Annual PCA Training

As part of Virginia’s regulatory requirements, PCAs are required to undergo annual continuing education to keep their PCA certification. Below are some educational materials to help you. Please review the materials, take the short quiz, and we will load this into your personnel file. Thank you!

SECTION 1: HEALTH AND SAFETY

Indirect safety is an important component of a Caregiver/PCA’s duties. Ensuring your clients’ well being is a top priority so it’s important to understand all of the roles and responsibilities of a Caregiver/PCA when it comes to health and safety. Each section below goes into further detail on a number of subjects that a Caregiver/PCA can be responsible for while working with their clients at home. This information can be valuable to current Caregivers/PCAs just looking for a quick refresher on these important topics.

Communicable Diseases

As a Caregiver/PCA, you need to understand the role of bacteria and viruses in causing communicable diseases.

Communicable diseases, also called infectious diseases, are caused by viruses, bacteria, protozoa, fungi, and rickettsiae. These microorganisms can be inhaled, ingested, or injected into the host (affected person). The microorganisms multiply inside the host and cause an infection. Thereafter, the pathogens start exiting through mouth, nose, eyes, ears, intestines, urinary tract and open wounds of the infected person. When this host comes in contact with others, he transmits his infection to another person, that is, a new host. The new host spreads the disease to other unaffected individuals.

To break this chain of communicable disease, you need to break the infectious process. Practicing good hygiene and wearing gloves, surgical masks, face shields are some of the ways in which you can prevent the spread of communicable diseases. Other barrier devices that help Caregivers/PCAs from coming in contact with microorganisms include protective glasses, laboratory coats, gowns, mouthpieces, and resuscitation bags.

The most communicable diseases are:

Common Cold: This is a viral infection. Using good hygienic practices such as hand washing can help the disease from spreading.
Whooping Cough: This is a highly communicable disease-causing high-pitched uncontrollable coughing, respiratory infection, runny nose, and fever.
Strep Throat: This is another common communicable disease caused by Streptococcus pyogenes. Avoiding close contact with the infected individual is the only way to prevent this infection. Sneezing, coughing and handshakes spread the throat bacteria easily. Good hygienic practices such as hand washing can avoid the spread of this disease.
Gastroenteritis: This is a highly contagious disease that can occur due to eating contaminated food. Rotavirus and norovirus cause Gastroenteritis.
Pink Eye: Pink eye refers to bacterial or viral conjunctivitis, caused by staphylococcus or streptococcus. Avoiding handshakes and hugs with an infected person, and maintaining good personal hygiene helps to control the spread of this disease.
Gonorrhea: Gonorrhea is transmitted sexually by the Neisseria gonorrhoeae bacterium. Avoiding unprotected sex prevents the spread of Gonorrhea.
Hepatitis B: Hepatitis B virus causes hepatitis B, which causes inflammation of the liver, resulting in liver failure or cirrhosis.
HIV (human immunodeficiency virus): HIV is present in the vaginal fluids or semen of an infected person and gets transmitted sexually. In the late stages of this infection, it causes AIDS (acquired immunodeficiency syndrome). Sharing needles with HIV or AIDS hosts can also transmit this disease.
Warts (verruca): This is caused by the Human papilloma virus. There are circumscribed outgrowths on the skin which can be communicated by direct or indirect contact with the affected person.

The spread of communicable diseases can also be prevented by:

Providing proper education to the client about the type of disease
Explaining how the infection works
Encouraging:

- Hand sanitization
- Appropriate methods of storing and cleaning personal items
- Proper disposal of contaminated items

Medical and Surgical Asespsis

Proper knowledge of medical and surgical asepsis technique helps a Caregiver/PCA to prevent the transmission of infection.

Medical Asepsis

Medical asepsis is about eliminating the spread of microorganisms. It is a state of being free from disease-causing pathogens.

Hand hygiene and using alcohol-based hand rubs are some of the ways in which medical asepsis can be maintained. Let’s look at each of these procedures.

Hand hygiene – Using soap and water

Soap and water are used when hands are visibly soiled or dirt/organic material is present on hands.

