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Basic Care Standards (Inpatient Adult) (13.12)

Basic Care Standards (Inpatient Adult) (13.12) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Basic Nursing Procedures

13.12

NURSING PATIENT CARE POLICY & PROCEDURE

I. PURPOSE

The Basic Care Standards focus on the maximum promotion of comfort and healing
for all adult inpatients and are intended for use by registered nurses (RNs), nursing
assistants (NAs) and patient care technicians (PCTs).

II. DEFINITIONS

Support person(s): The patient has the right to identify a support person(s) (e.g.,
family member, significant other, friend) to be involved in care, treatment decisions
and services (to the extent authorized by the patient). If the patient is incapacitated
and unable to make decisions related care and treatment, staff should check for an
Advance Medical Directive and activated Power of Attorney for Healthcare or Legal
Guardianship according to UWHC Hospital Administrative Policy 4.37, Advance
Directives.

III. POLICY

Basic care standards will be provided for all patients and will be individualized
according to patient needs and nursing judgment. Completion or declination of basic
care should be documented in the clinical record as appropriate.

IV. PROCEDURE

A. Compassion, Respect, and Presence
1. Introduction to Patients and Support Persons
a. All RNs, NAs and PCTs will introduce themselves and their roles to
assigned patients within one hour of the start of their shift and
additionally when appropriate. Nursing staff will explain to the
patient and/or support person(s) how to contact staff when needed.
b. Nursing staff will ask about a patient’s name preference and
document it in the clinical record.
2. Compassion and Respect
a. Nursing staff will respect differences in culture, values, lifestyles,
coping skills, and health care practices.
b. Nursing staff will provide developmentally and culturally appropriate
information that allows patients and support person(s) to understand
their illness and plan for restorative care. Validate and clarify
patient/support person(s) perceptions and concerns.
c. Confidentiality will be protected. See UWHC Hospital
Administrative Policy 6.29, Notice of Privacy Practices.




Effective Date:
September 30, 2016


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 13.12A

Original
Revision

Page
1
of 8

Title: Basic Care Standards (Inpatient Adult)

Page 2 of 8

d. Privacy will be provided. Assure patients are covered modestly when
in public places, when door to room is open, or when a patient is
visible through a window. Knock and ask for permission to enter
whenever possible.
e. Patients should be encouraged to send home non-essential belongings
or valuables in order to prevent loss of items while hospitalized. Any
such items patient chooses to keep with them will be their
responsibility. Refer to Policy 7.27, Management of Patient
Belongings for further requirements and process for inventorying
belongings and valuables.
3. Presence
a. Intentional Rounding will be conducted by RNs, NAs and PCTs
according to UWHC Nursing Patient Care Policy 14.35 AP,
Intentional Rounding (Adult and Pediatric).
b. Care will be provided within a timeframe that meets patients’ needs.
See UWHC Nursing Administrative Policy 6.27, Nurse Call System.

B. Hygiene and Personal Cares

The following table outlines assistance that will be provided for those unable to
do so independently. All patients will be encouraged to do as much for themselves
as they are safely able to. Hygiene and Personal Cares are to be documented in
the patient’s clinical record.

Care Standard Definition Minimum
Frequency
Considerations for
Cognitively Impaired
Patients
Hygiene

General Principles:
• Chlorhexidine gluconate (CHG) treatment is to be done daily. Patient education is
provided when a patient refuses the treatment (refer to Health Facts for you: Daily
Chlorohexidine Gluconate (CHG Treatment). .
• Use the term treatment instead of bath.
• Chlorhexidine gluconate (CHG) should be used to bathe intact skin only or to
clean closed incisions unless otherwise specified in provider orders. Wash around
areas of skin breakdown.
• For perineal care use Aloe Vesta® foam soap.
• If severe skin irritation occurs, discontinue daily CHG bathing and bathe with
Aloe Vesta® foam soap.
• Only use CHG compatible lotion for patients which includes Aloe Vesta®,
Cetaphil®, or Aquaphor®
Shower, tub bath, bed bath, or staff-
assisted bathing. Staff will offer to
wash/comb hair when clinically
appropriate and will assist with
shaving if requested. Apply lotion to
skin after bathing unless there is a
medical reason prohibiting it.

Daily unless
contraindicated
Consider special needs
and challenges such as
fear, agitation, and
restlessness that may
impact patient’s
willingness to bathe.

