The independent living philosophy holds that individuals have the right to live with dignity and appropriate support in their homes.

Key Principles

• Consumer’s choice
• Communication
• Independence
• Dignity of Risk

Appropriate vs. Inappropriate Approaches

Inappropriate approach:

• DCW: “All right, it’s time for you to eat lunch.”
• Consumer: “No, I am fine now.”
• DCW: “You have to. I have already put it on your table.”

Appropriate approach:

• DCW: “Okay, Mrs. Smith, are you ready for lunch?”
• Consumer: “No, no, no. I am not hungry now.”
• DCW: “May I serve you later, then?”

Working with Family Members

When dealing with relatives or other caregivers, maintain respect for the consumer’s choices while communicating effectively with family members.

Four General Helping Rules

1. The care plan is the starting place – Always read and understand each consumer’s care plan
2. When unsure, ask – Ask the consumer about their preferences and needs
3. Use a person-centered approach – Respect each person’s uniqueness and right to be involved in decisions
4. If immediate danger exists, act – Move to help immediately if consumer is at risk of injury

ADLs (Basic Activities)

• Eating & drinking
• Ambulating (moving about)
• Transferring (getting in/out of bed, chair, toilet)
• Taking medications
• Personal hygiene
• Bladder & bowel management
• Positioning and changing positions
• Securing health care

IADLs (More Complex Activities)

• Using the telephone
• Shopping
• Doing laundry
• Obtaining appropriate clothing
• Making appointments
• Writing correspondence
• Social and leisure activities
• Using prosthetic devices
• Managing finances
• Transportation

Understanding Changes in ADLs and IADLs

Types of consumers:

1. Long-term inability – Have had time to adjust and develop preferences
2. Recent loss – Still adjusting, may display anger or frustration
3. Brain damage – May not remember previous interactions
4. Short-term loss – Will recover, may be impatient with healing process

Assistance with Mealtime

1. Preparing the Consumer for Meals

• Ask if they want help with grooming
• Check if they need to use the bathroom
• Help wash hands or face if needed
• Ensure dentures are in place
• Ask where they’d like to sit

2. Serving Meals and Aiding During Meals

• Serve meals calmly and place within easy reach
• Ensure all needed utensils are available
• Check frequently if help is needed
• Cut food into small pieces to prevent choking
• Offer alternatives if food is refused
• Allow time between courses

What to Report to Supervisor

• Changes in assistance needed while eating
• Changes in mealtime behaviors
• Changes in attitude
• Choking while eating or drinking
• Eating more or less than usual
• Refusal to eat

Cultural Considerations

• Respect cultural preferences and beliefs
• Allow time for prayer if requested
• Honor food preferences influenced by culture, ethnicity, and religion

Cognitive Impairment

A temporary or permanent change within the brain affecting thinking, reasoning, and learning.

Temporary causes:

• Stress, medication, depression
• Vitamin deficiency, thyroid disease
• Alcohol, head trauma

Permanent causes:

• Severe head trauma, illness
• Brain disease, brain damage at birth

Disorders Causing Cognitive Impairment

• Depression – emotional sadness and withdrawal
• Anxiety – persistent feelings of fear and nervousness
• Suspiciousness – distrust of others
• Delusion – false belief not supported by reality
• Paranoia – irrational feeling of being persecuted
• Schizophrenia – suspiciousness, paranoia, and delusion
• Mental retardation – slowed or stopped brain maturation
• Dementia – progressive mental deterioration due to organic brain disease

Approaches for Advanced Dementia

Reality Orientation: Helps consumers remain aware of their environment, time, and themselves.

Validation Therapy: Helps consumers improve dignity and self-worth by acknowledging their feelings and memories.

Reminiscing: Allows consumers to talk about past experiences, especially pleasant ones.