Step 1: Bare the hands, forearms by pushing the gown sleeves above the wrists. Remove all items such as rings or wristwatch from the hands. Clothes and jewelry facilitate bacterial growth.
Step 2: Turn on the water and wet your hands and wrists.
Step 3: Apply 3 to 5 ml liquid soap from a soap dispenser to your wet hands. Rub the soap all over your hands.
Step 4: Rub your hands for 15 seconds. Ensure to lather each finger, by rubbing around them. Also, rub the back of your palms and under the fingernails. This helps to remove microorganisms from the hand.
Step 5: Rinse and dry your hands thoroughly. Blot with a paper towel to reduce skin irritation. The rubbing motion should be from the fingers to the forearm.
Step 6: Use the paper towel to turn off the faucet to prevent contamination. Do not touch the paper towel with the opposite hand.

Using Alcohol-based hand rubs

Alcohol-based hand rubs are used when the hands are not soiled, but you suspect the presence of microorganisms.

Step 1: Bare the hands, forearms by pushing the gown sleeves above the wrists. Remove all items such as rings or wristwatch from the hands. Clothes and jewelry facilitate bacterial growth.
Step 2: Apply a good quantity of antiseptic hand rub on your hands and wrists.
Step 3: Rub your hands for 15 to 30 seconds till the solution is dry. Ensure to rub each finger, the back of your palms and under the nails. This effectively disinfects the hand.

Surgical Asepsis

Surgical asepsis is a technique that ensures that sterile items remain sterile.

For instance, once hand hygiene is completed, the Caregiver/PCA dons sterile personal protective equipment (“PPE”) such as gloves, gown, face mask, hair cover, shoe covers, and face shields. It is important to use proper procedures to handle this PPE so that the sterility of this equipment is maintained to prevent contamination.

Follow these steps for maintaining sterility of the gown and gloves:

Step 1: Lift the gown at the neckline. Ensure that it does not come in contact with non-sterile areas.
Step 2: Hold the gown up, so that it falls open. Slide both arms into the gown sleeves. Do not extend the hands beyond the cuffs.
Step 3: Ask another assistant to stand behind you. Ask him to pull the gown shoulders up and tie the necktie.
Step 4: With fingers inside the gown sleeves, don the gloves on one hand first. Then with the gloved hand, don the gloves on the other hand. The gloves should be pulled over the gown cuffs. This maintains the sterility of the gown and the gloves.
Step 5: Hand the waist tie on the gown to the assistant and ask him to hold it with a sterile forceps. Make a turn and take the waist tie from the assistant. Secure the waist tie. Securing the gown ensures that the inside clothing is not exposed to a non-sterile area.

Protective Gear

Personal protective equipment or PPE is the equipment that Caregivers/PCAs use to avoid exposure to microorganisms and thereby prevent infection. This equipment includes:

Gloves:Gloves protect the hands by providing a barrier against fluids and blood when caring for clients.
Masks:Pathogens can spread through the respiratory system – the nose and mouth. Respiratory masks have a tight seal that covers the mouth and nose. These are especially useful to protect the nasal and oral mucous membranes against airborne organisms such as the tuberculosis bacillus.
Goggles:Face shields such as goggles can protect fluids from entering the eyes when there is splashing of fluids. Goggles protect the germs from entering the mucous membranes.
Gowns and Aprons: Gowns and aprons protect the inner clothing from getting contaminated. They are usually used during surgery to protect the Caregiver/PCA from infectious secretions such as wound drainage or discharges from the body.
Head and Shoe Covering:Headcovers protect the Caregivers/PCAs from sprays and airborne organisms. Similarly, shoe covers provide protection from airborne organisms and are used as a part of full barrier protection.
Disposal of PPE. There are special procedures for donning PPE and removing the equipment after use. The gown, gloves and other equipment should be worn in such a way that it is not contaminated. After use, the equipment should be disposed of in proper waste containers marked for cytotoxic PPE.

Equipment Care and Maintaining a Safe Environment

For infection control, the Caregiver/PCA should ensure that the client’s residence is properly disinfected.

Maintaining a safe environment – Spills, blood, vomit

The Caregiver/PCA uses certain strategies for decontaminating, cleaning and sterilizing the client’s residence. The strategies differ for small spots of blood or vomit, and larger spills.

The first step is to promptly remove the spots and spills. The next step is to clean and disinfect the area. In the case of small blood or fluid spills, the area can be cleaned with a detergent solution.

