Basic Nursing Care and Patient Hygiene
This domain tests the routine care a health care assistant performs daily: bed making, positioning, the hygiene sequence, pressure-injury prevention, and taking and recording vital signs within normal ranges.
Vital signs (adult, at rest)
- Temperature 36.5–37.5 °C (axillary slightly lower than oral).
- Pulse 60–100 beats/min, regular, normal volume.
- Respiration 12–20 breaths/min.
- Blood pressure about 120/80 mmHg; record systolic first.
- Report temperature above 38 °C, pulse below 60 or above 100, respiration above 24, or systolic below 90 mmHg.
Hygiene and comfort
- Early morning care: wash face and hands, mouth care, bedpan, straighten the bed.
- Morning care: bed bath, back care, oral care, hair and nails, change of linen.
- Evening (HS) care: wash, oral care, back massage, comfortable position, call bell in reach.
- Bed-bath order: eyes (inner to outer corner) → face → neck → arms → chest → abdomen → legs → back → perineum last, using a fresh part of the towel each stroke.
- Unconscious patient: nothing by mouth; clean the mouth with gauze held in forceps, keep suction ready, place the patient laterally.
- Pressure injury: reposition at least every 2 hours, inspect bony prominences, keep skin clean and dry, use a risk score, never massage a reddened area.
Positions
Fowler's/semi-Fowler's - breathlessness, NG feeding. Lateral - unconscious patient, pressure relief. Supine - routine examination. Lithotomy - delivery, pelvic examination.
Worked example
An unconscious stroke patient needs mouth care. Reasoning: the gag reflex is absent, so fluid would be aspirated into the lungs. Therefore no water or mouthwash, lateral position, gauze wrapped on forceps, suction at hand, and the number of gauze pieces counted and recorded.
Traps that cost marks
Giving sips of water to an unconscious patient; applying a hot water bottle to numb skin; recording a blood pressure as the pulse; omitting time, site or route when charting temperature; leaving side rails down.