Responses to Difficult Behavior

1. Remain calm, speak slowly and clearly
2. Avoid approaching from the side or back
3. Try to calm with appropriate physical comfort
4. Distract and redirect behavior
5. Allow expression of feelings if it reduces agitation

Dementia Clients Need Assistance With:

• Safety – Monitor movement and appropriate use of objects
• Nutrition – Assist to dining area, allow extra time, serve one food at a time
• Hydration – Offer fluids frequently, watch for signs of thirst
• Dressing – Choose appropriate clothing, offer limited choices
• Bathing – Prepare area, explain procedures, check temperature
• Elimination – Take to bathroom frequently, provide perineal care

As a direct care worker, protecting yourself and consumers from infectious diseases is essential.

What Are Infectious Diseases?

Infectious diseases are disorders caused by bacteria, viruses, fungi, or parasites that can pass from person to person through:

• Contact
• Body fluids
• Air
• Insects and animals
• Contaminated food or water

Common Flu-Like Symptoms to Watch For

• Elevated temperature (usually above 100.4°F/38°C)
• Fever, chills, and sweats
• Headache, fatigue
• Dry and persistent cough
• Shortness of breath, chest discomfort
• Muscle pain, sore throat
• Runny nose, nausea, vomiting, abdominal pain

Signs of Infected Wounds

• Fever
• Foul odor near the cut or wound
• Blood or yellow pus from the wound
• Pain in the affected area
• Warm, red, and swollen skin near the area

Signs of Urinary Tract Infection (UTI)

• Blood in urine
• Cloudy urine
• Elevated temperature
• Painful urination
• Strong urge to urinate that doesn’t go away
• Strong-smelling urine

Tuberculosis (TB) Symptoms

• Fever, chills, chest pain
• Weight loss, night sweats
• Breathlessness, loss of appetite
• Excessive fatigue
• Coughing up blood-streaked mucus
• Persistent cough lasting three weeks or longer

Intestinal Infections (C. diff)

Mild Infection:

• Watery diarrhea 3+ times daily for more than 1 day
• Mild abdominal cramping and tenderness

Moderate to Severe Infection:

• Watery diarrhea 10-15 times daily
• Severe abdominal cramping and pain
• Rapid heart rate, dehydration
• Fever, nausea
• Blood or pus in stool

Skin Infections

Pressure Ulcers Warning Signs:

• Unusual changes in skin color or texture
• Swelling
• Pus-like drainage with foul smell
• Areas cooler or warmer to touch
• Tender areas

Common Sites:

• Tailbone or buttocks
• Shoulder blades and spine
• Backs of arms and legs
• Head, hip, lower back
• Heels, ankles, behind knees

Scabies Signs:

• Intense itching (worse at night)
• Thin, wavy tunnels of tiny blisters or bumps
• Found between fingers/toes, armpits, waist, wrists, chest, genitals

Chickenpox:

• Flu-like symptoms (fever, fatigue, body aches)
• Red spots starting on face and chest
• Spots develop into itchy, fluid-filled blisters
• Blisters weep, form sores, then crusts

When to Wash Hands

• Before and after wearing gloves
• At start of workday and throughout the day
• When hands are visibly soiled
• Before direct contact with consumer’s skin
• After direct contact with consumer’s skin
• After assisting with toileting
• After using restroom
• Before eating or preparing food
• After wiping nose, sneezing, or touching face
• After smoking

How to Wash Hands Properly

1. Wet hands under warm, running water
2. Apply soap and lather all surfaces for at least 20 seconds
3. Wash palms, sides, back of hands, between fingers, thumbs, under nails
4. Rub nails across palm to remove dirt
5. Rinse under warm running water
6. Dry with clean towel or paper towel
7. Turn off faucet with paper towel
8. Use paper towel to open door when leaving

Using Gloves

• Use when contact with blood, body fluids, or contaminated surfaces is possible
• Remove sharp jewelry before putting on gloves
• Put fingers in tips first, then pull over clean hands
• Remove by pulling inside out
• Dispose of soiled material immediately

Cleaning and Disinfecting

1. Follow directions on cleaning products
2. Clean surface with soap and water first
3. Apply disinfectant and let stand as directed
4. Wipe with disposable paper towel or washable cloth
5. Always wash hands after cleaning, even if gloves were worn

Universal precautions treat all human blood and body fluids as if they were infectious for HIV, HBV, and other bloodborne pathogens.