In the case of large blood or fluid spills, the Caregivers/PCAs should do the following:

Use paper towels to remove the spill.
Use a tool to remove any broken material such as glass.
Use absorbent material to soak up excess liquid.
Ensure that the appropriate PPE is worn at all times.

Alcohol is not used to clean any spills. However, sometimes sodium hypochlorite is used to eliminate bloodborne and gastrointestinal viruses, and bacteria.

Linen Care

Caregivers/PCAs should follow the client’s wishes regarding transport and storage of linen.

When handling used or contaminated linen, there is a risk of the spread of microorganisms on the clothing and in the environment. To avoid these risks, the Caregiver/PCA should do the following:

Use PPE such as gloves and aprons when handling and transporting used linen. This will prevent exposure of skin to microorganisms.
Hold the used linen away from the body when transporting it with hands. Avoid shaking it or dropping it on the way, as it can contaminate the area. Carry the linen in a bucket or a container.
Use appropriate laundry disposal equipment for disposing of used linen.
Ensure that the used linen is not washed in domestic washing machines, which are used for washing the client’s personal items.
Perform hand hygiene after handling used linen.

The used linen is washed with hot water and detergent as specified by the client or Agency policy. Ensure that clean linen is stored in a clean and dry place so that they are not contaminated by aerosol, dust, and moisture.

Client Safety

Client safety involves providing proper care to the client to keep him safe at home.

For this purpose, the Caregiver/PCA should ensure that the Client’s environment is safe:

Ensure that the client’s environment does not include slippery floors or objects on the floor that may cause falls.
Ensure electrical outlets and wires are not damaged or malfunctioning.
Ensure you know about a fire safety plan and know how to operate fire extinguishers.

Client safety also involves noting and informing any changes that occur in a client. Each client shows different symptoms of illness according to age and other factors. Therefore, it is important for Caregivers/PCAs to be attentive to the changes that occur in a Client at any point in time. The Caregiver/PCA should watch for physical and non-physical changes in a Client such as:

Movement: A change in movement such as poor balance, walking with wider steps, shifting balance to one side, indicate that the Client is at risk for falls, or he may be experiencing pain.
Bowel patterns or urination: If the client experiences constipation or urinary incontinence, it may indicate dehydration or some other medical condition such as kidney failure.
Appearance: Changes in the skin should be reported immediately as it may indicate infection, dehydration, or an illness that needs prompt attention. For instance, the Client may have a puffy or swollen skin, rashes on body, red or darkened skin (indicating the Client is bed sore), or dry and cracked lips.
Activity level: A Client may suddenly feel weak and there may be a decrease in his activity level which calls for immediate attention. Sudden weakness may also be a sign of stroke.
Vital signs: Change in temperature, blood pressure, pulse rate should be noted and informed immediately, as it may indicate an illness.
Appetite: Changes in appetite can indicate stomach problems, dental problems or sometimes even depression.
Sleeping: Poor sleep may indicate anxiety or depression. Medications, chronic problems, pneumonia, can also change sleeping patterns.

The first step for a Caregiver/PCA is to promptly report any such changes to the Agency Nurse. This will ensure that the Client gets prompt medical attention and also help protect them from further harm or injury. The Caregiver/PCA should also get information on what should be done and what should be avoided when providing care, to prevent the Client’s condition from becoming serious.

Effects of Aging on Clients

Aging causes different effects, such as physical and mental declines in a person. Knowledge of these effects will help a Caregiver/PCA to provide proper care for the elderly client.

The following effects are generally seen in all elderly clients:

Heart size increases and there is a decrease in cardiac output. This reduces the blood flow to the organs. There is also a decrease in the elasticity of blood vessels and reduced blood cell production. Decreased circulation also affects balance.
Respiratory muscles weaken.
Bone calcium decreases, and cartilage degenerates.
Subcutaneous fat decrease and hair and nails grow slowly. Skin becomes thinner and fragile.
There is a decrease in bladder capacity, metabolic rate, secretion of saliva, peripheral vision and sphincter control.
Liver function slows down and there is a reduction in the absorption of nutrients.
Eardrums thicken and there is an increase in wax production.
There is a decline in the sense of taste, smell and touch.
Hormone production decreases, sexual responses slow down and there is atrophy of the reproductive organs.
Hypertension, arthritis, diabetes, heart disease and obesity are commonly seen in older adults.
There are memory issues, such as loss of memory, unable to recall events, and reduced cognitive function.