Explain reason for
bathing as those with
impaired cognition
may be unaware of
hygiene needs or less

Perineal Care: Use Aloe Vesta®
foam soap.
Daily and after
incontinent episodes
(For patients with
indwelling catheters,

Page 3 of 8

Care Standard Definition Minimum
Frequency
Considerations for
Cognitively Impaired
Patients
see UWHC Nursing
Patient Care Policy
3.31AP - Insertion,
Removal, and
Maintenance of an
Indwelling Urinary
Catheter (IUC)
(Adult & Pediatric)
able to follow
instructions and assist
with care.
Bed Linens: Changing pillowcases,
fitted and flat sheets.
3 times/week and
more often when
soiled and according
to patient/support
person(s) request

Personal Cares Consider special needs
and challenges such as
fear, agitation, and
restlessness that may
impact patient’s
willingness to perform
(or receive help with)
personal cares.

Explain reason for
personal cares as those
with impaired
cognition may be
unaware of hygiene
needs or less able to
follow instructions
and assist with care.
Oral Care: Nurses will assess
mouth; care will be provided based
on individual assessment.

Patients without artificial airway:

• Offer soft bristle toothbrush and
fluoride toothpaste or toothettes
and oral debriding solution. As
needed, assist with brushing
dentures. If removed, store in a
labeled denture cup and in
patient belongings container.
(Remove dentures when patient
intubated.)
• Offer (or assist with application
of) lip balm or mouth
moisturizer to mouth and lips.

Patients with continuous
ventilation:
• Utilize oral care kit and CHG
oral rinse. Mouth swab and
suction every 4 hours, teeth
brush 2 times daily with CHG
• Offer (or assist with application
of) lip balm or mouth
moisturizer to mouth and lips.
Oral suction equipment:
Change oral care catheter, wall
suction canister and tubing.

Assess: Daily

Patients able to
perform own oral
care: offer brushing
and moisturizing
twice daily.

Patients unable to
perform self-oral
care:
• Without artificial
airway: every six
(6) hours and as
needed
• With continuous
ventilation: every
four (4) hours and
as needed unless
contraindicated


Equipment: Change
every 24 hours.


Skin Care: Skin will be assessed for
any skin integrity issues. The Braden
Scale will be used to assess pressure
ulcer risk.

Inspection:
Admission, transfer,
daily and as needed.


Remain vigilant in
watching for signs of
skin breakdown since
those with impaired
cognition may be

Page 4 of 8

Care Standard Definition Minimum
Frequency
Considerations for
Cognitively Impaired
Patients
Braden Scale: Upon
Admission and daily
unaware or unable to
verbalize their skin
care needs.
Assess areas covered
by devices which may
create pressure points.
Remove device if
unable to assess.
Foot Care: Feet will be inspected
for areas of redness, irritation,
discoloration, or induration. Socks,
TEDs, and slippers will be removed.
After washing feet, dry thoroughly.
Pat dry between toes. Apply lotion
to skin but not between toes.
Inspection: Daily

Washing: With
complete bath (see
above)

Nail Care: Fingernails and toenails
will only be filed; clipping may be
done by support person(s). For
patients with long or thick nails,
which increases risk for foot
ulceration, a Podiatry consult should
be requested.
Nail filing: As
requested by patient
and/or support
person(s)

Nail clipping: Not
done; initiate consult
as indicated

Ear Care: Inspection of patient’s
ears
Diagnosis specific.
Perform as ordered.


C. Elimination and Nutrition

Care
Standard
Definition Minimum
Frequency
Considerations for
Cognitively Impaired
Patients
Elimination General Principles:
• Toileting will be offered according to UWHC Nursing Patient Care Policy 14.35AP,
Intentional Rounding.
• Any new onset of incontinence will be reported to RN and/or provider.
• Patient intake and output (I&O) will be documented according to provider order.
• Weights should be documented according to provider order. Refer to “Implementation
Guidelines for Documenting Intake and Output (I&O)” in the Related section on
UConnect.
Bladder Care: As needed, a voiding
schedule can be implemented.
Equipment (e.g., commode, urinal,
and/or raised toilet seat) will be used to
meet patient needs. Use of bedpans
and/or urinals will be avoided unless
ambulation is contraindicated. Bladder
Management Protocol will be utilized
as ordered.

Bladder Care: Offer
assistance with
voiding/toileting with
hourly rounding.






