Patient Care Fundamentals

Patient care is the foundation of healthcare work. Whether you are a certified nursing assistant (CNA), patient care technician (PCT), home health aide, or medical assistant, you will spend more time with patients than almost anyone else on the care team. Your technical skills, observation abilities, and human touch directly affect patient outcomes, comfort, and safety. This guide prepares you for day-one competence in direct patient care.

The Patient Care Mindset

Before any procedures or protocols, understand this: every patient is a whole person. They have a name, a life, fears, preferences, and dignity. The room number, the diagnosis, the insurance status - none of that defines them.

Core Principles

• Knock before entering a patient's room, every time. This is their space.
• Introduce yourself and explain what you are about to do before doing it. "Hi, my name is Maria. I am here to help you get cleaned up and take your blood pressure. Is that okay?"
• Cover patients during care to protect their privacy. Only expose the area you are actively working on.
• Listen when patients talk, even if they repeat themselves or are confused.
• Offer choices whenever possible. "Would you like to wear the blue gown or the green one?" gives a patient control in a situation where they often feel powerless.
• Treat confused or difficult patients with the same respect. Dementia, delirium, pain, and fear can all change behavior. It is not personal.

Infection Control

Healthcare-associated infections (HAIs) affect millions of patients every year. Many are preventable, and prevention starts with you.

Hand Hygiene

Hand hygiene is the single most important thing you can do to prevent the spread of infection. The evidence is overwhelming.

When to perform hand hygiene (the WHO "Five Moments"):

1. Before touching a patient
2. Before a clean or aseptic procedure
3. After body fluid exposure or risk
4. After touching a patient
5. After touching patient surroundings (bed rails, IV pole, call light)

Alcohol-based hand rub (ABHR):

• Apply a palmful of product
• Rub all surfaces of hands: palms, backs, between fingers, fingertips, thumbs, wrists
• Continue rubbing until hands are dry (at least 20 seconds)
• ABHR does not work on visibly soiled hands or against C. difficile spores

Soap and water handwashing:

• Required when hands are visibly soiled
• Required after caring for patients with C. difficile or norovirus
• Wet hands, apply soap, lather all surfaces for at least 20 seconds
• Rinse under running water, dry with a paper towel, use the towel to turn off the faucet

Standard Precautions

Standard precautions apply to every patient, every time, regardless of diagnosis:

• Hand hygiene before and after patient contact
• Gloves when touching blood, body fluids, mucous membranes, or non-intact skin
• Gown when your clothing may contact blood or body fluids
• Mask and eye protection when there is a risk of splashing
• Safe sharps handling and disposal
• Proper cleaning of patient care equipment
• Safe handling of soiled linens

Transmission-Based Precautions

Some patients require additional precautions based on how their infection spreads:

Contact precautions (MRSA, VRE, C. difficile, scabies):

• Gown and gloves for all contact with the patient or their environment
• Dedicated equipment (stethoscope, blood pressure cuff) that stays in the room
• Hand hygiene with soap and water (not just ABHR) for C. difficile

Droplet precautions (influenza, pertussis, meningitis):

• Surgical mask within 3-6 feet of the patient
• Patient wears a mask during transport

Airborne precautions (tuberculosis, measles, chickenpox):

• N95 respirator (must be fit-tested)
• Negative-pressure isolation room with the door closed
• Patient wears a surgical mask during transport

Always check the sign on the patient's door or the care plan before entering. If you are unsure which precautions apply, ask the nurse.

Vital Signs - Comprehensive Guide

Vital signs are your most objective assessment tool. They tell you about the patient's cardiovascular, respiratory, and neurological status.

Blood Pressure

Normal adult range: Systolic 90-120, Diastolic 60-80 mmHg

Factors that affect readings: recent activity, caffeine, pain, anxiety, medications, arm position, and cuff size.

