconscious client. What is the first action?
Positioning comes first so fluid drains out of the mouth instead of into the airway. Suction may be needed, but you can't safely clean or suction until the client is positioned.
Concept 9 · Feeding
Upright during meals, and 30 minutes after
- Position: high Fowler's (90 degrees) during meals and for 30 minutes after
- Sit at eye level. Never rush the meal
- Low vision: clock method. "Chicken at 12, vegetables at 3"
- Dysphagia: confirm the ordered texture, small bites, time between swallows
- Check for pocketing in the cheeks. Keep suction at the bedside
Quick check 3 of 4
Which action by assistive personnel feeding a client with dysphagia needs correction?
The client must stay upright for 30 minutes after eating to prevent aspiration. The other actions are correct technique for dysphagia.
Concept 10 · Dignity and culture
Function lost, choice kept
- Privacy: knock every time, close the curtain, drape, expose only what you need
- Explain and ask before you do anything
- Choice: clothes, bath time, grooming style
- Adult language: no "sweetie" or "dear." Don't talk about the client as if they aren't there
A legitimate cultural or religious need, not a "difficult client." Accommodate when possible. If you can't, explain respectfully and document.
Many cultures cleanse the perineum with water. Offer a peri-bottle or bidet access when asked.
Never cut or shave hair without permission. Sikh clients may not cut hair for religious reasons. Ask about products and techniques.
Coordinate a religious fast with the provider instead of insisting the client eat. Some cultures eat only with the right hand.
Pearl: on a cultural ADL question, the answer is to ask the client: not to assume, and not to dismiss.
Concept 11 · Medical examiner cases
Some deaths you don't touch
- Pronounce: a provider, or an RN where state law allows
- Notify the provider and family. Document the time of death
- Ask: does this death go to the medical examiner?
Medical examiner case or routine?
Tap a death, then tap the box it belongs in.
Watch out: in an ME case, leave every tube, line, drain, and dressing in place. Don't bathe or reposition the body. It is evidence.
Concept 12 · Postmortem care
The final act of dignity
- Position
- Supine, arms at the sides or on the abdomen, pillow under the head
- Face
- Close the eyes, rolled towel under the chin, dentures in
- Devices
- Remove per policy. Cap lines that must stay
- Bathe
- Gently, with an absorbent pad under the hips: sphincters relax
- ID tags
- Wrist, ankle, and outside the shroud
- Belongings
- Inventory, family signs, secure valuables
Quick check 4 of 4
After an expected death from terminal cancer (DNR), which postmortem action is correct?
The pillow keeps blood from pooling in the face, so the family sees a natural appearance. Dentures go in before rigor mortis, and in a non-ME case lines are removed per policy.
Concept 13 · Faith after death
Ask who touches the body
Match the tradition to a common practice
Pearl: ask first, every time. Not every family follows every tradition. Jewish and Muslim families usually avoid autopsy unless the law requires it.
Decide it
Bath day
Back to Mrs. A · bath due · male NA assigned
She pulls the blanket up and says, "I'm sorry. I can't have a man bathe me."
What do you do?
That dismisses her beliefs and damages trust. It is never the NCLEX answer.
Right. Same-gender care is a legitimate religious need. Accommodate it whenever you can.
She refused the caregiver, not the bath. Skipping it leaves her care undone.
The female NA fills the basin. Mrs. A offers to test the water with her left hand.
Her affected hand may not sense heat. Never rely on the client's touch.
Backward. Go cleanest to dirtiest: face first, perineum last.
Right. Her weak left side may not sense heat well, so her touch can't judge the water. Go cleanest to dirtiest and expose one area at a time.
Time to put on her gown.
Right. The weak arm goes in while the gown is loose. To undress, the strong arm comes out first.
Then the weak arm has to work through a tighter opening.
Unsafe and painful for a weak arm. Dress the affected side first.