Bloodborne Pathogens Include:

• HIV, Hepatitis A, B, C
• Staph and Strep infections
• Gastroenteritis, Pneumonia
• Syphilis, TB, Malaria
• Measles, Chicken Pox, Herpes
• Urinary tract infections, Blood infections

Other Potentially Infectious Materials (OPIM):

• Semen, vaginal secretions
• Cerebrospinal fluid, synovial fluid
• Pleural fluid, pericardial fluid
• Peritoneal fluid, amniotic fluid
• Saliva in dental procedures
• Any body fluid visibly contaminated with blood
• Unfixed tissue or organs

Standard Precautions Apply To:

1. Blood
2. All body fluids, secretions, and excretions (except sweat)
3. Non-intact skin
4. Mucous membranes

Transmission-Based Precautions:

• Airborne Precautions – for infections spread in small particles (chickenpox)
• Droplet Precautions – for infections spread in large droplets (influenza)
• Contact Precautions – for infections spread by skin-to-skin contact (herpes)

General Emergency Guidelines

• Notice and record what, where, and when
• Call 911 if you cannot handle the situation
• Give operator phone number, street address, and directions
• Write emergency information in advance and post it visibly
• Stay with consumer until help arrives

Warning Signs of Heart Attack

• Chest pain or discomfort
• Pain in arms, back, neck, jaw, or stomach
• Shortness of breath
• Nausea, lightheadedness, cold sweats

Warning Signs of Stroke

• Sudden numbness or weakness of face, arm, or leg
• Confusion or trouble speaking
• Blurred vision
• Trouble walking, dizziness
• Severe headache

Preventing Falls

• Ensure rugs and carpets are secured
• Check for clutter
• Provide adequate lighting
• Ensure chairs/couches are easy to exit
• Check for electrical/phone cords in walkways
• Proper footwear for weather conditions

When Someone Falls

• Try to communicate with the consumer
• If they can move, assist them carefully
• If they cannot move, do not force movement – call 911

Oxygen and Smoking Safety

DANGER: Smoking while using oxygen can cause explosions!

• If consumer refuses to stop smoking while on oxygen, do NOT unplug their oxygen
• Call supervisor immediately for instructions
• You may be instructed to leave the house immediately
• For small fires with accessible extinguisher, use it, otherwise evacuate and call 911

Safety Risks in Consumer’s Home

• Falls – Most common hazard
• Overexertion – From improper lifting
• Unsafe surroundings – Assess neighborhood safety
• Hostile pets – Should be locked up
• Guns – Should be locked up and out of sight
• Bad weather – Use good judgment, don’t compromise safety

Documentation is the cornerstone of quality care outcomes.

Main Reasons for Documenting

Communication: Share information among staff and service providers

Assessment: Primary reference for coordinators and case managers during re-assessments

Continuity of Care: Helps all staff understand current care needs

Shared Knowledge: Allows different staff members to understand medical history and interventions

Continuous Quality Improvement: Helps identify trends and changing needs

Physical Evidence: “If it isn’t written down, it never happened”

EVV Manual Correction (Timesheet)

When electronic system isn’t working, manually record:

• Type of service provided
• Name of individual receiving service
• Date and location of service delivery
• Name of individual providing service
• Time service begins and ends

All consumers have the right to be free from abuse, neglect, and exploitation.

What is Abuse?

Physical Abuse:

• Rough handling during care or transfers
• Over or under medicating
• Forced feeding or depriving of food/water
• Physical confinement or restraints
• Isolating consumer
• Denying access to phone calls or mail

Emotional Abuse:

• Yelling, making threats
• Humiliating or ridiculing
• Threatening gestures
• Ignoring consumer
• Menacing looks

Sexual Abuse:

• Rape, sodomy
• Unwanted kissing or touching
• Coerced nudity
• Forced oral sex
• Sexual harassment

Neglect

Willful deprivation of goods or services necessary to maintain physical or mental health:

• Ignoring care needs
• Not following care plan
• Not reporting new care needs
• Abandonment or desertion

Exploitation

• Unauthorized use of consumer’s resources
• Unexplained bank account changes
• Disappearance of valuables
• Unauthorized use of property or money

Reporting Requirements

• Immediately make oral report to area agency on aging or abuse hotline: 1-800-490-8505
• Within 48 hours submit written report
• Immediately notify agency manager about reports made

Understanding Behavioral Problems

Behavioral problems can result from depression, dementia, medications, or medical conditions.

