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This is a discussion on Teaching CNA-1 classes & Std Precautions in Nursing Issues On Patient Safety, part of General Nursing ... I've been a nurse for 15 years in all kinds of settings-long term care, acute care, home health,...by mcneillmama3 Jun 1, '12I've been a nurse for 15 years in all kinds of settings-long term care, acute care, home health, geriatric case management. I recently went back to teaching CNA-1 classes and I'm confused about how the books are teaching certain skills such as bathing, foot care, hand care, and massage.
Standard precautions state to use gloves if in contact with body fluids except for sweat, and non-intact skin, when shaving a pt, when providing oral care, when providing perineal care, or if your own hands have open lesions, cuts, or injuries, etc. So why do the CNA textbooks show to wash a persons' hands and arms, wearing non-sterile gloves if that person's skin is intact and the person is not on wound/skin/contact precautions. The same book states for hand and foot care to wear gloves if there is a likelihood of coming in to contact with non-intact skin. The book states the same for a back rub. If we can touch a person's arms to take a BP or perform ROM exercises without applying gloves, then why are gloves being required to wash the same hand and arm?
My Mosby nurse skill videos I had from nursing school show the nurse bathing the arms, hands, abdomen and back only using a bath mit. Then the nurse applies gloves to wash the lower half of the body. This is the way I've always bathed my patients on the ICU. The only rationale I can come up with is that new CNAs lack the judgment to know when they should or shouldn't use gloves.
Does anyone know what the CDC's guidelines are for this? I found a chart on the CDC website which pretty much reiterates use gloves if coming in to contact with non-intact skin and mucuous membranes or for person's on contact precautions.
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- Jun 1, '12 by classicdameI have no answers but suggest goggling CDC and other infection control related sites. Also, there are sites for CNA continuing education that might have insight.
- Jun 1, '12 by mcneillmama3I found the answer to my question and I was right after 15 years of nursing. This is from the WHO website, the watchdog for infectious outbreaks, so I trust this information. If you'll look at page 3, there is a very useful pyramid that delineates when gloves are needed and when they are not needed. I'm sharing this with everyone. I figure if I'm confused by it, then others are too. I think the only raitonale for teaching bathing using gloves the entire time for CNAs is that they may lack the professional judgement that a LPN or RN would have from experience.
- Jun 1, '12 by Ashley, PICU RNQuote from mcneillmama3I disagree. I was a CNA for two years while in nursing school and gave plenty of bed baths to residents. I wore gloves. Here's why:I think the only raitonale for teaching bathing using gloves the entire time for CNAs is that they may lack the professional judgement that a LPN or RN would have from experience.
Nursing home residents do not always have the ability to keep themselves sufficiently clean. There are many residents who are said to be "independent" with toiling, but can't actually clean themselves thoroughly. There are many residents who are incontinent who are not cleaned thoroughly. There are residents who may have wounds, sores, skin tears, non-intact skin, that they, and I, are not aware of. Bed linens which may have been soiled overnight are not always changed in a timely manner, or the resident does not report the accident.
I can't tell you the number of times that I reached out to wash the hand or arm of a resident, who appeared clean and intact, and touched feces, dried blood, or skin that was wet with urine. Or the times that I adjusted the bed linen only to find that the resident had been incontinent and my hands were damp with urine.
So when giving a bed bath to nursing home residents, there is definitely a possibility that I would come into contact with body fluids and non-inact skin. Therefore I wore gloves.
- Jun 8, '12 by GDiFioreI have found that the texts of books agree with the CDC guidelines of wearing gloves for mucous membranes and non intact skin, but pictures and demo videos show the nurse or CNA wearing gloves all the time. I have read articles of the problem of over-gloving, including contamination of the environment and cross contamination of patients. Handwashing!
- Jun 8, '12 by mcneillmama3I agree with GDiFiore. Gloves don't prevent the spread of infections, handwashing does. I told my CNAs, if you walk into a patient's room and it is wreaking with feces or urine, that's an indication that you should glove up as soon as you walk in the room and probably gown up too. I've actually seen BM smeared on the side rails of beds when we were only turning and repositioning, but I think we still should be using professional judgement. I don't don gloves to take a BP or pulse or listen to an apical pulse, but I DO wash my hands and clean my stethoscope with alcohol before leaving the room. For example, the making an occupied bed skill states, "use gloves if indicated." We have to be educated enough to know when gloves are indicated and when we are over using. I've worked as a flu clinic nurse for many years and the CDC pink book guidelines state that gloves are not indicated for SC or IM injections. However our employer tells us in orientation each and every year that we are to use gloves only because the public thinks that gloves prevent the spread of infection and the public expects to see us wearing them. That is not correct rationale and it does not prevent the spread of infection since vinyl gloves are not sterile gloves. Plus it is causing skin break down on my own 52 year old skin from repeatedly removing vinyl gloves that stick to my skin and take the skin off with them. It is our responsibility as nurses to educate the public the correct way and stick to the evidence based/ science based practices that work.
- Jun 8, '12 by orthonurse55No matter what WHO or the CDC says, we have to teach the CNA students to wear the gloves according to the rules in the book. This is how they are going to be tested. As older nurses, we know it's not always needed or practical, but this is the way we teach it. I also teach from Mosby's - removing PPE is ridiculous! And it is definitely not what the CDC recommends.
- Jun 9, '12 by mcneillmama3That's what I told my students. They are the ones that will be standing in front of the examiner. The CNA text is inconsistent as well. Three skills state gloves "if indicated", then when it comes to washing somebody's hands and face, it tells them gloves are required. It makes no sense at all. I caught the removal process not being correct as well.
Let me ask you something-when you were taught sterile gowning and gloving, were you not taught that everything below the waist is considered contaminated? I was. So that means when you get ready to remove the gown, you should untie the waist strings with your gloves still on so as not to contaminate your hands. Then remove the gloves. Their books are telling them to remove their gloves, then untie the waist strings. It just boggles my mind. If the gloves are contaminated and the waist strings are contaminated, then the gloves should touch the waist strings, not the bare hands. Isn't that right? I got my Taylor nursing book out from nursing school and that's what Taylor states with the raitonale for why.
I love this forum. It is the best place to find practical, no nonsense answers.
- Jun 9, '12 by orthonurse55You are so right about taking off the gown with the gloves off! My other objection is washing their hands after removal of every piece of PPE. Ridiculous! It would take forever to get them out of a room! I've talked to our state inspectors about it and also showed them the CDC guidelines and they stand firm on the way Mosby's has it. (I am in Illinois).
- Jun 9, '12 by mcneillmama3I'm in NC and the entire process is just ludicrous. It does nothing to help ease the nursing shortage either! I had to complete EMT hands on skills testing at a state testing site back in the late 1990s and it was nothing compared to this new CNA testing. I think it's a big money racket. So many NAs are failing the hands on skills challenge on the first attempt and they have to pay every time they repeat the test. Who came up with this idea anyway? What bugs me is the books are so inconsistent across the board. They are going to learn these skills one way to pass a CNA test, and then if they go to nursing school, they are going to be taught the way we were and have to relearn everything they were taught.
I was taught in nursing school (and I've never contaminated myself or a patient) that you untie the waist strings with gloves on. Then remove gloves. Then untie the neck strings without touching your neck. Then you wash your hands before touching around your face. Then take off the mask. Then wash hands one more time before leaving the isolation room. Is that the way you learned sterile scrubbing?