How it ends
- She washes her own face, arms, and chest. The NA does her back and legs
- Dressed in her own clothes with a front-opening top
- The care plan records her request for female caregivers and her Katz score: 4 of 6
Lock it in
Three hooks to carry into the exam
Two more
- Body vs beyond: basic ADLs care for the body. IADLs are what it takes to live on your own
- Weak in, strong out: dress the affected side first, undress the unaffected side first
Rapid fire
A client who needs supervision to bathe scores as independent on the Katz.
Supervision, direction, or hands-on help all count as dependent.
Feeding is the last basic ADL lost and the first to return.
Katz's order: bathing goes first, feeding last, and recovery runs in reverse.
Let the client test the bath water with their hand to respect their preference.
Use a thermometer or your inner wrist. Weakness or neuropathy can hide a burn.
Dentures are put in during postmortem care.
They keep the face natural and are very hard to insert once rigor mortis sets in.
After an unexpected death 10 hours after admission, remove the IV and Foley before the family visits.
A death within 24 hours of admission is an ME case. Leave everything in place.
NCLEX traps
What the exam will try to trick you with
Wrong. Promote maximum independence. Set up, cue, and help only with what she can't do.
No. Katz is yes or no. FIM or Barthel shows partial progress.
Never. Use a padded tongue blade, after positioning side-lying.
Never the answer. Accommodate same-gender requests whenever possible.
Don't. In an ME case nothing is washed, moved, or removed.
Cheat card
The whole lesson on one card
ADLs
- Basic: body. IADLs: beyond
- DEATH: dressing, eating, ambulating, toileting, hygiene
- IADLs lost first, then bathing
- Feeding lost last, back first
Tools
- Katz: 6 basic ADLs, 1 or 0
- Lawton: IADLs, early dementia
- FIM: 1 to 7, rehab progress
- Barthel: 0 to 100, rehab
Care
- Bath water 105 to 110 F, use a thermometer
- Face first, perineum last
- Affected side on first
- Upright 30 minutes after meals
Dignity and death
- Ask about culture first
- Unconscious: side-lying for oral care
- ME case: leave everything
- Head on a pillow, dentures in
The printable version is in the Cheat Sheets library.
Lesson quiz · 1 of 5
A 78-year-old admitted after a fall feeds herself and is continent but needs help to bathe, dress, transfer, and use the toilet. What is her Katz score?
She earns one point each for feeding and continence. Bathing, dressing, transferring, and toileting all need help, so each scores 0, for a total of 2.
Lesson quiz · 2 of 5
A client with early Alzheimer's disease is being planned for discharge. Which tool best shows whether the client can live independently?
Lawton measures the skills for living in the community (medications, money, cooking, transport), and IADLs decline first in early dementia. Katz measures basic ADLs, which may still be intact, and the GCS measures level of consciousness.
Lesson quiz · 3 of 5
In inpatient rehab, a client who needed total assistance with dressing now needs only verbal cues. Which finding best reflects this progress?
FIM's 7-point scale captures the change: 1 is total assist and 5 is supervision or cues. Katz can't show partial gains, and a Barthel score of 10 means fully independent, which overstates the progress.
Lesson quiz · 4 of 5
A client dies unexpectedly 12 hours after admission. The family asks to bathe and dress the body. Best action?
A death within 24 hours of admission is reportable to the medical examiner, so the body is not washed or changed until cleared. Explain this with compassion. Calling the chaplain instead delays the required notification.
Lesson quiz · 5 of 5
A Jewish family's loved one has just died. They ask what happens next. Most culturally sensitive response?
Asking honors this family's own wishes: not every Jewish family follows the same traditions. Setting a burial time or arranging a watcher without asking is still an assumption, and routine bathing may conflict with ritual washing.
Wrap-up
0 / 5
Quiz score
Back to Mrs. A · day 3
What is her Katz score? 4 of 6. Independent in feeding, continence, toileting, and transferring (a cane still counts). Dependent in bathing and dressing, the first two functions lost.
Which arm goes in first? Her left, the affected arm. To undress, her right arm comes out first.
Who bathes her? A female staff member. Same-gender care is a legitimate religious need. Accommodate it, and let her wash what she can.
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