Behavioral Problem Criteria:

• Creates danger for consumer
• Creates danger for caregivers or others
• Interferes with essential care
• Associated with emotional distress

Physical Aggression

• Never retaliate regardless of what consumer does
• Back away and use skills to help refocus and calm
• Make situations more pleasant when possible
• Join their reality rather than correcting them
• Use natural behavioral patterns when possible

Safe Approach Rules

• Approach slowly from 45-degree angle
• Never approach from behind
• Smile and make eye contact
• Identify yourself and explain actions
• Use calm, soothing, friendly voice
• Don’t lean over their body during care
• Be patient, don’t rush
• Accept who they are, be flexible
• Always be respectful

Verbal Abuse Response

• Remember: “This is not a bad person”
• “These are not willful behaviors”
• “This is not personal”
• Focus on providing essential care
• Remain professional at all times

Dealing with Frustration

• Assist without taking over completely
• Spend quality time with familiar activities
• Treat with kindness and dignity
• Act as if they are family members
• Build rapport for better service

Bathing Safety Tips

• Never leave confused or frail person alone
• Always check water temperature first
• Use hand-held showerhead
• Use rubber bathmat and safety bars
• Use sturdy shower chair for unsteady persons

Before Bathing

• Gather supplies: soap, washcloth, towels, shampoo
• Ensure bathroom is warm and well-lighted
• Play soft music if relaxing
• Be matter-of-fact about bathing
• Be gentle and respectful
• Don’t use bath oil (slippery and can cause UTIs)

During Bath or Shower

• Allow person to do as much as possible
• Put towel over shoulders or lap for dignity
• Use sponge or washcloth to clean under towel
• Distract with conversation if upset
• Give washcloth to hold (reduces hitting)

After Bathing

• Pat skin dry, don’t rub
• Dry between skin folds
• Use protective ointment if incontinent
• Consider sponge bath if transfer is difficult

Other Bathing Tips

• Full bath 2-3 times per week is sufficient
• Daily sponge bath for face, hands, feet, underarms, genitals
• Hair washing in sink may be easier
• Get professional help if needed

Shaving

Getting Ready:

• Decide between razor or electric shaver (electric usually safer)
• Collect supplies and mirror
• Ensure good lighting
• Have person sit in chair or up in bed

Electric Shaver Steps:

1. Wash and dry area or use electric-shaver cleaner
2. Hold shaver at 90-degree angle
3. Use back and forth strokes (or circles for rotary)
4. Apply moisturizer or aftershave if desired
5. Clean shaver according to directions

Standard Razor Steps:

1. Wash face with warm water to soften hair
2. Apply shaving cream
3. Shave with direction of hair growth
4. Press firmly but not too hard
5. Use short strokes, be careful around Adam’s apple, mouth, nose, chin
6. Rinse blade frequently
7. Remove lather with warm, moist cloth
8. Dry and apply moisturizer/aftershave if desired

Dressing Tips

• Allow person to dress independently as long as possible
• Lay out clothes in order they should be put on
• Hand one item at a time or give step-by-step instructions
• Reduce choices by putting away some clothes
• Keep closet locked if needed
• Buy multiple sets of same outfit if preferred
• Choose loose-fitting, comfortable clothing
• Avoid difficult fasteners
• Use Velcro or large zipper pulls instead of buttons
• Try slip-on shoes or shoes with Velcro straps

Grooming

Mouth Care:

• Show how to brush teeth step by step
• Help clean dentures
• Use water rinse after meals and mouthwash daily
• Try long-handled, angled, or electric toothbrush if needed

Other Grooming:

• Help with makeup if previously used (no eye makeup)
• Help with shaving using electric razor for safety
• Arrange barber or beauty shop visits
• Keep nails clean and trimmed

