Chapter 27 HYGIENE AND COMFORT
Hygiene is the science of health and its preservation and can also be described as cleanliness that is conducive to the preservation of health. Personal cleanliness helps the individual to maintain a positive body image and helps protect the body against disease such as infection. Comfort may be described as ease or wellbeing; for people to feel comfortable their physiological, psychological and spiritual needs must be met. This chapter introduces nurses to knowledge and skills required to assist clients with their hygiene and physical comfort needs.
The thing that I value most is the nurse who is calm and organised, gets all of my things ready before helping me get undressed for my shower. There is nothing worse than being left cold and shivering while the nurse runs to get something that was forgotten. It makes a difference, too, having my mouth cleaned thoroughly, especially after I’ve eaten, and having my hair brushed properly. It’s so frustrating not being able to do everything for myself anymore. I wonder if the nurses really know what a huge difference it makes to my life to feel clean and fresh and tidy and to get that way with a minimum of fuss.
Many factors influence whether or not a client is comfortable; they relate to physical, emotional and spiritual needs being met. To most people, physical comfort means being clean, dry, warm and free of hunger and pain. Emotional comfort relates more to being relatively free from stress and feeling satisfied with interpersonal relationships; in particular, people are more likely to be emotionally content when they feel loved and are able to love others. Spiritual comfort is connected to a sense of purpose and satisfaction in life that may or may not be entwined with religious meaning. The nurse considers all these interrelated elements when caring for clients’ comfort. This chapter deals with the physical elements of comfort, specifically in relation to hygiene care and moving and positioning clients. Management of pain is dealt with in depth in Chapter 35. Information about assisting clients with stress and spiritual comfort is provided in Chapters 11 and 13.
Personal hygiene refers to the measures people take to keep their bodies clean. Neglect of personal hygiene can have a detrimental effect on physical and psychological health and the comfort of an individual. Many factors influence people with regard to personal hygiene practices. It is important for nurses to appreciate that emphasis on cleanliness varies according to an individual’s personal preference, cultural or religious values, and lifestyle. Other factors that may affect an individual’s hygiene practices include:
Nurses should respect individual preferences and cultural norms and whenever possible enable clients to follow their usual routine of personal cleansing. For example, if a client prefers to bath rather than shower or to shower in the evening rather than the morning, or to shower every second day, these practices are best continued. Maintaining routine and normality can help limit the stress of illness.
Many clients will be able to attend to their own hygiene, while others will require partial or total assistance from the nurse. Some clients — those who are unconscious, for example — will be unable to participate in planning their own hygiene care. In these instances it is the responsibility of the nurse to ensure that suitable nursing care plans are devised to meet hygiene needs. Assessing clients’ abilities to care for their own hygiene needs safely and effectively includes identifying factors such as loss of balance, poor vision, decreased sense of touch or limitations in mobility. In the case of some older people with dementia, the ability to remember, plan and carry out self-care activities will need to be assessed. It is important for the nurse to recognise that an inability to care for personal hygiene needs without assistance, and the lack of privacy that accompanies intervention by another person, can be very embarrassing for the client. The associated loss of independence can be demoralising and depressing. A calm, sensitive, caring and professional approach can help reduce these effects. The nurse who is providing care in the client’s home needs to be mindful that, for some, even necessary visits by helpful professionals may feel like an invasion of the sanctity that home normally provides.
Wherever care is provided, the nurse’s role is to ensure that the client maintains high standards of personal hygiene for efficient body function and sense of wellbeing. It is important for the nurse to be aware of the function and care requirements of areas such as the skin, hair, mouth, eyes, nose, ears and nails to help clients maintain high standards of personal hygiene in each of these areas. Assisting with hygiene provides an ideal opportunity for the nurse to observe and assess the client for any abnormalities or changes in health status. It also provides a time to talk informally together, which can provide the nurse with insights about the client’s psychological and spiritual wellbeing. The nurse must, on every occasion, seek the consent of the client before starting to provide any personal care and assistance.
The skin is a semipermeable layer that protects underlying tissues and organs from injury or invasion by microorganisms. It is waterproof, controls the rate at which water is lost from the body by evaporation, helps regulate body temperature, and produces keratin, melanin, sweat and sebum. The skin also plays an important role in perception of sensation through the sensory nerve endings it contains, which are sensitive to touch, pressure, pain and temperature. (See Chapters 37 and 42 for more information about the skin and sensory abilities.)
If the skin is not washed regularly dirt, sebum, dried sweat and dead skin cells collect, providing an ideal medium for the growth of bacteria and fungi. Bacteria decompose the dirt and dried sweat producing an unpleasant body odour, and infections such as boils are more likely if the skin is not cleansed adequately.
Skin undergoes many changes during a person’s life span and, as a result, care needs may vary according to the client’s age or stage of development. In addition, characteristics of normal skin may vary according to ethnic or racial background.
In infancy the skin is soft and smooth and less resistant to injury or infection. It is very sensitive to heat or cold, so it is vital that the temperature of bath water is tested before bathing. Mild non-irritating soaps and lotions should be used on the skin and, as the infant has no bladder or bowel control, thorough cleansing of the genital and anal areas is necessary to prevent excoriation. After washing, the infant’s skin should be patted dry with a soft towel paying particular attention to skin creases and folds. Cradle cap, a crusting on the scalp, which may occur as a result of an accumulation of sebum, can usually be prevented by regular gentle washing and drying of the scalp and hair (Barker 2007; Pantley 2003).
Adolescence is accompanied by many changes that are due to hormonal activity. Sweating from the axilla usually occurs at this stage and the adolescent may need education concerning the importance of having a regular shower or bath. Education can also include information about the function of deodorant and antiperspirant. Acne is a common problem, and skin hygiene, together with a balanced diet, is important in preventing secondary skin infections.
Middle age is often associated with further skin changes, particularly during the female climacteric or menopause. Because of a decrease in circulating ovarian hormone levels, the skin may become drier and the pubic and axillary hair may become sparse. Some women experience thinning and dryness of the external genitalia, which may be accompanied by pruritus. Lubricants are available to reduce the discomfort this can produce.
Older age is associated with increasing changes in the dermis, with the result that skin is thinner, less elastic and dry. The decreased production of sebum and associated dryness mean that the skin of older people is less able to tolerate soap. To help counteract the dryness, a mild soap or soap-free washing lotion can be used. Oil may be added to the bath water, or a moisturising lotion applied after a bath or shower. To prevent skin irritation caused by dry skin some older people choose to change from a daily shower or bath to every second day or less frequently (Clinical Interest Box 27.1).
CLINICAL INTEREST BOX 27.1 Hygiene and the elderly
My skin just won’t tolerate being washed every day now, even when I use plenty of cream, my legs are still flaky and itchy, so now I only have a shower every other day. You know, I just stand at the sink and wash the essential bits, under my arms and the private bits down below. A ‘top and tail’ I call it. Even when I do shower I can’t use soap on my legs.
(Mrs Bolton, age 72)
Care of the skin includes maintenance of cleanliness and protection from injury. The skin must be protected against injury by gentle handling and the use of appropriate bed linen and equipment. Cleansing involves the use of soaps and lotions that do not cause irritation or dryness, and careful drying of the skin, particularly in folds or creases. If the client wishes, and it is not contraindicated, deodorants, powders and perfumes may be used to enhance the feeling of freshness and to improve morale. Cleansing of the skin may be achieved by several means and the method selected depends on the client’s level of mobility and independence. Some clients will be able to have a bath or shower, while more dependent clients may require a bed or trolley bath. Whichever method of cleansing is used the nurse must ensure the client’s privacy, comfort and safety. It is now sometimes a reality that male and female clients are accommodated in the same ward or unit area and some even share bathroom and toilet facilities. This can increase the client’s discomfort and concerns about privacy, especially during hygiene and toileting procedures. The nurse will need to be sensitive to the concerns of clients faced with this situation and make every possible effort to reassure them that every effort will be made to maintain their personal privacy (Crisp & Taylor 2005; deWit 2005; Springhouse Staff 2007).
A client may have either a bath or a shower, depending on individual preference and general condition. Both methods of cleansing refresh the client, stimulate circulation and promote relaxation. They also provide an opportunity for the nurse to observe the condition of the client’s body, including assessment of mobility and strength.
If clients are able to attend to personal hygiene needs safely and independently, they may be left to bath or shower in private. It is the responsibility of the nurse to ensure that the bathroom has been prepared for use, and that the client has all the necessary items. The nurse should ensure that the client knows where the signal bell is and how to use it to call for a nurse.
It is the nurse’s responsibility to assess how much assistance a more dependent client requires. Some clients may need help to get in or out of the bath or shower, while others will require the nurse to remain with them throughout the entire procedure. The nurse should remain with, and provide assistance for, any client who is weak, frail, unsteady or confused. Some clients may require a waterproof chair to sit on during the shower. For example, a chair would be helpful for a postoperative client who can walk to the shower but is at risk of becoming easily fatigued.
Handrails fixed to the wall at the side of the bath or shower can be used for support by clients who are able to stand. Bath benches or seats fit across the top of a bath, allowing clients who find it difficult to get in and out of the bath to sit with their feet in the water and be sponged down or, if there is a shower nozzle fitted over the bath, to be showered. Bath seats are commonly used in the home. Grab rails are often fitted on the wall adjacent to the bath to assist clients who are frail or weak.
A mobile hydraulic or electronic lifting device consists of a sturdy metal frame with a wide base of support from which a seat or sling is suspended. The lifting device is on wheels, which makes it relatively easily moved by one person when it is empty. A rechargeable battery is used to power an electronic device that enables even heavy clients to be moved with ease. A hydraulic pump is used to lift the client. A mobile lifting device can be wheeled to the bed and the seat or sling lowered to bed level so that the client can be transferred safely. The design and use of lifting devices varies according to the manufacturer, but safety and the client’s sense of security are best maintained by having two nurses present when a client is being lifted with any mechanical device. One nurse can then operate the device while the other supports and guides the client during the lift and transfer to the bathroom.
It is generally easier to remove the client’s clothing before the lift and transfer to the bathroom, but being moved around in a lifting device can feel extremely undignified and distressing. The utmost care must be taken to ensure that the client’s privacy and dignity are maintained, in particular the client’s private body areas must be securely covered from view during transfer to the bathroom. The prospect of being lifted in a machine can be very frightening and may increase existing feelings of vulnerability. It may help reduce anxiety if clients are given an opportunity to see how the hoist works before the first occasion on which it is used to lift and assist them.
When the client is correctly and safely positioned in the seat or sling, two nurses wheel the machine to the bathroom. The client can be lowered effortlessly into the bath by mechanically adjusting the height of the seat or sling. The client remains on the seat or sling throughout the procedure. Mechanical hoists facilitate safe client transfer in and out of the bath and they eliminate strain on the nurse’s back. Mechanical hoists with fabric slings can also be used to transfer clients between bed and chair or bed and trolley. Any client that requires the use of a mechanical lifting machine must never be left unattended in the device or in the bath. Clients who may require the use of a mechanical lifter include those who are heavy or extremely weak, frail or helpless. As hoists are made in a variety of styles, the nurse must check the manufacturer’s instructions concerning the use of each machine, in particular the safe application of the fabric slings.
Hoists are large pieces of equipment. When clients require them in the home, structural alterations to the house may be necessary to facilitate their use. Government-funded care packages sometimes provide for this need. In some situations nurses teach family members who are providing home-based care for dependent relatives how to use the hoist safely.
Fixed bath chairs are fixed to the floor at the side of the bath. They are equipped with a hydraulic mechanism for lowering and raising the seat. The client sits on the seat, which is manoeuvred over the edge of the bath and then lowered into the water. The client remains on the seat while being bathed and during transfer out of the bath.
Mobile baths are available in some health care facilities. A mobile bath can be moved to the client’s bedside. The client is transferred from the bed into the bath and transported to the bathroom. The bath is filled and the client bathed in the usual manner.
Shower trolleys are designed for use in the normal shower area. Using a hoist, the client is positioned onto the trolley and wheeled to the bathroom. A foot pump is then used to blow up an inflatable edge that surrounds all sides of the trolley. This converts the trolley into a shallow bath. A drainage hose underneath the trolley is directed to the drainage hole of the shower recess and the client is washed by the nurse using the shower nozzle.
Whenever and wherever mechanical aids are used, nurses must be familiar with the operational safety aspects of each one. A full explanation about the aid being used, reassurance about its safety, and maintaining the client’s personal privacy and dignity during use are important components of reducing stress and embarrassment for the client. Examples of some aids that are available are illustrated in Figure 27.1.
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.)
|Review and carry out the standard steps in Appendix 1|
|Prepare the bathroom:|
• 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)
|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:|
|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.
Careful handling is necessary to avoid kinking or dislodging any tubing, and precautions must be taken to prevent the IV insertion site becoming wet. Mechanical IV pumps may be switched to battery mode during the time a client is showering. The pump can be switched off for a short period of time while the client’s clothing, such as night attire or hospital gown, is removed and replaced with a clean one.
Intravenous tubing and the flask or bag containing the IV fluid should be positioned above the level of the client’s heart to maintain flow of the fluid into the vein. Lowering the container causes a reversal of pressures that may result in the infusion stopping and blood from the client’s vein flowing into the IV tube.
The Enrolled Nurse (EN) should check the nursing care plan, providing it is current, or ask the nurse in charge if the dressing or bandage is to be removed before the bath or shower. If wound coverings or bandages are to remain in position they must be protected from moisture.
A substance to be added to the bath water may be prescribed, such as salt or pinetar preparation. The nurse should also ascertain whether a lotion or cream has been prescribed for application following the bath. The nurse must be aware of the policies, guidelines and scope of practice for ENs in the geographical area of employment in relation to the application of any cream or lotion that contains medication. Where the application of medicated creams or lotions is within the nurse’s scope of practice, gloves should be applied before they are administered because they are absorbed through the skin.
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.
|Review and carry out the standard steps in Appendix 1|
|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|
|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|
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).
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).
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.