Practice Documenting: ADLs

Aisha is a 72-year-old female at a long-term care facility. They have Parkinson’s disease and need assistance with their activities of daily living. Today they are feeling well on the day shift. Normally they have more energy in the morning and can do more for themself. You are the nurse assistant helping them today. After greeting Aisha, you help them swing their legs over the edge of the bed and let them dangle. Then you put their slippers on their feet and put the gait belt around their waist. You hold on to the gait belt and walk with them to the bathroom until they feel steady on their feet. Once in the bathroom you take their comb, toothbrush, and toothpaste from the drawer and place them on the counter. You stand next to them in case they get dizzy or need help. They comb their own hair and brush their own teeth without any difficulty. They clean their glasses and put them back on their face. Once done you assist them onto the toilet and give them some privacy so they can urinate. You ask them what clothes they would like to wear today and go get those from the closet. After donning your gloves, you run warm water into the wash basin, wet the washcloth, and hand it to them so they can wash their face. You go through the process of the partial bath by offering them a soapy and a rinse washcloth and a towel, allowing them to wash, rinse, and then dry each body part. You hand the bra and shirt to them, and they put those on themself. You remove their slippers and assist in placing their feet and legs into their underwear and pant legs. You place their socks and shoes on their feet for them. You replace the gait belt in case they need assistance in standing, but they do not today. They stand up and pull up their underwear and pants. You then walk with them using the gait belt out of the room, down the hallway, and into the dining room, where they eat breakfast with their friends without help. Throughout the day you continue to check on them every two hours and assist them to the toilet as needed. You help them walk to lunch by using the gait belt and walking them down the hallway to the dining room again. In the afternoon they become tired and want to take a nap. You assist them from the chair in their room to their bed in the same manner as before, remove their shoes, and let them rest comfortably until the 3–11 folks start their shift.

How would you document Aisha’s activities of daily living on the 7–3 shift?