Use respectful, simple,
and understandable
language; monitor for
signs of anxiety; assess
the environment to
ensure safe mobility,
and provide behavioral
cues (bathroom and/or
commode should be
clearly visible).

Page 5 of 8

Incontinence Care: Cleanse perineum
and buttocks with incontinence
cleanser; apply barrier cream after
cleansing as indicated. Nurses will
consult the Wound and Skin Nursing
Team as needed for assistance with
incontinence or related skin
management. Resources in Skin Care
(RISC) nurses are also available on
units as a resource for staff.
Incontinence Care:
Assist with skin care
as needed after every
incontinent episode.
Bowel Care: Institute measures to
reduce risk of constipation (encourage
adequate fluid and fiber intake,
increased mobility as able, upright
positioning when able, etc.).

Incontinence Care: Cleanse perineum
and buttocks with incontinence
cleanser; apply barrier cream after
cleansing as indicated. Nurses will
consult the Wound and Skin Nursing
Team as needed for assistance with
incontinence or related skin
management. Resources in Skin Care
(RISC) nurses are also available on
units as a resource for staff.
Bowel Care: Offer
assistance with
toileting with hourly
rounding.


Incontinence Care:
Assist with skin care
as needed after every
incontinent episode.

Nutrition General Considerations:
• Provide assistive devices for eating as necessary.
• Avoid interruptions during meals.
• Nurses will ensure diet orders and/or other nutrients considerations (i.e., aspiration
precautions) are followed. Consult dietitian for those patients who may be at risk for
nutritional deficiencies.
• Obtain diet, food allergies, and eating habits on admission. Document height and
weight and calculated BMI.
• Consult speech and swallowing specialists (request MD order) for patients who cough
or gag while eating or have difficulty swallowing.
Eating: Assist patient to
prepare to eat as needed
(assistance to wash hands,
repositioning, move to
chair, opening food
containers, etc.); assist
patient after meals as
needed (assistance to wash
hands, transfer back to bed,
etc.); remove meal tray and
document food/liquids
consumed as indicated or
ordered.

Patients unable to eat
independently will be
assisted.
Eating: With all meals. Compensate for sensory
deficits (e.g., hearing aids,
glasses, dentures).

Consider offering one food
at a time, cutting food in
small pieces, and offering
finger foods and easy-to-
swallow foods.



Page 6 of 8

D. Mobility and Rest

Care
Standard
Definition Minimum Frequency Considerations for
Cognitively Impaired
Patients
Mobility and
Rest
General Principles:
• Support patient’s need for mobility and return to optimal function prior to illness
and/ or procedure during their hospital stay.
• Mobility should be promoted for patients as appropriate based on their conditions
and abilities to reduce risk of functional decline.
• Involve patient and support person(s) in reinforcing patient-indicated therapeutic
exercises and therapies when possible.
• Assure Safe Patient Handling and Mobility Equipment and/or assistance devices
needed for reinforcing exercise and therapies are available on the unit or in the
patent’s room when possible.
• Avoid bedrest.
• Refer to the Mobility Decision Support Tool (MDST) to help determine if a patient is
safe to ambulate and/or determine what Safe Patient Handling and Mobility
Equipment would be appropriate to utilize. https://uconnect.wisc.edu/clinical/patient-
safety/quality-safety/smart-resources-and-tips/mobility-decision-support-tool/
• Minimize nighttime interruptions as much as possible.
• Refer to policy 13.07 Standard Precautions & Transmission-based Precautions
(Isolation) for Inpatient Settings for ambulation of isolation patients.
• Document cares related to Mobility and Rest in the patient’s clinical record.
Immobile
Patients
Reposition/turn in bed; provide
range of motion (active, passive,
or assisted); splint hands and feet
to prevent contractures and foot
drop; advance elevation of head of
bed as tolerated unless
contraindicated; assist with
activity (dangling at side of bed
and getting out of bed); facilitate
Physical and/or Occupational
Therapy (PT/OT) consultation
(provider order required) as
needed.
Repositioning: Every
two (2) hours and as
needed or requested by
patient/support
person(s).