Hair Care for Seniors

Understanding Senior Hair:

• Grows more slowly with aging
• May become dry, brittle, and break easily
• Oil glands shrink, contributing to dryness
• Shedding may increase

Best Products:

• Shampoos with natural oils (argan, coconut)
• Conditioners with keratin, olive oil, shea butter
• Oil hair masks for moisture
• Boar bristle brushes (gentler)

Salon vs. Home Decision Factors:

• Physical mobility and safety
• Cognitive status
• Ability to process new environments

Hair Care for Bedbound Consumers:

• No-rinse shampoos
• Sage shampoo caps
• Hair wash basins

Washing Technique:

1. Fold pillow in half under back to lift head
2. Place towels under basin and on shoulders
3. Dilute shampoo in water
4. Pour on hair and gently rub through
5. Rinse thoroughly
6. Comb and dry gently
7. Style front area for appearance

Skin Care

Importance: Skin is the largest organ and primary barrier against infection.

Age-Related Changes:

• Becomes thin and dry
• Small cracks and tears occur easily
• Lacks mobility, leading to pressure sores

Daily Skin Care:

• Keep nails short and trimmed
• Don’t wear jewelry that might scratch
• Check skin during each encounter
• Excellent perineal care for incontinent consumers
• Reposition bed-bound or wheelchair consumers every 2 hours
• Keep skin dry with disposable pads
• Watch for signs of scratching (dry skin)
• Apply moisturizer after cleaning (heavier in winter, lighter in summer)
• Don’t apply lotion between toes
• Ensure proper nutrition and hydration

During Baths:

• Best time to observe skin condition
• Check for redness, blisters, cuts, dry patches
• Report anything new or unusual

Dental and Oral Care

Importance: Good oral health linked to overall health and lower pneumonia risk.

Denture Care:

• Remove at bedtime
• Handle carefully
• Clean regularly (avoid hard bristles and abrasive cleaners)
• Keep wet in denture case with water or cleaning solution
• Clean tongue, palate, gums after removing dentures
• Massage gums to stimulate circulation
• Use both sides of mouth when chewing

Warning Signs to Report:

• Bleeding gums
• Changes in how teeth fit together
• Red, swollen, tender gums
• Pus at gum line
• Changes in denture fit
• Bad breath
• Loss of taste or weight loss
• Loose or chipped teeth

Dry Mouth Solutions:

• Stay hydrated with regular water sips
• Suck on ice cubes or chips
• Avoid acidic or sugary foods
• Ask about saliva substitute sprays
• Use sugarless hard candies or gum

Ambulation (Walking)

Benefits: Prevents muscle atrophy, maintains cardiovascular/pulmonary function, prevents pressure injuries and contractures.

Before Ambulating:

• Check client chart for recent ambulation history
• Explain distance and assistance method
• Check functionality of assistive devices
• Ensure clear, non-slip route
• Check IV lines are untangled
• Ensure proper dress and non-skid footwear
• Get additional help if needed
• Stay with client throughout process

Preventing Orthostatic Hypotension:

• Get client to “dangling” position first (sitting on edge of bed)
• Allow time to adjust before standing
• Watch for dizziness or fainting

Transferring from Bed to Wheelchair

Pre-transfer Requirements:

• Consumer can bear weight on both legs
• Can take small steps predictably
• Use two-person transfer or mechanical lift if not

Transfer Steps:

1. Apply footwear before transfer
2. Adjust bed height, lower rails, position wheelchair at 45-degree angle
3. Apply brakes, place wheelchair on stronger side if applicable
4. Help client sit on edge of bed with feet on floor
5. Attach gait belt around waist if necessary
6. Place hands on consumer’s waist
7. Position legs outside consumer’s legs
8. Help consumer lean forward as you grasp gait belt
9. Rock front to back until reaching standing position
10. Take small steps backward until legs feel wheelchair
11. Have consumer grasp wheelchair arms
12. Lower slowly into wheelchair using arms for support
13. Ensure proper positioning and comfort