Caregivers/PCAs should encourage the following behaviors in elderly clients for a healthy lifestyle:

Encourage the client to eat a healthy diet, as it delays aging. Add seasonings to counter the loss of taste.
Encourage the client to be active, if possible. Physical activity postpones the effects of aging. Exercise also reduces the risk of osteoporosis, hypertension, and diabetes.
Encourage the client to care for themselves and perform activities of daily living (ADLs).
Encourage cognitive exercises such as reading, writing, solving puzzles, and using a computer, to aid cognitive functioning

SECTION 2: PERSONAL CARE SKILLS & ACTIVITIES OF DAILY LIVING

You’ll want to pay extra close attention to this Client Care section. As always, be very aware of the Client Plan of Service and the Tasks assigned to you by the Agency Nurse. They should always guide your ADL activities.

Bathing:

Encouraging personal hygiene in Clients, and bathing critically ill clients are important duties of Caregivers/PCAs. Bathing clients is especially important as the clients are at a greater risk for infection if harmful microorganisms are not removed from the body. Bathing also relaxes the muscles and tissues, improves blood circulation and makes the Clients feel good.

When bathing clients, the Caregivers/PCAs should follow these guidelines:

Ensure safety: There is a possibility of various accidents during bathing, so the Caregivers/PCAs should ensure the safety of the environment. For instance, wet and slippery floors are likely to cause falls. Such accidents can be avoided by providing assistive devices to clients such as walkers. Notice for any signs of weakness, dizziness that can cause falls. Use lukewarm water and mild soap, when bathing the elderly clients. Other than accidents, there may be scratches or skin breaks that need to be prevented when bathing Clients. Skin breaks can become an entry point for disease-causing microorganisms. Drying the body parts with a towel is also important as microorganisms thrive in wet and warm areas such as armpits and buttocks.

Ensure privacy: Ensure that curtains are used and/or close the door when undressing and bathing the client.
Note any skin conditions: Redness or blisters on the client’s skin should immediately be reported to the Agency Nurse so that the client receives prompt treatment. Some clients with disabilities may have bed sores or pressure sores that occur when the client is confined to the bed for a long time. Bedsores are likely to be found in elderly clients on areas such as the hips, elbows, spine or shoulders.

As bedsores are painful and do not heal easily, it is important to treat them properly and in time. The best approach is to ensure that the clients do not develop bedsores. For that purpose, the Caregivers/PCAs can take the following actions:

Turn the clients at regular intervals, so pressure is not prolonged on one particular bony area
Re-position clients to make them comfortable
Use protective devices such as pressure relief cushions
Provide proper diet

Oral Care

Caregivers/PCAs may need to provide oral care to clients who are unable to eat, drink or clean their mouth without assistance. Proper oral care helps prevent infections and other oral problems. Oral care management involves using appropriate oral care equipment and providing proper oral care periodically. For instance, materials such as pediatric toothbrushes, sponge-stick, oral aspiration tools, tongue depressor, and sterilized water are used to keep the client’s mouth clean, hydrated and free from microorganisms.

Oral care procedures are different for each client. For most clients, the Caregiver/PCA should perform the following actions:

Inform the client about oral care so that the client can assist in the care process.
Perform hand hygiene and wear gloves. Raise the client’s head and cover the chest with a towel.
Use a pediatric toothbrush and a small amount of toothpaste to clean the client’s teeth, gums and tongue.
When brushing, note any signs of bleeding or infection in the client’s mouth. If any lesions or abscesses are seen, report immediately to the Agency Nurse so that appropriate treatment can be provided.
After brushing, help the client take small amounts of water into the mouth to remove the toothpaste.
Place the client back onto the bed.

If the client is using dentures, ensure that these false teeth are also brushed and cleaned properly with warm water. Dentures should be rinsed and placed in a container stating the client’s name, to prevent loss or damage.

To avoid bad breath, and the growth of bacteria in the mouth, tooth brushing should be done at least twice daily.

Shaving

Shaving hair is one of the important activities for a client to look well-groomed. Some clients may not be able to skillfully shave which may result in accidental cuts. Apart from pain and bleeding, such cuts also act as an entry point for the disease-causing microorganisms to enter the body. Therefore, shaving clients becomes one of the important tasks for the Caregiver/PCA. To avoid accidents, the Caregiver/PCA should use proper equipment for shaving.