Range of motion:
Every four (4) hours
while awake

Splinting: According
to schedule defined by
team

Activity: Chair and/or
dangle at bedside at
minimum of three (3)
times per day as
indicated and tolerated;

PT/OT consult: As
needed.
Recognize greater risk of
accelerated functional
loss during
hospitalization for those
with cognitive
impairment, especially
older adults.
Patients
Requiring
Assistance
Assist with activity (assist to chair
and with ambulation); use gait
belts and/or Safe Patient Handling
and Mobility Equipment when
patients when indicated (using
MDST as guide), unless
contraindicated (i.e., an abdominal
Activity: Up to chair at
minimum three (3)
times per day as
indicated and as
tolerated; ambulate at
minimum three (3)
times per day as

Page 7 of 8

wound) according to UWHC
Nursing Patient Care Policy 8.25,
Gait Belt and Patient Mobilization
Procedures.

indicated and as
tolerated.
Patients
Independent
with
Ambulation
Encourage to ambulate in the
hallway and other movement in
bed (e.g., foot pumps, knee
extension, hip abduction, and hip
flexion) unless contraindicated.
Activity: Ambulate at
minimum three (3)
times a day (unless
contraindicated).


E. Safety
1. Environment
a. Patient environment will be kept clean, organized, and free of clutter.
See UWHC Hospital Administrative Policy 12.36, Storage Policy.
b. Assure all equipment is functioning and being used as ordered; remove
any equipment no longer in use.
2. Fall Prevention
a. All patients are to be assessed for fall risk on admission and with
condition changes throughout hospital stay. Implement fall precautions
according to UWHC Nursing Patient Care Policy 13.15AP, Fall
Prevention for Inpatients (Adult and Pediatric).
b. All beds are kept in the lowest position whenever the patient is not
attended.
c. Side rails are used judiciously and cautiously according to UW Health
Clinical Policy 2.4.2, Restraint and Seclusion.

V. UWHC CROSS REFERENCES

A. Health Facts For You 7403, Daily Chlorhexidine Gluconate (CHG) Treatment
B. Hospital Administrative Policy 4.37, Advance Directives
C. Hospital Administrative Policy 6.29, Notice of Privacy Practices
D. Hospital Administrative Policy 7.27, Management of Patient Belongings
E. Hospital Administrative Policy 12.36, Storage Policy
F. Hospital Administrative Policy 13.07 Standard Precautions & Transmission-based
Precautions (Isolation) for Inpatient Settings
G. Nursing Administrative Policy 6.27, Nurse Call System
H. Nursing Patient Care Policy 3.31AP, Insertion, Removal and Maintenance of an
Indwelling Urinary Catheter (IUC) (Adult and Pediatric)
I. Nursing Patient Care Policy 8.25, Gait Belt and Patient Mobilization Procedures
J. Nursing Patient Care Policy 13.15 AP, Fall Prevention for Inpatients (Adult and
Pediatric)
K. Nursing Patient Care Policy 14.35 AP, Intentional Rounding (Adult and Pediatric)
L. UW Health Clinical Policy 1.2.7, Suspected Domestic Violence and Abuse
M. UW Health Clinical Policy 2.4.2, Restraint and Seclusion
N. UW Health Clinical Policy 3.3.5, Participation of Patients’ Primary Supports and
Visitors




Page 8 of 8

VI. RELATED REFERENCES

A. How to Use Hibiclens, on U-Connect
B. Implementation Guidelines for Documenting Intake and Output (I&O)
C. Mobility Decision Support Tool (MDST)
https://uconnect.wisc.edu/clinical/patient-safety/quality-safety/smart-resources-and-
tips/mobility-decision-support-tool/
D. Male External Catheter (MEC) Care Document

VII. REFERENCES

A. Boltz, M., Capezuti, E., Fulmer, T., & Zwicker, D. (2012). Evidence-Based
Geriatric Nursing Protocols for Best Practice. New York, NY: Springer
Publishing Company.
B. Joosse, L., Palmer, D., & Lang, N. (2013). Caring for elderly patients with
dementia: nursing interventions. Nursing: Research and Reviews, 3, 107-117.
C. Potter, P., Perry, A., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8
th

Ed.). St. Louis, MO: Elsevier.
D. Berman, A., Snyder, S.J., Kozier, B., Erb, G.L. (2008) Fundamentals of nursing:
Concepts, process, and practice (8
th
Ed.). New Jersey: Pearson Education, Inc.
E. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L. (2014). Medical-
Surgical Nursing: Assessment and management of clinical problems (9
th
Ed.).
Missouri: Elsevier Mosby.

VIII. REVIEWED BY

Clinical Nurse Specialist, Geriatrics
Clinical Nurse Specialists, Nursing Quality and Safety
Nursing Practice Council, August 2016
Nursing Patient Care Policy and Procedure Committee, September 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer