Clients who are weak, frail, unsteady or confused will require the nurse’s assistance to bath or shower. Key aspects of assisting a client are outlined in Table 27.1. A client may feel faint and collapse in the bath or shower. If this occurs the nurse should immediately drain the bath or turn off the shower. Towels should be used to cover the client for warmth and dignity and extra towels should be placed under the client’s legs and feet to increase venous return. The nurse should summon immediate assistance and remain with the client, ensuring that the airway is clear. (See Chapter 48 for full emergency care actions in situations in which a person has fainted.)

TABLE 27.1 GUIDELINES FOR ASSISTING A CLIENT TO BATH OR SHOWER

Review and carry out the standard steps in Appendix 1

Action	Rationale
Prepare the bathroom:
• Adjust temperature and exclude draughts • Ensure bath or shower is clean • Ensure there is a non-slip mat or strips in the bottom of the bath or shower recess and a bathmat on the floor • Place a chair beside the bath or shower, or in the shower if needed (unless a mechanical hoist is used) • Ensure that all the required items are assembled in the bathroom and within easy reach	Avoids chilling Prevents cross-infection Provides non-slippery areas, thus preventing falls Provides a seat for the client while undressing and dressing or showering Avoids the nurse needing to leave the area at any stage
Assess the client’s mobility and strength, and gain assistance if necessary to assist client to the bathroom	Adequate assistance is necessary to promote safety and comfort
Offer the client use of toilet facilities before procedure	Helps to promote comfort
Adjust the water flow and temperature (if not automatically regulated) before client begins cleansing. Water temperature of 38–41°C is comfortable and safe for most clients. Turn on cold water first, then hot water when filling bath. Turn hot water off first	Prevents scalding. Water that is too hot may cause peripheral vasodilation and faintness
Help the client sit down and undress	Reduces the risk of falls
Observe the condition of the client’s skin	Detects any abnormalities
Using mechanical devices if appropriate, assist the client into the bath or shower. Offer a chair to sit on in the shower	Promotes safety, prevents falls
Ensure that the client is positioned away from the taps	Reduces risk of scalds
Encourage the client to participate as much as able, ensuring that all body areas are washed and that the skin is rinsed free of all soap	Promotes independence and adequate cleansing
When the client has completed washing, drain the bath or turn off the shower	Facilitates easier and safer exit from the bath or shower
Assist the client from the bath or shower and ensure that drying is thorough	Prevents excoriation, promotes comfort
While being dried the client should be seated or standing, holding supporting rails if able	Reduces fatigue, promotes safety
Enquire if the client wishes to use powder or deodorant. Avoid excessive amounts of powder	Powder can accumulate and ‘cake’ on the skin
Ensure that the client is dressed without delay	Helps to minimise fatigue and prevent chilling
Ensure that the client’s oral hygiene and hair-care needs are attended to.	Promotes comfort and self-esteem
Assist a male patient with a facial shave as required
Escort the client back to their room and allow a rest period if required	Restores energy after the exertion of the bath
Ensure that the client is comfortably positioned with all requirements within reach	Helps to promote comfort, sense of security and safety
Attend to the bathroom:
• Air room if possible • Ensure that bath or shower is clean • Remove any soiled linen • Return personal articles to the client’s unit	Ventilates the room and removes steam, prepares area for further use and minimises risk of cross-infection
Report and document	Client’s condition is evaluated so that appropriate care can be planned and implemented

Some clients will require special consideration when bathing or showering; for example, special attention is needed for clients who have drainage or intravenous (IV) tubing, wound dressings, plaster casts or specific skin disorders. There may also be special needs associated with surgical or other interventions.

BATHING THE CLIENT IN BED

Clients who are confined to bed or whose condition does not enable them to have a bath or shower may be provided with equipment for washing in bed, or may be given a bed bath by the nurse. If clients are able to wash unaided they are provided with all necessary items, the upper bedclothes turned down, and a towel placed over them for warmth and privacy. The nurse will need to help with washing and drying the back and any other parts of the body the client is unable to attend to independently. When each bath is completed and each client’s hair and teeth have been attended to, the nurse remakes the bed.

A complete bed bath involves washing the entire body of a client in bed. It is performed by the nurse when a client is unable to wash unaided. Clients who may require a bed bath include those who have a debilitating illness or are paralysed or unconscious. A bed bath is also frequently needed after surgery. Depending on the client’s level of mobility, either one or two nurses perform the procedure. Health care facilities commonly adopt their own specific guidelines concerning how to perform a bed bath. An alternative to the traditional sponge bowl method is the bag bath method (Clinical Interest Box 27.2).

CLINICAL INTEREST BOX 27.2 Bag bath method of washing a client in bed

This method involves the use of a bag containing 10 pre-moistened disposable cloths, each one used for a different area of the client’s body. A bag bath is convenient because it is made ready quickly by warming in the microwave oven and it avoids the use of a bowl filled with water. Bowls, if not cleaned satisfactorily, are a source of microorganisms. Therefore bag baths can reduce the risk of infection. However, they are an expensive option and are not used as commonly as other methods.

The following description of conducting a bed bath explains a more common approach. The basic equipment required for a bed bath is:

• Wash bowl with warm water

• Soap (on a soap dish)

• Two bath towels

• Two face washers

• Items for oral hygiene (e.g. toothbrush, toothpaste, denture cup, water)

• Hair brush and/or comb

• Powder, deodorant, body lotion (optional)

• As indicated:

— clean bed linen

— clean night clothes

— nail brush

— shaving equipment, make-up

— container for soiled linen.

• Throughout the bed bath the nurse should promote the privacy, safety and comfort of the client, while ensuring that all hygiene needs are met

• During the bed bath the nurse assesses the status of the client’s skin, hair, nails and level of mobility. The bed bath also provides time to talk with the client without interruption and it is often during this time that issues of concern are raised

• Clients should be encouraged to help themselves as much as they are able, to promote independence

• Clients who have not been bathed in bed before may be embarrassed about the exposure of their bodies and their loss of independence. It is the responsibility of the nurse to demonstrate sensitivity and to ensure adequate privacy throughout the procedure. The client’s privacy and warmth is maintained by exposing only the area that is being washed: this is achieved by using a dry towel to cover other areas of the client’s body

• The nurse who is to perform the bed bath must be aware if there are any limitations of movement or positioning for the client. For example, a client who has had a total hip replacement must not lie on the affected side and a client who is experiencing difficulty in breathing may need to remain sitting up throughout the bed bath to prevent further respiratory distress

• When dressing a client who has some impairment of an arm or leg (e.g. paralysis), the affected limb should be placed into the garment first so that maximum use may be made of the flexibility of the unaffected limb

• If a client is experiencing pain (e.g. after surgery) ensure that prescribed analgesia is given before the bed bath is performed

• Ensure that the water is the correct temperature and changed throughout the procedure when it becomes cool, too soapy, dirty or after washing the genital area

• If clients have a range of movement that permits it, when cleaning nails it may be helpful to place their hands and/or feet in the bowl of water. This is more refreshing for clients and enables the nails to be cleansed more effectively

• Ensure that all soap is rinsed off the skin, as residual soap may cause dryness

• Special care should be taken to ensure that all skin folds and creases are washed and thoroughly dried; for example, under breasts, in the groin area, between the buttocks, fingers and toes. If these areas are not dried properly the skin may become excoriated and painful

• If the client’s skin is very dry, bath oil may be used instead of soap, or a moisturising lotion applied after the bed bath

• Throughout the bed bath the client’s skin should be observed for areas of redness, breaks, bruises and other deviations from normal. (See Chapter 37 for information concerning skin changes and identifying signs of developing pressure ulcers [decubitus ulcers].) Deviations should be reported and documented. Nursing measures should be implemented as appropriate

• If the client has an indwelling urinary catheter or has had certain types of perineal or vaginal surgery, special care should be taken with perineal hygiene

• During the bed bath the client’s joints should be put through the full range of motion, unless this is contraindicated. Movement improves circulation, maintains joint mobility, and preserves muscle tone.

Table 27.2 provides the complete guidelines for performing a bed bath.

TABLE 27.2 GUIDELINES FOR PERFORMING A BED BATH

Review and carry out the standard steps in Appendix 1

Action	Rationale
Offer the client use of toilet facilities before starting the procedure	Helps promote comfort during the procedure
Clear the top of the locker or over-bed table	Provides space for bath equipment
Shut windows and doors and/or draw the screens around the bed and close blinds	Promotes privacy and warmth
Adjust the bed to a suitable height	Facilitates the procedure and prevents strain on the nurse’s back
Assemble all the items necessary at the bedside	Nurse must remain with the client throughout the procedure
Ascertain whether the assistance of a second or more nurses or a mechanical lifting device is necessary	Promotes comfort and safety
Wash and dry hands	Prevents cross-infection
Remove the upper bed covers and place them on a chair. Place a towel over the client	Facilitates the procedure and promotes warmth and privacy
Remove the client’s upper nightclothes	Exposes the body for adequate cleansing
Position the client lying back on one or two pillows, unless contraindicated	Allows a relaxing position, facilitates the procedure and prevents it from causing discomfort or distress
Begin to wash and dry the client (using one towel to protect the bedclothes) in the following suggested order:	Logical progression that ensures that all areas of the body are washed
• Face and neck • Arms and hands • Axillae, chest and breasts • Abdomen • Legs and feet • Genitals and groin (change water now) • Back and buttocks
Roll the client onto one side of the bed to wash the back. Straighten or replace the bottom bed sheets	Avoids moving the client again unnecessarily
Roll the client onto the other side and fit the bottom sheet into position over the mattress	To complete making the bottom part of the bed
Dress the client in clean nightclothes	Promotes warmth and comfort
Replace pillows and assist the client into position	Promotes comfort
Attend to the client’s hair and oral hygiene and a facial shave if necessary	All hygiene needs must be attended to
Replace the upper bedclothes and remove the towel	Promotes comfort and warmth
Replace equipment (e.g. the client’s personal items in the locker, and the signal device in easy reach)	Ensures that the surroundings are tidy and that client has easy access to their belongings
Disinfect wash bowl and tooth mug after use, in accordance with agency protocol	Infection control
Remove soiled linen container
Wash and dry hands
Note client’s response, document the procedure and report observations	Appropriate care can be planned and implemented

Perineal care

Many clients prefer to wash their own perineal area, and privacy should be provided for them if they are able to do so. The nurse may provide a degree of privacy by holding the covering towel or sheet up and away from the client’s body, forming a tent while the client washes their genital area beneath it. If the client is unable to wash the perineum unaided the nurse is advised to put on gloves and to place an underpad beneath the client to protect the mattress. Only the area to be washed should be exposed. If faecal material is present it should be enclosed in a fold of underpad or tissue or removed with disposable wipes or tissues. The anus and buttocks are then cleansed and dried and the soiled underpad removed and replaced with a clean one. The perineum should be washed and rinsed thoroughly and patted dry. Care should be taken to wash a female client’s perineum from front to back to minimise the risk of contamination from the anal area. Frequent perineal care may be needed for menstruating women. If needed, a fresh perineal pad should be put in place at the completion of the perineal wash.

Care should be taken to retract the foreskin of uncircumcised adult male clients so that the head of the penis can be cleaned effectively. Once the area is cleaned the foreskin should be returned to its natural position. The scrotum should be lifted and the area below washed, rinsed and dried thoroughly. Retraction of an infant’s or child’s foreskin is not recommended. The foreskin is resistive to retraction until separation of the foreskin and glans penis occurs naturally at about age 3–5 years. After this it is recommended that the child’s foreskin be checked only very occasionally for retraction. It is recommended that the child’s mother undertake this during the routine bath at home (Leifer 2007; Pantley 2003). Therefore, under normal circumstances the nurse will not need to retract the foreskin of children during their hygiene care. However, if the tip of a child’s penis shows signs of irritation this should be reported and documented. Normally this will clear up within a few days if a protective ointment, such as oil of vitamin E or an antibiotic ointment is applied after gentle cleansing (Peron 1991).

If there is a urinary catheter in situ, the area around it should be carefully washed with soap and water. When the perineal wash is completed the underpad is removed and the client made comfortable.

Providing intimate care can cause embarrassment to the nurse and to the client, but this should never result in personal hygiene being neglected. A professional, dignified and sensitive manner can help with uncomfortable feelings. Chapter 12 addresses issues of embarrassment during intimate care (Crisp & Taylor 2005; deWit 2005).

BATHING AN INFANT

Bath time should be an enjoyable occasion for the infant, and the bath should be completed as quickly and safely as possible. Preparation for a bath includes:

• Ensuring that the room is warm and draught-free

• Warming the towels and clothing

• Assembling all the items required: baby bath half-filled with water at 38°C; bath thermometer; two towels; a face washer; cotton wool swabs and cotton tipped applicators; mild soap or cleansing lotion; a clean set of clothing and napkins; baby oil, cream or powder; clean linen for the cot; a receptacle for soiled linen; hair brush; nail scissors; and gown or apron

• Preparing an area (e.g. on the bench or table beside the bath) on which the infant can be placed while being undressed, dried and dressed. A towel should be placed on the bench to provide a soft and warm area on which to place the infant.

The procedure for bathing the infant is as follows:

• Wash hands and put on gown or apron

• Lift the infant from the cot and place on the prepared area beside the bath

• Undress the infant, except for the nappy, which is left on

• Wrap the infant in a towel, and wash the face with cotton wool swabs moistened with warm water. Items such as cotton swabs should not be inserted into the nose or ears (Leifer 2007). The inside of the ears should be left alone, but the outer ear should be cleansed with moistened cottonwool. Pat the face gently to dry

• With the infant on the bench, unwrap the towel and remove the nappy. The infant should be washed in a top-to-toe direction, turning the surface of the washcloth as the bath progresses. The genitalia should be washed from front to back to prevent faecal matter from coming into contact with the urethra, as this would risk the onset of a urinary tract infection. A mild soap may be needed for heavily soiled areas. The type of soap used varies with each health care agency. Alkaline soaps should be avoided because they alter the pH of skin (Leifer 2007). Particular attention should be paid to the skin folds, axillae, groin and between the fingers and toes

• The nurse lifts the infant by sliding the left arm under the infant’s neck and shoulders to hold the infant’s left upper arm. The nurse’s right arm is placed under the infant’s buttocks to hold the left leg. The infant is gently lowered into the water, and the nurse’s left arm and hand remain in position to support and control the infant’s movements. (A left-handed nurse would probably be more comfortable reversing these arm positions.)

• Using the right hand the nurse rinses off the infant’s body. The infant should be allowed some time to splash and kick in the water

• The nurse then lifts the infant from the bath and returns the infant to the prepared bench. The infant is dried quickly but thoroughly. Where skin areas come in contact with each other there is a possibility of chafing, and particular care is needed when drying these areas, which include the folds of the neck, behind the ears, the axillae and the groin. Oil or cream may be applied sparingly (e.g. to the buttocks). The type of oils and creams used varies with different health care facilities. The use of baby powder is not recommended because it may irritate the respiratory tract (Leifer 2007)

• The infant is then dressed before becoming cold. The nappy is placed on first, then the singlet, then the gown, and then the hair is gently brushed.

The infant is then returned to the cot, which is made up with clean linen. A second nurse may be available to make the cot while the infant is being bathed, or the infant may be placed in an infant chair while the cot is made up. The infant should be placed in the cot lying on the back — the position recommended to reduce the incidence of sudden infant death syndrome (SIDS) (Barker 2007; Leifer 2007; Pantley 2003). Very young infants feel more secure if they are wrapped in a light blanket before the upper bedclothes are placed over them. The nurse should ensure that the sides of the cot are pulled up and fastened securely.

The used items are then attended to and the bath cleaned before it is used again. After washing the hands the nurse reports and documents anything of concern relating to the infant. (Areas that should be observed and assessed and abnormalities that may occur in infants are outlined in Chapter 23). As the infant grows rapidly in the first 12 months, the procedure is adapted to suit the child’s developmental level and, as the child grows, most of the actual washing is done in the bath, with the nurse supporting the infant as needed. Infants and young children must never be left unsupervised in a bath. Nurses have an important role in providing support and reassurance for new mothers, particularly when instructing them how to bath their babies.

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Tags: Tabbners Nursing Care Theory and Practice

Feb 12, 2017 | Posted by admin in NURSING | Comments Off

Nurse Key

Fastest Nurse Insight Engine

HYGIENE AND COMFORT

FACTORS AFFECTING PERSONAL HYGIENE

SKIN AND SKIN CARE

INFANTS

ADOLESCENTS

THE MIDDLE YEARS

OLDER ADULTS

NURSING OBSERVATIONS OF THE SKIN

BATHING AND SHOWERING

NURSING OBSERVATIONS AND ASSESSMENT

DEVICES TO ASSIST WITH BATHING OR SHOWERING

CLIENTS REQUIRING SPECIAL CONSIDERATION

A client with IV tubing

A client with a urinary catheter or wound-drainage tubing

A client with a wound dressing or bandage

A client with a plaster cast on a limb

A client with a skin disorder, or who has had perineal or rectal surgery

BATHING THE CLIENT IN BED

Perineal care

BATHING AN INFANT

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