The Caregiver/PCA should perform the following actions when shaving clients:

Apply a thin layer of shaving cream or a towel soaked in lukewarm water to areas that are to be shaved. Using a warm towel softens the skins and makes it easier to shave.
Use an electric razor for shaving, as manual razors increase the risk for cuts and bleeding.
Stretch the skin if required and shave in the direction where the hair grows.
After shaving, wash the client’s face and pat it dry with a towel.

Nail Care

One of the important duties of a Caregiver/PCA is to provide nail care to a client. Some clients are too weak to perform activities of daily living and may need the assistance of a Caregiver/PCA. Nail care is important to prevent the spread of infections that may occur due to scratching. The clients’ nail beds are also likely to have microorganisms that may enter the body if there is breakage in the skin due to scratching.

The Caregiver/PCA should use the following guidelines while providing manicure and pedicure to a client:

Ensure to have suitable sterile materials for nail care such as warm water, soap, nail cutter, lotion, towel, and orange stick.
Perform hand hygiene and put on your gloves.
Ensure that the client is comfortably situated before beginning nail care.
To sterilize the client’s fingers and toes, soak them in warm soapy water.
Take the hands/feet from the water and use the orange stick to gently clean the nails. Next, clip one nail at a time.
Look for any signs of fungal growth or inflammation in the nail beds. If there are any signs of infection, report immediately to the supervisor.
Once cleaned and clipped, use a towel to wipe the client’s fingers/toes.
The rough or sharp areas of the nails are then filed, for smoothness.
Apply hand/feet lotion as required.
Ensure to correctly dispose of all soiled material, linen or wash-cloth used for manicure and pedicure. Perform hand hygiene.

Providing nail care to a diabetic client is critical as a small nick can result in a serious infection. It is usually performed by a doctor or a nail care specialist. In a diabetic client, the body tissues do not repair naturally, so a minor scratch on the skin can cause an infection. An orange stick is also not ideally used for a diabetic client as it increases the risk for nail fungus. The cuticles should not be clipped, but gently pushed back. Clipping the nails too short may also cause irritation and should be avoided. In case there are ulcers on the skin, avoid pedicures and manicures until the ulcers heal completely.

Hair Care

Assisting clients with hair care is one of the duties of a Caregiver/PCA. Clients with weak motor movements or other disabilities may find it difficult to comb, wash or oil their hair. It becomes imperative for the Caregiver/PCA to assist such clients and make their hair clean and healthy.

However, there are no standard procedures for providing hair care to a client. It is one of the grooming activities that can keep the client healthy both physically and emotionally, and improve their self-esteem.

Before performing hair care, the Caregiver/PCA should inform the client that he or she is going to brush or comb the client’s hair. Talking to the client’s family members to understand the client’s preferences is another way to make the client comfortable. For instance, some clients may prefer a cosmetician to do their hair, and their decision should be considered.

When providing hair care, the Caregiver/PCA should take the following actions:

Put on the gloves and gather all the required supplies for hair care such as comb, oil or other hair care products.
Enquire how the client would like his hair done.
Even when you are brushing the hair, talk to the client to know how the client is feeling or is experiencing any pain.
Use gentle movements when combing towards the scalp.
Observe the client’s facial expressions for any signs of pain.

Nutrition

As a Caregiver/PCA, you need to ensure that a Client gets proper nutrition, is properly hydrated and eats a balanced diet.

Encouraging the client to eat a balanced diet, containing the right amounts of protein, carbohydrates, fats, minerals, and vitamins will positively impact the health and wellness of a client. At the same time, ensuring that the client consumes the right amount of water each day will keep the client’s body hydrated, replace fluid loss, aid digestion and help maintain the body temperature.

Caregiver/PCAs should ensure that the client eats a diet which contains the following nutrients:

Carbohydrates: Grains, fruits, vegetables, sugars
Fats: Butter, oils, meat, milk, nuts
Proteins: Meat, fish, cheese, beans
Calcium: Dairy products, broccoli, kale
Iron: Beef, chicken, nuts
Vitamins: milk, eggs, liver, cereals, sweet potatoes, kale

The Caregiver/PCA should ensure that there is a balance between the calories consumed by the client and the calories expended. This will help maintain a proper body weight.