Manual blood pressure procedure:

1. Have the patient sit quietly for 5 minutes. Support the arm at heart level.
2. Select the correct cuff size. The bladder should encircle at least 80% of the upper arm. A cuff that is too small gives a falsely high reading.
3. Place the cuff 1 inch above the elbow crease. Align the artery marker with the brachial artery.
4. Palpate the radial pulse and inflate the cuff until the pulse disappears. Note that number and add 30 mmHg. This is your target inflation point.
5. Place the stethoscope diaphragm over the brachial artery (do not tuck it under the cuff).
6. Inflate to your target, then release the valve slowly (2-3 mmHg per second).
7. The first Korotkoff sound (tapping) is the systolic reading.
8. The point where sounds disappear is the diastolic reading.
9. Record the reading, which arm, the patient's position, and the cuff size if it is not standard.

Critical values to report immediately:

• Systolic above 180 or below 90
• Diastolic above 110 or below 50
• Any reading significantly different from the patient's baseline

Pulse

Normal adult range: 60-100 beats per minute (bpm), regular rhythm

Radial pulse (most common):

1. Use your index and middle fingers on the radial artery (thumb side of the wrist).
2. Never use your thumb (it has its own pulse).
3. Count for a full 60 seconds. Note rate and rhythm.

Apical pulse (more accurate, used for cardiac patients):

1. Place the stethoscope at the 5th intercostal space, midclavicular line (just below the left nipple area).
2. Count for a full 60 seconds.
3. Used when a patient has an irregular radial pulse, is on cardiac medications, or before administering certain drugs.

Report: pulse below 60 or above 100, irregular rhythm, a weak or bounding pulse, or any significant change from baseline.

Respirations

Normal adult range: 12-20 breaths per minute

Count the chest rises for a full 60 seconds without telling the patient (people change their breathing pattern when they know it is being counted). Observe for:

• Depth: are breaths shallow, normal, or deep?
• Pattern: regular or irregular?
• Effort: is the patient using accessory muscles (neck, abdomen)? Are the nostrils flaring? Is there retracting between the ribs?
• Sounds: wheezing, gurgling, stridor?

Report: rate below 10 or above 24, labored breathing, use of accessory muscles, cyanosis (bluish tint to lips or nail beds), or any acute change.

Temperature

Normal range: 97.0-99.0 degrees F oral (36.1-37.2 degrees C)

Routes and considerations:

• Oral: most common for alert, cooperative patients. Place under the tongue, to the side. Wait until the thermometer signals. Do not use right after the patient has had hot or cold liquids (wait 15 minutes).
• Tympanic (ear): quick, good for all ages. Pull the ear up and back for adults to straighten the ear canal.
• Temporal (forehead): non-invasive, fast. Follow the manufacturer's technique.
• Axillary (armpit): less accurate, reads about 1 degree lower than oral. Used when other routes are not available.
• Rectal: most accurate, but invasive. Used in specific clinical situations.

Report: any temperature 100.4 degrees F (38.0 degrees C) or above. Also report hypothermia below 95.0 degrees F (35.0 degrees C).

Oxygen Saturation (SpO2)

Normal range: 95-100%

Place the pulse oximeter on a fingertip. Ensure the finger is warm, clean, and free of dark nail polish. Wait for a stable reading with a strong waveform. False low readings can be caused by cold fingers, poor circulation, dark nail polish, patient movement, and certain medical conditions.

Report: SpO2 below 90% immediately. Report below 92% per the care plan or facility policy.

Pain Assessment

Pain is sometimes called the "5th vital sign." Use a consistent pain scale:

• Numeric scale (0-10): "On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, what number is your pain right now?"
• Wong-Baker faces scale: for children or patients with communication difficulties
• FLACC scale: for non-verbal patients (observing face, legs, activity, cry, and consolability)

Document the location, quality (sharp, dull, burning, aching), duration, what makes it better or worse, and the numeric rating.