Wheelchair to Bed Transfer:

• Position chair at 45-degree angle
• Lock brakes, raise footplates, rotate leg rests outward
• Have consumer scoot forward over feet
• Block knees for additional support
• Avoid letting consumer lean on bed edge (wheelchair may tip)

Meal Preparation

Food Safety:

• Wash hands thoroughly before handling food
• Cook food thoroughly to proper temperatures
• Don’t reuse utensils/surfaces that touched raw meat

Portion Control:

• Smaller portions may be better for poor appetite
• Serve small meals frequently throughout day
• Use smaller plates and cups

Preparation Methods:

• Ask for consumer requests and preferences
• Avoid serving same thing daily unless requested
• Prepare by baking, slow-cooking, grilling, or broiling to limit fat
• Add healthy fats if weight gain needed
• Adjust spices for changing tastes
• Use plastic utensils if metallic taste reported

Managing Aromas:

• Cook when consumer is out or asleep
• Use fans to move cooking smells
• Prepare cold meals if odors are problematic
• Use cups with lids and straws

Planning:

• Use meal planning worksheets
• Coordinate with friends/family helpers
• Label prepared foods with eat-by dates
• Use online resources for coordination

Feeding Techniques

Hydration:

• Limit liquids during meals to build appetite
• Stop drinking 30 minutes before meals
• Serve moist foods (tomatoes, fruits, soups, puddings)
• Use food pictures to stimulate appetite

Social Aspects:

• Make meals social and fun
• Follow predictable schedules
• Respond compassionately to needs while maintaining health requirements

For Elderly Consumers:

• Consider dietary restrictions (low-salt, religious requirements)
• Pay attention to consistency, temperature, texture
• Cut foods to appropriate sizes
• Best foods for dementia: finger foods, small portions
• Present food attractively
• Be patient during feeding

Feeding Position:

• Position with head slightly flexed, chin downward
• Adjust seat to proper table height
• Guide gently if visual impairments exist
• Give emotional attention and respect opinions

Basic Safety Tips

• Encourage independence as much as possible
• Never lift consumer outright or have them pull on you
• Hold trunk and hips for stability, not arms or legs
• Always bend knees when supporting, not waist
• Stay close and ready for balance support

Clear Communication

Use short sentences and give plenty of time:

• “The toilet seat is right behind you. Squat down slowly to sit.”
• “I’m going to help you stand up now. Scoot your butt forward.”
• “Lean forward and put your hands on my forearms when you’re ready.”

Getting to Bathroom Safely

• Allow walking at their own pace but stay close
• Use small steps to turn around until toilet is behind them
• Make regular trips to reduce urgency (after meals, every couple hours)

Sitting and Standing Safely

Sitting:

• Ask them to lower slowly while placing hands on your forearms
• Steady with hands on their trunk
• Bend your knees as they lower

Standing:

• Ask them to scoot forward first
• Have them place hands on your forearms before rising
• Keep hands on their trunk and bend knees
• Don’t let them hold walker during sit/stand (could tip over)

Who Can Self-Administer Medications?

Individual must be able to:

1. Recognize and distinguish their medication
2. Know how much medication to take
3. Know when to take medication
4. Take or apply their own medication (with or without assistive technology)

Information Sources

Individual Care Plan (ISP) provides:

• Medications taken and assistance needed
• Special instructions for assistance type

Types of Assistance Needed

No assistance required

Assistance with self-administration may include:

• Reminding when it’s time to take medication
• Opening medication containers
• Pouring/placing specified dosage into consumer’s hand
• Observing while medication is taken
• Helping with pre-prepared medication organizers

Total assistance:

• Use of medication organizers prepared by responsible person
• Clear, simple instructions required
• Exact dose in clearly marked container with specific instructions

Documentation Requirements

• Record date and time when assistance was provided
• Document medications were administered according to consumer’s instructions
• Follow medication organizer schedule as directed

What DCW Cannot Do

• Cannot use professional judgment about medications
• Cannot make decisions about medications
• Cannot help identify medications if consumer is confused
• Cannot help sort out dosage/timing if consumer is confused