The dietary requirements of each client are different, and the Caregiver/PCA should ensure that the client is consuming the prescribed diet. For instance, a soft diet should have everything that has a soft and smooth texture. A low sodium diet should have very low amounts of salt. As a rule, the Caregiver/PCA should check the client’s chart before giving them food.

Caregiver/PCAs should also note any dietary changes in elderly clients. In elderly clients, aging affects the sense of smell, thirst, and taste leading to a decrease in appetite. This may further lead to malnourishment and body malfunction if their bodies do not get the daily calorie requirement. The Caregiver/PCA should encourage the client to eat as much as possible. It is also a good strategy to feed the client in small portions. Another strategy is to add healthy and prescribed supplements, seasonings to food that will encourage the client to eat well. Adding the client’s favorite food to the meal, if not forbidden by the physician, will also increase the client’s appetite.

Using the Toilet

Assisting clients with toileting is one of the responsibilities of the Caregiver/PCA. Helping the client use the toilet successfully also helps the client maintain self-respect. It also helps to avoid any accidents such as falls in elderly clients, who experience weakness, blood pressure changes, or are prone to accidents such as falls.

When assisting with toileting, the primary responsibility of the Caregiver/PCA is to be present with the client for balance and support. The Caregiver/PCA should walk the client to the bathroom, clean them, and be aware of their toileting needs. Sometimes, some clients experience age-related incontinence, or in some cases, medications or too little water intake can cause constipation. In such cases, it becomes important for the Caregiver/PCA to monitor the client’s toileting routine, and also monitor their food and fluid intake.

While assisting with toileting, the Caregiver/PCA should also note any problem associated with defecation such as watery stools, diarrhea, or signs of dehydration. Any problem should be promptly noted to the Agency Nurse so that immediate treatment or dietary changes can be prescribed for the client.

Some elderly clients have inconsistent toileting routines, while others become unaware or forget to go to the bathroom. They may also defecate on themselves, or on the floor, due to decreased control in eliminating wastes. Such incidents can be embarrassing and also cause accidents such as falls. In order to prevent such incidents the Caregiver/PCA should take the following actions:

Keep a record of the client’s fluid and food intake.
Clean up the area immediately in case the client defecates or urinates.
Ensure that all members of the healthcare team are aware of the toileting routines of the client.

Caregiver/PCAs should also have proper infection control procedures of how to use the bedpan and urinal in order to maintain sanitation. Gloves should be worn when handling any waste such as feces or urine. Proper hygienic practices should also be followed after assisting the client.

Rest and Comfort

Rest and sleep are important for a client to restore the energies of the body, keep him mentally relaxed, free from worry, and physically calm. Lack of proper sleep can cause fatigue, increase blood pressure, impair the ability to think clearly and make the client susceptible to infections.

Most of the time, chronic pain and discomfort due to conditions such as osteoarthritis, osteoporosis, amputation, surgery, cancer, or other disabilities, may affect the client’s sleep patterns. Other factors that affect sleep can include unfamiliar beds, roommates, wrinkled linens, or bright lights in the room.

In such cases, it is the Caregiver/PCA’s responsibility to promote the client’s sleep by increasing client comfort and managing their pain.

The Caregiver/PCA should take the following actions to manage the client’s pain. Relief from pain will immediately increase client comfort.

The first step is to recognize the symptoms of pain and discomfort in the client. This includes observing the verbal and nonverbal expressions of pain such as moaning, wincing, restlessness, or rubbing body parts.
Report any signs of pain immediately to the Agency Nurse so prompt actions can be taken for pain relief.
Assist Client with the application of heat and cold to affected body parts and as prescribed as they are effective strategies for pain relief.
Provide back rubs for stress relief. Repositioning the client is another strategy to increase client comfort.

The Caregiver/PCA should perform the following actions to promote rest and sleep in the client:

Be aware of the client’s bedtime and waking time. Try and maintain this routine every day.
Ensure that the client’s bladders/bowels are empty, to reduce discomfort related to these areas.
Engage the client in exercise or physical activity during the day and reduce napping times.
Educate the client on the importance of sleep and techniques to promote sleep.
Ensure there are no distractions at night, such as bright lights, loud noises, etc, so that the client sleeps peacefully.

Ensure that the sleeping environment is restful and neither too hot nor cold.