Assisting with Activities of Daily Living

Bathing

Bed bath procedure (detailed):

1. Gather supplies before starting: basin, warm water (100-105 degrees F), 2-3 washcloths, 2 towels, soap, lotion, clean clothing, gloves, bath blanket.
2. Offer the patient the opportunity to use the bathroom or bedpan first.
3. Close the door and pull the privacy curtain.
4. Raise the bed to a comfortable working height. Lower the side rail on the side you are working from.
5. Cover the patient with a bath blanket. Remove the top sheet from underneath.
6. Wash in order from cleanest to dirtiest:
   • Face: use water only, no soap. Start at the inner eye and wipe outward. Use a different section of the washcloth for each eye. Wash the forehead, cheeks, nose, chin, ears, and neck.
   • Arms: wash from hand to shoulder. Support the arm. Wash the axilla (armpit). Let the patient soak hands in the basin if possible.
   • Chest and abdomen: wash, rinse, dry. For female patients, wash under the breasts carefully and dry thoroughly to prevent skin breakdown.
   • Legs and feet: wash from ankle to thigh. Let the patient soak feet in the basin. Dry between toes thoroughly to prevent fungal infection.
   • Back: turn the patient to their side. Wash from shoulders to buttocks. This is a good time to assess the skin for pressure injuries.
   • Perineal area: change the water. Put on fresh gloves. For female patients, wash from front to back. For male patients, retract the foreskin if uncircumcised, wash, and return the foreskin. Use a clean area of the washcloth for each stroke.
7. Apply lotion to dry areas (not between toes, not on broken skin, not on areas with poor circulation).
8. Help the patient dress.
9. Lower the bed, raise the side rails, and position the call light within reach.
10. Document the bath and all skin observations.

Oral Care

For alert patients: Assist to a sitting position, provide supplies (toothbrush, toothpaste, cup, emesis basin), and let them brush. Help as needed.

For unconscious or ventilated patients:

1. Position the patient on their side with the head turned toward you (prevents aspiration).
2. Place a towel under the chin.
3. Use oral sponge swabs moistened with water or prescribed oral care solution.
4. Gently swab all surfaces: teeth, gums, tongue, palate, inner cheeks.
5. Suction excess fluid if trained and authorized.
6. Apply lip moisturizer.
7. Perform oral care at least every 2 hours for unconscious patients.

Positioning and Turning

Patients who cannot reposition themselves must be turned every 2 hours to prevent pressure injuries.

Common positions:

• Supine: lying flat on the back. Support the head and knees with pillows.
• Lateral (side-lying): lying on the side. Place pillows between the knees, behind the back, and under the upper arm.
• Fowler's (45-60 degrees): sitting up in bed. Used for eating, breathing difficulty, and certain treatments.
• Semi-Fowler's (30 degrees): slight elevation. Good for resting after meals and for patients at risk for aspiration.
• Prone: lying face down. Rarely used in general care.

Pressure injury prevention:

• Turn and reposition every 2 hours. Use a turning schedule.
• Check bony prominences (heels, sacrum, elbows, shoulder blades, back of head) for redness every time you turn the patient.
• Keep skin clean and dry. Moisture from incontinence is a major risk factor.
• Use pressure-relieving devices: foam mattresses, heel boots, positioning wedges.
• Ensure adequate nutrition and hydration (malnourished patients develop pressure injuries faster).
• If you see a new area of redness that does not blanch (turn white) when pressed, report it immediately. This is a Stage 1 pressure injury.

Intake and Output (I&O) Monitoring

For patients on I&O tracking, you must measure and record all fluids going in and all fluids coming out.

Intake includes:

• All oral fluids (water, juice, coffee, soup, gelatin, ice cream)
• IV fluids (usually recorded by the nurse)
• Tube feeding volume

Output includes:

• Urine (measure in a graduated container)
• Emesis (vomit)
• Wound drainage
• Diarrhea (estimate if unable to measure)
• Ostomy output

Common equivalents:

• 1 cup = 240 mL
• Small carton of milk = 240 mL
• Juice box = approximately 120 mL
• Bowl of soup = approximately 180 mL
• Ice chips = approximately half their volume when melted

Record all I&O at the time it occurs. Totals are calculated at the end of each shift.

Communication with the Healthcare Team

SBAR Reporting

When calling a nurse or physician about a patient concern, use the SBAR format:

• S - Situation: "I am calling about Mrs. Johnson in room 204. Her blood pressure is 88/52, which is much lower than her usual 130/78."
• B - Background: "She is 78 years old, admitted for heart failure. She takes lisinopril and furosemide. She has been up to the bathroom several times today."
• A - Assessment: "I am concerned she may be dehydrated or having a reaction to her medications. She also says she feels dizzy when she stands up."
• R - Recommendation: "Could you please come assess her? Should I hold her next dose of furosemide?"

SBAR keeps your communication focused, professional, and efficient. Practice it until it becomes second nature.

Handoff Communication

At shift change, give a thorough report to the incoming caregiver:

• Current vital signs and any trends
• Care provided during your shift
• Changes in condition
• Pending tasks (medications due, tests scheduled, family arriving)
• Any concerns or observations
• The patient's current pain level and emotional state

Never leave a shift without giving a proper handoff. Gaps in communication are one of the leading causes of medical errors.

Safety Essentials

Fall Prevention

Falls are the most common adverse event in healthcare. Risk factors include:

• Age over 65
• History of falls
• Medications (sedatives, blood pressure drugs, pain medications)
• Mobility impairment
• Confusion or delirium
• Incontinence (rushing to the bathroom)
• Unfamiliar environment

Prevention strategies:

• Keep the bed in the lowest position with brakes locked
• Ensure the call light is within reach at all times
• Keep the room well-lit, especially the path to the bathroom
• Non-slip footwear (never let a patient walk in socks alone on a hard floor)
• Clear clutter and cords from walkways
• Assist with toileting on a schedule to prevent urgent trips
• Use bed alarms for high-risk patients per facility policy
• If a patient starts to fall while you are assisting them, do not try to catch them. Guide them slowly to the floor, protect their head, and call for help.

Restraint Awareness

Physical restraints are a last resort and require a physician order. If your facility uses restraints:

• Check circulation, sensation, and skin condition every 2 hours (or per facility policy)
• Release restraints every 2 hours for range of motion, toileting, and repositioning
• Ensure the patient can reach the call light
• Document restraint checks meticulously
• Never tie restraints to a side rail that can be lowered

Patient Identification

Before any care or procedure, verify the patient's identity using two identifiers:

• Full name and date of birth (ask the patient to state them)
• Compare to the wristband, chart, or care plan
• Never assume. Even if you have cared for the patient for weeks, follow the identification protocol every time.

Emotional and Psychological Care

Physical care is only part of your job. Patients are dealing with fear, pain, loss of independence, loneliness, and sometimes the reality of dying.

• Listen actively. Sometimes a patient does not need you to fix anything. They just need someone to hear them.
• Validate feelings. "It makes sense that you feel frustrated" is powerful.
• Respect cultural and spiritual practices. Ask about dietary requirements related to faith. Accommodate prayer times. Respect modesty requirements.
• Report signs of depression: withdrawal, crying, loss of appetite, statements like "I do not want to be a burden" or "What is the point?"
• Maintain normalcy when possible. Encourage patients to wear their own clothes, keep personal items nearby, and maintain routines.

Documentation Standards

• Document in real time or as close to it as possible
• Use objective, factual language ("Patient states..." or "Observed...")
• Use facility-approved abbreviations only
• Never erase, white-out, or backdate entries
• If you make an error, draw a single line through it, write "error," initial, and date it
• Sign every entry with your name and credentials
• If you did not document it, legally it did not happen