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This book has been devised for those providing clinical care. It will provide in-depth advice on
aspects of basic care for the inexperienced, and serve as a salutary reminder of fundamental
care provision that should be inherent to clinical professionals of all grades and experience.
Acknowledgments
I have learnt so much from so many people that I cannot thank them all by name. To all those
trainers and colleagues who have been my mentors and friends – you know who you are –
“thank you”.
With reference to the production of this book, I need to thank the following people for their
invaluable support and encouragement over the past decade:
Alison Haines and Debra Chatterton ,Registered Nurse colleagues who
encouraged me to write this, have kept me focused and have provided
invaluable objectivity.
Barry Howarth, for giving me the freedom to develop as a trainer
ultimately writing this book
My brother Andy for his endless patience with the I.T. side of writing.
Valerie, Bea, Nicki and Jean for editing.
Our son and daughter, Chris and Jo Long for their support,
encouragement and feedback.
And above all, thanks to my wonderful husband Dave – for always
believing in me.
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Contents
1 WELCOME....................................................................................................................................5
2 WHAT HAS CHANGED IN NURSING? .......................................................................................6
3 NEW TO THE NURSING ROLE...................................................................................................8
3.1 Caring for a relative or loved one..........................................................................................9
3.1.1 Support for home carers............................................................................................. 10
3.2 What do they mean? .......................................................................................................... 11
3.3 Incompatible patients and carers ....................................................................................... 11
4 THE SIX FUNDAMENTAL PRINCIPLES OF NURSING CARE............................................... 13
4.1 Real communication........................................................................................................... 14
4.1.1 Barriers that can affect communication ..................................................................... 14
4.1.2 Hearing ....................................................................................................................... 15
4.1.3 Visual .......................................................................................................................... 16
4.1.4 Language barriers ...................................................................................................... 17
4.1.5 Words used................................................................................................................. 18
4.1.6 Patient unconscious ................................................................................................... 18
4.1.7 Disorientation.............................................................................................................. 19
4.1.8 Learning disability....................................................................................................... 20
4.1.9 Appearance and Body language................................................................................ 21
4.1.10 Patient in pain or frightened ....................................................................................... 21
4.2 Patient privacy .................................................................................................................... 22
4.3 Patient dignity ..................................................................................................................... 23
4.4 Infection control .................................................................................................................. 24
4.4.1 Reducing the risk of infection..................................................................................... 24
4.4.2 Hidden infections........................................................................................................ 25
4.4.3 Infection control by isolation....................................................................................... 26
4.4.4 Preventing infection via clinical waste ....................................................................... 26
4.5 Patient consent................................................................................................................... 27
4.5.1 Unable to give informed consent? ............................................................................. 28
4.6 Respecting the patient’s culture and religion..................................................................... 28
5 APPLYING THESE SIX PRINCIPLES ...................................................................................... 30
5.1 Providing appropriate personal care / hygiene .................................................................. 31
5.1.1 Equipment necessary for both full and assisted hygiene .......................................... 33
5.1.2 Principles applicable to all types of personal care delivery ....................................... 34
5.1.3 Assisted hygiene (partial self wash)........................................................................... 34
5.1.4 Full wash / blanket bath.............................................................................................. 36
5.1.5 Bath or shower ........................................................................................................... 38
5.1.6 After the patient has completed any type of personal hygiene ................................. 38
5.1.7 Passive movements ................................................................................................... 39
5.1.8 Oral care – mouth care............................................................................................... 40
5.1.9 Shaving....................................................................................................................... 43
5.1.10 Care of nails on hands and feet ................................................................................. 43
5.1.11 Care of the nose......................................................................................................... 44
5.1.12 Care of eyes ............................................................................................................... 44
5.1.13 Care of hair ................................................................................................................. 45
5.2 Managing nutritional needs – Feeding............................................................................... 46
5.2.1 Swallowing difficulties (Dysphagia)............................................................................ 49
5.2.2 Enteral Feeding .......................................................................................................... 50
5.2.3 Enteral feeding tubes ................................................................................................. 51
5.2.4 Testing for enteral tube misplacement....................................................................... 52
5.2.5 P.E.G. (percutaneous endoscopic gastrostomy) feeding tube.................................. 52
5.2.6 Care of the P.E.G. insertion site ................................................................................ 52
5.2.7 Feeding using enteral or PEG tubes.......................................................................... 53
5.2.8 Other enteral feeding notes........................................................................................ 54
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5.3 Managing Toileting - Elimination........................................................................................ 54
5.3.1 Screening urine samples............................................................................................ 56
5.3.2 MSU – mid stream urine specimen............................................................................ 57
5.3.3 CSU specimens.......................................................................................................... 58
5.3.4 Urinary incontinence................................................................................................... 59
5.3.5 What is a Urinary Catheter and why are they used?................................................. 60
5.3.6 Care of the urinary catheter and catheter bag........................................................... 61
5.3.7 Emptying / changing the urinary catheter bag ........................................................... 62
5.3.8 Urinary catheter removal............................................................................................ 63
5.4 Bowel care .......................................................................................................................... 64
5.4.1 Risks associated with faecal incontinence................................................................. 65
5.4.2 Administering an enema or suppository .................................................................... 66
5.4.3 Administering suppositories ....................................................................................... 66
5.4.4 Administering an enema............................................................................................. 67
5.4.5 Colostomy / ileostomy ................................................................................................ 68
5.4.6 Cleaning a colostomy or ileostomy bag ..................................................................... 68
5.4.7 Emptying a “clipped” colostomy or ileostomy bag ..................................................... 69
5.4.8 Problems with colostomies and ileostomies .............................................................. 70
5.4.9 Post toileting needs .................................................................................................... 71
5.4.10 Pressure Ulcers .......................................................................................................... 71
5.4.11 How to prevent pressure ulcers developing............................................................... 73
5.5 Managing pain relief ........................................................................................................... 76
5.5.1 Delivering varied pain killers (analgesia) ................................................................... 77
5.5.2 Common side-effects of pain killers ........................................................................... 78
5.6 Making clinical observations .............................................................................................. 79
5.6.1 Observation of the patient .......................................................................................... 79
5.6.2 Responsive to communication ................................................................................... 79
5.6.3 Temperature, Pulse and Respiration (T.P.R.) ........................................................... 80
5.6.4 Temperature ............................................................................................................... 80
5.6.5 Measuring temperature orally .................................................................................... 81
5.6.6 Measuring temperature rectally.................................................................................. 81
5.6.7 Measuring temperature axially (under the arm)......................................................... 81
5.6.8 Measuring temperature aurally (in the ear)................................................................ 82
5.6.9 Measuring a pulse ...................................................................................................... 82
5.6.10 The pulse rate............................................................................................................. 82
5.6.11 The Rhythm ................................................................................................................ 83
5.6.12 Amplitude.................................................................................................................... 83
5.6.13 Taking a patient’s pulse.............................................................................................. 83
5.6.14 Assessing the radial pulse ......................................................................................... 84
5.6.15 Respirations................................................................................................................ 84
5.6.16 Assessing the patient’s respirations........................................................................... 85
5.6.17 Blood Pressure (B/P).................................................................................................. 85
5.6.18 Recording a patient’s blood pressure ........................................................................ 87
5.6.19 Recording a patient’s B/P using a manual sphygmomanometer .............................. 87
5.6.20 Recording a patient’s B/P electronically .................................................................... 89
5.6.21 Oxygen saturation levels – known as “Sats”.............................................................. 89
5.7 Care of the unconscious and / or dying patient ................................................................. 90
5.7.1 The anticipated (expected) death .............................................................................. 90
5.7.2 Communicating with the dying patient ....................................................................... 92
5.7.3 Sudden death ............................................................................................................. 92
5.7.4 Washing the deceased patient in hospital ................................................................. 92
5.7.5 Death in other institutions or at home ........................................................................ 94
6 USEFUL REFERENCE MATERIAL FOR THE NEW CARER.................................................. 95
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1 Welcome
I present this handbook from a position of experience, having completed more than 40 years
continuous nursing within the NHS. This is a guide to the fundamental principles of good
nursing care. For those already in the nursing or caring professions, it may serve as a useful
aide memoire. For those new to a caring role, it gives vital guidance to the fundamental
principles of nursing on which competence, confidence, and excellence can be built. It is also
hoped that those caring for a relative or loved one will find the guidance helpful. Anyone who
has cared for a sick child or relative has an idea of what it means to be a nurse and may find
this book useful.
The author fully acknowledges that there are many thousands of excellent nurses and carers
(both Registered and non registered) who deliver superb care all day every day and she does
not mean to insult them or appear patronising by re-emphasising the foundations of their
profession. Fellow professionals know that there is a problem with some staff in the care
sector. There have recently been reports1 in which the quality of nursing has been questioned
and there have also been many reports in the press suggesting that nurses don’t care and
that many Registered Nurses are “too posh to wash”.2
As usual, the media goes too far. There are some absolutely inspiring nurses and carers,
many of whom have not completed any formal training. The value of their experience and
commitment should never be underestimated. Conversely, the value of a qualification should
not be overestimated. Most qualified nurses and carers are excellent but some have been
able to qualify without showing any compassion or demonstrating / acquiring the caring skills
that should underpin everything they do. Those with a qualification are generally presumed to
have knowledge of the fundamental principles of nursing but, sadly, we know that this is not
always true. In some cases, the lack of compassion or caring skills can be explained by the
absence of any formal requirement to learn and practice them. This resource is intended to
go some way to filling that void. It could be considered as a valuable support to the
recommendations from the Cavendish Review published in 2013.
Several newly qualified Registered Nurse Practitioners have welcomed this resource in draft
form, saying that their academic training did not focus on these skills. They felt that it was
sometimes presumed that they would pick these skills up when working on the wards. They
had, but they were still grateful to see them clearly laid out for the first time.
While technically inaccurate, within this book I refer to “caring” and “nursing” as though they
are synonyms because, although nursing can be much more than caring, it should have
caring at its core. When I use the term “carer”, the context generally makes it clear whether I
mean a nonregistered care worker, a Registered Nurse Practitioner, an Allied Health
Professional3 or a Doctor: I often mean all of them because all of them should have these
basic caring skills.
1 I am thinking particularly of The Francis Report – February, 2013. The Cavendish Review July 20132http://nursingstandard.rcnpublishing.co.uk/students/clinical-placements/patientcentred-care/holistic-care/too-posh-to-
wash-nurses3
Allied Health Professional (AHP): a specifically trained non nurse or doctor Registered Practitioner working within the field
of health. Examples are:, social workers, physiotherapists, Occupational Therapists, Dieticians, Speech and Language
Therapists.
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2 What has changed in nursing / caring ?
If there is sometimes a temptation to think that carers of all grades from the inexperienced
support worker through to the experienced Doctor have forgotten what they were trained to
do, this is not generally so. The demands on carers has changed significantly over recent
years, as have the equipment and drugs in common use. During my career, nurse training
has changed as much as anything else.
I completed my general nurse training in the 1970s. It gave me the solid foundation of basic
nursing skills that has allowed me to have a varied and fulfilling nursing career. To qualify in
those days, we had to pass both practical and theoretical modules that many of us failed at
the first attempt. We had “dragons” for tutors – but they made us work and would not
compromise their standards for anyone. I remember having to resubmit an essay that had
achieved a pass mark because my tutor thought I was capable of a better mark. These days,
there seems to be an almost whimsical reverence for nursing as it used to be. While the
delivery of basic nursing care might have been better than today, the old days were far from
perfect. Patients were expected to be the passive recipients of all care delivered. Their total
compliance was expected – and usually received! Non compliant patients were labelled as
“awkward” and I cannot recall the words dignity or privacy ever arising – or indeed any
consideration of a patient’s religious beliefs or cultural background. Nurses were effectively
the doctors’ handmaidens and there was a hierarchical structure that was both complex and
terrifying. So I am not saying that the old ways were perfect and I am not advocating a return
to the old approach. I describe how it was merely to provide a contrast between my training
and the current “pass number” approach to training which sometimes appears to place
emphasis on passing the student regardless of their performance. This can only lower the
standard for everyone.
Today, the training as a Registered Nurse omits much of the hands-on ward experience I had
in favour of far more demanding academic requirements. This has a plus side because
Registered Nurses are now “Registered Nurse Practitioners”, able to routinely undertake roles
that were once the responsibility of medical staff4. This allows hard-pressed medical staff to
focus on other aspects of patient care. Registered Practitioners are vital to the effective
running of today’s high-tech, fast-lane, NHS. Significantly, the Registered Nurse is no longer
expected to unquestioningly “takes orders” from medical staff and is legally accountable for
any action or omission on their part. Recent reports have recognised sub optimal provision
of basic care within some areas. The Cavendish Review has recommended that a ‘Higher
Certificate of Fundamental Care” become available for Non Registered Staff to present
evidence of their recognition and delivery of standards of excellence in the delivery of basic
care
Some Registered Nurses with extensive practical experience undertake further academic
study to become “Specialist Nurses” in an area of expertise such as diabetes, cardiac
rehabilitation, tissue viability, infection control, Accident and Emergency, etc. Many of these
Specialist Nurses hold their own clinics, releasing medical staff to undertake their specialised
roles. And although these Specialist Nurses may no longer routinely deliver care at the
4 Within the NHS, the term “medical staff” is used to refer to Doctors, Junior Doctors, Consultants and Specialists in
discrete medical disciplines.
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patient’s bedside they still need to use the six fundamental principles of nursing care (see
Chapter 4) in everything they do.
The technology in hospitals has changed too. An example is the introduction of limited
intervention techniques such as “scoping”5 which reduce the need for a patient to stay in
hospital. These improved surgical techniques mean that large surgical wounds are rarely
required, so reducing the time that a patient needs to stay in hospital after an operation. One
unexpected consequence of improved intervention and surgical techniques is the fact that the
proportion of really sick patients in a ward has risen dramatically.
Not long ago, many beds were filled with post operative patients or those in hospital for
“investigations”. In consequence, there were only a few very sick patients in a ward at any
one time and there was time for the nursing staff to focus on the sick. Today, just about
everyone occupying a hospital needs active treatment but staffing levels and their skill mix do
not always seem to reflect these changes in demand.
Throughout the history of nursing, most caring has been carried out at home – often by a
patient’s relative. Usually the patient wants this, so it is a good thing. But many people find
themselves taking on a caring role without feeling adequately prepared for the responsibility
and without feeling confident about what the role entails. I hope that this book may be
especially useful to them.
5 5Passing a special instrument with a light attached into the patient’s body without needing to cut the skin. Biopsies can be
obtained simultaneously. These are routinely undertaken without the patient needing to stay in hospital overnight.
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3 New to the Nursing / Caring role
Today, nursing / caring roles can fall to a wide range of people. These may be specifically
trained and qualified people with a title such as Registered Nurse6 or may be Non Registered
Carers who are given a variety of titles such as Care Workers, Support Workers, Health Care
Assistants or as suggested within the Cavendish Review – Nursing Assistants. The term ‘non
registered carer’ within this book encompasses all of these titles. Evidence of sub optimal
delivery of basic care within some areas was identified within the Francis Report. Among the
recommendations of The Cavendish Review is a nationally recognised standard of basic care
– demonstration of which should culminate in the awarding the non registered carer with a
Certificate of Fundamental Care
Increasingly, entirely untrained people also find themselves in a nursing /caring role looking
after a loved one or relative at home. While qualifications and experience can give
confidence, a new carer does not need them to deliver excellent basic care.
Whatever a carer’s training background, they share a responsibility to deliver care of the
highest standard.
The above summary makes it clear that all paid professional carers have both a responsibility
for and accountability over their delivery of care.
The non registered carer has a responsibility to deliver high quality care and should have the
knowledge or skills required to conduct the tasks asked of them. When they do not, they must
make that fact known to those above them, seeking supervision or training as required. The
Cavenish Review calls for a rigorous quality assurance mechanism for training courses and
6 Also known as Registered Practitioners, and formerly known as Staff Nurses and Sisters.
Summary of Accountability and delegation for carers*
All patients should expect the same standard of care, whoever
delivers it.
When delegating any aspect of care, it must be determined that
delegation is in the best interest of the patient. The person who
delegates the task is accountable for the appropriateness of the
delegation.
If the delegation of a task to another person is appropriate, the
support worker is accountable for the standard of performance.
The level of supervision provided must be appropriate to the
situation and take into account the complexity of the task, the
competence of the support worker, the needs of the patient and the
setting in which the care is being given.
*From RCN 003 942 Accountability and delegation, Published October 2011
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vocational qualifications that include a focus upon basic care of a high standard. The result of
this requires all employers to ensure these standards are met as of 2015
The Registered Practitioner is subject to the Registered Nurse Practitioner Code of conduct7
and has a responsibility to ensure non registered nurse competence as part of his or her
delegation of roles and for ensuring that accurate records are compiled and updated.
There is only one simple way to deliver care of the highest standard. The carer must both
consider and apply the six fundamental principles of nursing care to each aspect of their
work. This will require both application and self discipline until it becomes second nature. For
a true carer, the only acceptable excuse for failing to deliver the highest standard of care is
their own initial inexperience.
It does take time to learn how to apply the fundamental principles in situations that are
unfamiliar, although it takes no time for a careless8 person to ignore them. If the principles
within this book are followed, superb basic nursing care standards will develop and will
quickly become second nature.
Be thorough, think it through and do things properly. This generally takes only
seconds longer than taking a short cut. Short cuts create problems – remember if
they really were a better way of doing things they would not be short cuts.
3.1 Caring for a relative or loved one
Anyone caring for a relative or loved one should want to do so. Nursing used to be
considered a vocation and there are still many who would say that if you do not have the
vocation, no amount of training will compensate for that. Wanting to care is a good start but
their emotional involvement can make a caring role more difficult. Becoming a competent
carer always takes both time and practice – and the carer can become anxious and frustrated
when they are afraid of letting down a person they are caring for.
The new carer could use this book as a tool to teach themselves, and also as a guide to
assess the care provided by others. If any other caring support is provided, the new carer
should watch them work and help them with their care delivery. If an external carer does
something they do not understand or thinks inappropriate, they should mention it. The
professional carer may have a good explanation, or may need to be reminded about the
application of the principles.
If basic nursing care is new to you, give yourself time.
By referring to this book and by watching how it is done by those with more experience, the
new carer’s confidence should grow. There is no need to copy the way it is done by others
slavishly. The fundamental principles can be applied in many ways and each person’s care
will be subtly different.
You are human. Don’t forget, no one is perfect.
7 Nursing and Midwifery Code of Conduct 2015,8 It is not merely semantic to say that a truly ‘”careless” person cannot also be a true “carer”.
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It always takes time to become proficient at all new skills and this will be complicated when a
carer is emotionally involved with the person they are caring for. For example, expressing
emotion to the person being cared for may seem very appropriate but the delivery of care with
compassion based on the patient’s needs should always be the aim. When the expression of
emotion is the need of carer rather than the person being cared for, that is not ideal. The new
carer should strive to achieve objectivity because that can protect them as well help them to
deliver the best care to the person being nursed.
3.1.1 Support for home carers
Throughout the U.K. there will be some support networks for the home carer and the person
being cared for. Many things influence the level of support that may be available – from
politics and the economy to the rarity of the patient’s condition and their geographical location
– but the carer owes it to the person they are caring for to explore what support is available
and to make best use of it for the patient and for themselves.
The patient’s General Practitioner (G.P.) and the local hospital should be able to let the carer
know what is available. The patient’s G.P. has a responsibility to help the carer identify
potential support streams (networks). The Royal College of General Practitioners (RCGP) has
recently acknowledged the tremendous work undertaken by family carers, often to the
detriment of their own health. The RCGP has suggested that health screening mechanisms
be introduced for all such carers.
If the person being cared for has a definite diagnosis the carer could telephone the local
hospital and ask whether they have a “Specialist Nurse” covering the condition. If they do, the
nurse should be able to advise about all aspects of care and provide contact information for
any support networks in the area.
Social workers may be a source of support. The local Council should be able to give the carer
contact information for social workers in the area. Social workers are also care workers and
have in-depth knowledge that can be of great help to the home carer. Some specialise in the
needs of “children” others “adults with learning difficulties”, others with “dementia” and others
with simply “adults”. The carer may need to ask for their help, after which the social worker
should call and examine the support that the patient is entitled to. This entitlement might
include transport to day centres, meetings, etc.
The home carer may be sharing their role with a variety of carers who call at specific times of
day. Local councils franchise (pay) external (non NHS) agencies to provide some personal
care (washing, feeding, help getting out of bed etc.) to patients in their own homes. Many of
the carers who deliver these services are non registered nurses. Some may have a
qualification like an NVQ, while some do not. These carers are very rarely Registered Nurse
Practitioners (they could earn far more in other caring work) but these non registered carers
still have a duty to consider and apply the Six fundamental principles of excellence in nursing
care. The home carer may learn from them, and may need this book to give them the
confidence to question the quality of the services being delivered.
Home carers often feel isolated and should be aware that “soldiering on alone” is probably
not in the best interests of the patient, or of themselves. They should find out about available
informal support networks. A search of the internet can often be useful, providing contact
details for support groups for specific ailments or conditions. Local Libraries can also be a rich
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source of information about support groups and their contact details. Meeting with others who
are dealing with the same condition can be of great help to both the patient and the carer.
The help can be “emotional” but also lead to the sharing of skills and strategies that improve
the care for the patient. It may also lead to offers of carer respite, where responsibilities can
be shared and the carer be given “time off”.
3.2 What do they mean?
When a carer has managed to access NHS support networks they may have a problem
understanding the advice and support that is being offered. NHS staff often speak in a
specialist language of technical terms and acronyms that are meaningless to those who do
not share their background. Of course this should not happen because all staff should take
responsibility for ensuring that the communicate clearly, but it does. The carer should not feel
out of their depth, belittled or ignorant. They should insist on being spoken to in terms that
they understand clearly.
When a carer does not understand, that is the failing of the person advising
them, not of the carer.
The NHS has its own language (NHS speak) which all staff use to speed up communication.
This makes sense internally but it is usually inappropriate to use with anxious patients or
relatives. Every patient or relative is nervous and or frightened and this often impairs
concentration. Compound fear impaired concentration with the fact that the staff are speaking
an NHS language and the result is often appallingly ineffective communication.
The use of NHS speak to patients and relatives may be arrogant, elitist or simply
inconsiderate – but mostly it occurs because the work level of the staff is so high that they
simply do not think about it. Whatever the reason, the new carer and the patient should not
accept it. When they don’t understand, they must ask. All carers, relatives and patients should
remember that they are speaking to people for whom part of their paid role is to communicate
clearly. If the carer or patient asks for clarification, any nurse, doctor or carer should
recognise that they were not clear in their explanation and make every effort to explain in a
way that is understood.
3.3 Incompatible patients and carers
This may never be a problem but it can be and must be recognised when it does occur. New
carers can be particularly vulnerable to feeling an incompatibility simply because their
relationship with the patient is not “perfect”. For professional carers, that is just part of the job
and must be overcome without taking any friction personally, and without ever being the
cause of friction themselves.
In my 41 years with the NHS I experienced two patients who, for reasons I never understood,
took an instant dislike to me. This was before the time of “acknowledge and discuss” so I had
to ignore the patients’ obvious dissatisfaction with everything I did for them. This was not a
major problem because I worked in the acute sector where patient stay was of limited
duration but if you are caring for someone long term you must acknowledge this kind of
problem and resolve it, however that might be.
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Any carer can find themselves caring for someone who instinctively neither like or trusts
them. Equally, a carer can find themselves caring for a patient who they have problems
relating to. Whichever way the problem goes, it is an incompatibility that must be
acknowledged and overcome. All those employed in the “care sector” must report an
apparent incompatibility to their supervisor, record it in writing and ensure their managers are
aware of the difficulty. It may be that a patient has a problem relating to every available carer,
in which case the carer may not be able to minimise their contact with the patient. While it is
part of carer’s responsibility to acknowledge the problem it cannot be used as an excuse for
them to choose “easier” patients. But if it is a problem and it affects the quality of care that
can be delivered, the carer must find a way around it either by negotiating with their
managers to avoid contact with that patient, or by resolving the conflict.
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4 The Six Fundamental Principles of Nursing Care
So what are the Six fundamental principles that must be behind all caring activities before the
care delivery can be considered “excellent”?
They are:
1. Enabling real communication
2. Preserving patient privacy
3. Promoting patient dignity
4. Controlling the risk of infection
5. Asking for patient consent
6. Respecting the patient’s Culture and Religion
Often abbreviated to the titles Communication, Privacy, Dignity, Infection Control, Consent
and Culture & Religion, these are fundamental requirements that should underpin all care
delivered at every level from unqualified carers to senior medical consultant.
These requirements may appear “obvious” because they are. But when you examine patient
care in hospitals and other institutions today you will find evidence that these Six are not
known or are being ignored by some. Others may nod at them without having fully
understood what they mean.
People new to caring will need to keep reminding themselves of the application of each
fundamental principle to each newly acquired competence of nursing care. This might be
hard for a carer who is looking after someone they love. It should be rather easier for a
professional who is able to keep an emotional distance.
Whatever competence is being acquired, the trainer must ensure that the trainees consider
the activities in relation to the six fundamental principles of nursing care. I have found it useful
to ask trainees to roll a dice and explain how the principle that comes up applies to the matter
under discussion. The principles lend themselves to this by being the same number as the
sides of a dice. An ordinary dice can be used with the numbers having a meaning assigned
as below – or a special dice can be prepared.
1. Communication
2. Privacy
3. Dignity
4. Infection Control
5. Consent
6. Culture and Religion.
Using a dice introduces an element of chance into the learning experience and ensures that
the more challenging principles are also discussed.
It could be suggested that I am omitting a vital principle – compassion. There are many
slightly different definitions of “compassion”. Some stress “caring”, “understanding” or
“empathy” but it is tremendously significant that they all include the desire to resolve whatever
is the problem. Every carer of any grade should exercise compassion throughout every
contact or task they are delivering. They should care and want to help resolve problems for
the patient. Compassion is not something that can be taught. If it is not “felt” this raises the
question of whether the person is suitable for a caring role.
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As a natural progression from this desire to resolve any patient problems it is incumbent upon
every carer to write down (record) the care they have delivered and any problems they have
been unable to resolve.
4.1 Real communication
Communication is an essential part of daily life. It enables us to affect changes to the world
around us, to socialise, to inform about events and so on. Communication takes a variety of
forms:
Verbal – face to face, telephone, involving speech, sound, listening
Non verbal – body language, gestures, facial expressions
Electronic – email, intranet/internet, computer records, social networking
Written – patient notes, nursing records, leaflets, letters, symbols.
In its simplest form communication is about one person sending a message to a second
person and that second person understanding it accurately. It is not real communication
unless the second person understands it accurately.
Communication is at the heart of everything we do. All patients and
relatives have a basic right to affect, through communication, the conditions
of their existence.
In every communication with a patient or their relatives the carer should try to “Listen
Actively”, giving their full attention to:
The verbal message;
The tone of voice;
The person’s posture; and
The person’s gestures.
When the carer also knows some of the patient’s background, that also allows them to put
things into context and see things from their point of view.
A good carer should never answer a question from a patient with the dismissive “sorry, you’ll
have to ask someone else” or words to that effect. It is the carer’s responsibility to find out the
answer and ensure that it is delivered whenever possible.
Even when the words cannot be understood, the tone and demeanour
can. The carer should try to be reassuring and comforting even when
they cannot be sure that full communication is taking place.
4.1.1 Barriers that can affect communication
The most common barriers to effective communication are introduced here. There may very
often be more than one barrier in place but I introduce them separately to try to communicate
them clearly.
In reality, when you add physical problems, language problems and the anxiety of a patient
together, there is often a complex and serious communication difficulty that the carer must
overcome in order to work effectively. When care staff of any grade ignore this, they can
cause entirely unnecessary distress to both patients and relatives.
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Each act of communication must be relevant to the individual, and must avoid appearing
patronising. It may sometimes be appropriate to avoid telling a patient or relative something,
but the carer should generally avoid lying. In most health cases the entire truth is not known
anyway, so saying the parts that will avoid distress can be both caring and appropriate.
4.1.2 Hearing
A problem hearing may be more than simply not hearing. It can also be mishearing or
interpreting an unfamiliar word or phrase as if it were a familiar one. Deafness is rarely as
simple as being deaf or not. Diminished hearing of some pitches and within certain ranges is
common and increases with age. The carer should be alert for signs of hearing trouble
whenever meeting a patient or relative for the first time. The patient may not tell the carer
because they may not have recognised that they have a problem, or may presume that
because it is obvious to them, it will also be obvious to everyone else.
Look out for hearing aids but don’t presume that their presence means that the wearer can
hear with them. On the contrary, their presence should alert you to the fact that there may be
a problem. When there are hearing aids, ensure that they are turned on, have functional
batteries, and are adjusted appropriately for the wearer. As the carer, it may be part of your
role to ensure that the patient has spare batteries, so asking them if they have spare batteries
and know where to get more can be a useful way of checking whether they can hear you
properly and respond appropriately.
Remember that most people with hearing problems do not wear hearing aids. Many hearing
problems are relatively minor and the person has found ways to live with them. So the
absence of a hearing aid does not mean that a person has perfect hearing.
With a hearing aid in place or not, many people with problem hearing compensate by lip
reading. Most will not have been taught to do so and may even be unaware that they are
doing it, but they watch the speaker’s lip movements and visually “read” some information
about the speaker’s words. The carer should position themselves so that the patient or
relative can see them, and then speak clearly, avoiding jokes or slang until communication
has been established.
Hearing loss is not always balanced and many people hear better in one ear than another.
The carer should find this out quickly and ensure that they never speak from the inappropriate
side.
Some people will not be able to easily turn to face the carer, so the carer must position
themselves so that the potential for lip reading and hearing is maximised.
Even when people have good hearing, background noise can introduce confusion. This is
especially true when the background noise is “new”, such as may occur when a patient
arrives in a busy hospital environment. The carer may be familiar with the background noise
and able to filter it out but the new arrival may find that impossible. Whenever possible, the
carer should always find a quiet place to talk.
When there is a hearing problem, the carer should notice which words and intonations seem
to work and try to use them as often as possible. Some words have distinctive lip patterns
while others can be mumbled too easily. The carer should use body language to help the
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communication, nodding vigorously and smiling for “yes” is almost too obvious to mention, but
often forgotten.
Profound deafness usually means being entirely deaf within the range of sounds used in
human speech. A profoundly deaf person may not wear hearing aids, although many do.
When meeting a profoundly deaf person, the carer should find out as much as possible about
the deafness. If it is recent, the person may need help to access appropriate treatment and
support. If the person has been profoundly deaf for a length of time, they may know how to
communicate using a sign language such as Makaton. If they do, one of their relatives or
another carer may know how to use it and be able to act as temporary “interpreter”. When a
carer is responsible for a person who uses a sign language, it is the carer’s responsibility to
communicate. The carer must find a way to do this, either by enlisting help from those who
know the sign language or by learning it themselves. When a carer has a “boss”, they should
discuss the need with them, report the need in writing and ensure that the need is met.
Failure to do this would be a form of neglect.
The main carer of a profoundly deaf patient who uses sign language should be able to get
support to learn signing themselves. Their managers, the patient’s G.P., local college or a
nearby hospital audiology (hearing) department should be able to advise.
4.1.3 Visual
Just as deafness is rarely as simple as being deaf or not, blindness is rarely as simple as
being able to see or not.
Understanding and supporting people in the everyday management of their visual problems is
fundamental to helping them cope with their additional needs. All too often, essential
information is provided in writing, presuming that the person can read it. The carer should
always ensure that they can read and when they cannot, must provide all the assistance
required.
The carer might consider the following:
Does the patient have spectacles, and if so – are they clean?
If the patient can read the information with difficulty, can they understand it? Some
functionally literate people can read, but they are concentrating on reading while they
do so and not thinking about what is being read.
Would the patient like to have the information read aloud to them?
Would the patient cope better with larger print?
Would the patient like access to audio books? If so, how can they be accessed?
(While many libraries do offer this service there is often a charge.)
The carer should try to understand their patient’s restricted vision and the impact it might
have on their everyday life.
We were extremely fortunate in my last hospital because Nina from our local association for
those with visual difficulties regularly visited new care staff and provided a basic explanation
of the more common visual ailments. She also brought along several pairs of special glasses
that provided the wearer with the experience of several common eye conditions – glaucoma,
cataract, tunnel vision etc. She then encouraged the carer to undertake some routine tasks
17
while wearing the spectacles, so experiencing just how the condition was affecting the
patient’s vision.
This experience was literally an eye opener for all staff. Carers wanting a similar experience
might find that the local yellow pages or an internet search yeild contact details for any local
associations for those with visual difficulties who could share their knowledge in a similar way.
Carers should not have difficulty accessing audio tapes or CDs for their patients, but if they
do, they should seek to find a way around the problem. It might be appropriate to start a local
library resource for the area. Local charity shops often have copies of either cassette or CD
audio books. They are easy to clean between patients by wiping with a damp cloth and the
appropriate cleaning solution for the area where the patient is.
Many patients have experienced a gradual reduction in sight over a long period and will have
developed their own coping strategies at home. If the patient is no longer within their home
they will require very specific support in order to create an environment that they feel
comfortable and confident within. This should include provision for independent personal care
and going to the toilet whenever possible. If a patient is acutely ill this might not be possible
initially but this requirement should be accommodated as part of their subsequent care. This
can be particularly difficult within the current NHS where there sometimes seems to be a
competition to see how often a patient can be moved, both within the ward or around the
hospital, but the carer must try. Simple things such as discussing with the patient where they
would like things to be left and then confirming that this has been done will maximise patient
independence even when they are often moved.
A partially sighted patient usually prefers to undertake as much as possible themselves – this
should be accommodated even though it may take slightly longer. One of the problems with
the ”timed” personal care delivery that is increasingly found within both hospitals and the
community is the fact that it does not encourage independence by giving the patient time to
undertake tasks themselves. It is undoubtedly quicker for the carer to undertake many tasks
for the patient but this should only be done when it is in the patient’s best interest to do so.
Often it is not, but it may be in the interests of the carer or their employer. When a patient has
relinquished their care to impatient carers they often lack the confidence to develop it again at
a later date.
4.1.4 Language barriers
The patient may be able to hear perfectly but that will be of little help to communication if they
do not understand the language you are speaking. In a professional environment, the carer
should have access to interpreters but these can take time to arrange and the cost generally
means that they are only available for a short time. The carer should make the need for an
interpreter known, in writing, and press those responsible to meet the need. In the meantime,
the carer must solve the immediate problem. The carer should prioritise this and follow it up
because without adequate communication, the patient will be confused and may be fearful,
distressed or even angry.
Often a relative or friend of the patient may be able to act as temporary interpreter allowing
limited communication to be established.
Some basic communication can be achieved without language, using an appropriate tone of
voice, reassuring smile and simple body language mime, for example. But this is a temporary
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fix that does not allow the true communication that must be in place between a carer and the
person they are caring for.
An interpreter does not have to cost a lot of money. When necessary, the carer should
identify the key words needed for communication about the patient’s needs and get a
competent linguist to write these clearly in both English and the appropriate language on
durable sheets of card. Several potential responses should also be written down for the
patient to point to. Some obvious phrases are:
Are you hungry?
Would you like a drink?
Are you in pain?
Point to the pain.
Do you need to go to the toilet?
Each patient is unique so the appropriate questions will not all be generic. At least some of
the questions should be patient specific.
Some communication can be established using pictures – and there are basic picture boards
available – but a patient specific series can be devised at little cost.
Picture boards and translation sheets should be laminated to allow them to be cleaned and to
give them a useful life.
When neither the patient nor their relatives can read or speak English and the use of picture
boards or translation sheets has not improved communication, communication will have to be
verbal and an interpreter must be provided.
4.1.5 Words used
Carers should avoid speaking to patients or their relatives in terms that are specific to the
caring profession. They should also avoid using acronyms unless they know they are talking
to someone who will understand them. UTI, for example, often (but not exclusively) stands for
a ‘Urinary Tract Infection’. UTI is not usually a major problem but patients and relatives may
think the acronym stands for something really serious. Using the acronym may save the carer
a second but that second may cause the patient and relatives hours of unnecessary anxiety.
A good carer will speak in ordinary English and never hide behind professional jargon.
4.1.6 Patient unconscious
Unconsciousness is usefully defined as the condition in which a patient is unresponsive to
touch or talk, and appears to be unaware of the environment and in a state of sleep. The
carer should never presume that an unconscious or semi-conscious person cannot hear.
There have been many reports of unconscious people hearing everything that was said
around them and recalling it in great detail when consciousness returns.
In some situations the patient’s level of response is assessed in order to gauge the depth of
their unconsciousness and their progress towards resuming consciousness. These formal
assessments use the Glasgow Coma scale.
There is another shorter assessment tool that carer’s may use - known as AVPU scale. On
this simple scale a patient’s response is assessed as being either A, V, P or U:
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(A) - Alert and fully responsive
(V) - responds to Voice or verbal stimulus
(P) - responds to Pain or discomfort
(U) - Unresponsive to any of these: Unconscious.
Unconsciousness is common and might be caused by an illness / condition or its treatment.
Common causes include hyperglycaemia (diabetic) keto-acidosis, stroke, head injury,
overdose, trauma, alcohol, post ictal (after a fit) and the patient becoming unconscious as
they approach death. The most common cause of unconsciousness related to treatment is
unconsciousness caused by an anaesthetic.
All unconscious patients are at risk of suffering an obstructed airway by choking on their
tongue. When a patient is unconscious, the smooth muscles in their body relax. The tongue is
a large smooth muscle and it can become so relaxed that it drops backwards to occlude
(block) the throat. This can be such an effective obstruction that it causes suffocation.
The easiest way of reducing this risk is to tilt the patient’s head slightly back while
simultaneously holding the patient’s chin to prevent the tongue from dropping back. This is
not practical for any length of time. Placing the patient in the recovery position with their head
tilted back will ensure that their airway remains open. This is not always possible, especially
when patients have suffered physical injuries or have spinal conditions. A device called a
Geudel or oro-pharangeal airway, can be used to keep the patient’s tongue forward but can
only be used by Registered Practitioners and must only be used on deeply unconscious
patients. If the patient is not unconscious but there is reason to think his / her airway is at
risk of getting obstructed by their tongue the Registered Practitioner may prefer to insert an
alternative airway tube into a nostril to keep the airway open.
When caring for an unconscious patient, the carer must:
1. Ensure that the airway is open at all times.
2. Talk to the patient, telling them what they are doing, and why.
3. Respect the patient’s privacy and dignity as if they were conscious.
4. Ensure that they have help when moving the patient.
5. Provide total nursing care.
The carer should never discuss the patient as if they were not there and not conscious.
The carer should always be discreet and comforting, just as they would if the patient were
fully awake. When nursing any patient the carer must tell the patient what is going on, what is
happening and, when possible, why.
Additional care may be required in some situations. For example if a patient is unconscious
following a stroke there is a Stroke Care protocol which the carer must follow.
4.1.7 Disorientation
The patient may understand English and hear perfectly well but still be unable to comprehend
because they are in a confused or disorientated state. This could be an acute (short term) or
chronic (long term) problem. Examples of acute causes include the patient having an
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infection (urinary tract infections frequently cause confusion in the elderly), a problem with the
salt levels (electrolytes) within the blood, a problem following a head injury, a specific
psychiatric problem or a problem following a general anaesthetic. Chronic confusion is often
caused by one of the dementias. Many patients experiencing early stages of dementia are
fully aware of their episodes of disorientation and are extremely distressed by it. They may
need a change of medication, physiotherapy or speech and language therapy to help them
communicate more clearly. Outside a hospital setting, these can be accessed via the patient’s
G.P. and the carer should act on their behalf to find out what support is available and ensure
that it is arranged.
When the patient has been diagnosed as suffering from one of the dementias they may have
had their capacity to make informed decisions assessed by a qualified Social Worker or a
dementia Specialist Nurse. When this has happened, they may have a legally appointed
designated guardian responsible for making decisions in their “best interests”. Some patients
who are aware of their own decline may of their own volition have elected to pass legal
responsibility to a relative without having had any formal assessment. The carer must respect
the guardian, involving them in all decisions about the patient’s care whenever possible.
When dealing with confused patients it is important to try to keep them orientated in time and
place. Small things can help to achieve this, such as:
• Keeping a large clock in easy view;
• Writing the day and date and leaving it in clear view of the patient; and
• Providing care in a single room where the presence of other people is not a
distraction.
The carer should offer stimulation to the patient depending on their interests, abilities and
diagnosis. For example, the carer might play cards, show photographs, read from the paper
or a book, or help with knitting, playing word games or doing jigsaw puzzles. A level of
recovery is common in many conditions but even when recovery is not likely, stimulation
improves the patient’s quality of life and is part of the carer’s role.
4.1.8 Learning disability
When a patient is known to have a significant learning disability, the carer must avoid
increasing dependence by doing more for the patient than necessary, but should also avoid
expecting too much. They should find out what the patient can understand and do, then tailor
their care accordingly.
The patient may have previously had an assessment of their mental capacity conducted.
When this has happened, they may have a legally designated guardian responsible for
making decisions in their “best interests”. The carer must respect the guardian, involving them
in all decisions about their care. This person will often be a source of reliable information
about the patient and their individual care needs.
Previous carers or relatives of long term patients will often have a wealth of experience about
the patient. They can explain what they can and cannot do, so helping the carer encourage,
maintain or even extend this level of independence, as appropriate. They can also advise
about what upsets, frightens or reassures the patient.
Any carer who fails to take advantage of the experience of their predecessors risks causing
unnecessary distress to both patients and relatives.
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4.1.9 Appearance and body language
First impressions count and are made before any verbal interaction has begun. The carer’s
expression, posture and general demeanour can be positive or negative. The carer should
strive to make it positive – even when the patient is not their direct responsibility.
Within our multicultural society it is important that carers are familiar with and accommodate
any specific cultural requirements the patient or their relatives may have and respect that.
The professional’s appearance is of fundamental importance, if a uniform is worn – it must be
clean. If no uniform is worn, the carer must wear suitable clothes and footwear. A “bare below
the elbows” policy has been required for several years now – for all grades of clinical staff
including medical staff.
Obviously the carer should be clean and should not smell. Perhaps less obviously,
overpowering perfume or aftershave can be offensive, as can the smell of stale tobacco. Hair
should be tied back from the carer’s face, not resting on their shoulders.
Jewellery, including watches, should not be worn by the carer while working for many reasons
including the fact that they are potential carriers of infective agents or may scratch the
patient’s skin.
There are a few basic rules about body language as a part of communicating.
It begins as the carer meets the patient and their relatives, when they should make brief eye
contact and smile. The carer might offer to shake their hands and start by saying “Hello, I am
here to help you” or asking “How can I help you?” The stress on “help” is important because
that is what the carer is there for, to support and advise.
The carer should read the patient’s posture and facial expression. A lot can be seen by
looking in a patient’s eye, without being challenging, of course. The carer should be aware
that their own body stance can send significant messages. For example, arms folded always
sends the message of being “not interested” in what is being said.
How the carer addresses the patient and those with them is important. They should be
addressed by their title and surname, not their first name. If they ask the carer to use their first
name, the carer should be led by them. It is disrespectful to address anyone by their first
name unless they have consented to this.
When the carer is in the patient’s home, they are a guest and must not presume the right to
sit down. They should wait to be invited.
4.1.10 Patient in pain or frightened
When a patient is suffering severe pain, the pain will be their main focus. Anyone who has
had a simple tooth abscess will appreciate how pain can take over your life. It follows that any
attempt at effective communication before the pain has been relieved is unlikely to be entirely
successful. It may “tick a box” on a form, but will not be a reliably accurate record of what the
patient knows and what they want the carer to know.
The carer must get the pain under control as soon as possible and double-check their
answers to any forms that were filled in or important communication that was not conducted
while the patient was still distracted by pain.
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Fear is also a great distraction. When a patient or their relative is fearful and distressed, try to
alleviate that before engaging in critical communication. If in doubt, check the answers you
received when the patient or relative is calmer. It is the carer’s responsibility to ensure that
communication is effective and accurately recorded.
Because fear causes distress and is never helpful, the carer should always avoid using words
or expressions that might cause fear in the patient or their relatives.
4.2 Patient privacy
Most people know that every patient has the right to confidentiality. The obligation to treat the
patient’s details as confidential extends to everyone who works in hospitals, care homes,
prisons, private homes etc., not only to their doctors and carers.
It may be less obvious that patient privacy is not an option either, it is a legal requirement just
like patient confidentiality. This is because, to the patient, privacy and confidentiality mean the
same thing. If the carer uses discretion, both privacy and confidentiality can generally be
maintained.
The carer should presume that the patient wants privacy. This means that they should ensure
that other people are not aware of what care is being delivered or what is being discussed
between the patient and the carer. If any other person is aware of what is going on between
the patient and the carer, the level of privacy being provided is less than optimal. When any
care delivered is less than optimal, the situation must be justified. In some instances the
context may give the carer little choice but if the patient objects, the carer must take action to
gain the privacy that is the patient’s right.
Communication with the patient should be discreet. Conversations should be spoken no
louder than necessary and from close to the patient so that no one else has to hear.
Delivering care in privacy in an area where there are several patients separated by curtains is
a “challenge”. Get close to the patient and speak no louder than necessary. If all else fails
speak as discreetly as possible directly into their ear. The carer must respect their right to
privacy even when they cannot deliver optimal privacy.
Carers may need to take informal notes about a patient to ensure that they remember all that
is relevant to perform their role well. The carer must remember to treat these notes with the
same degree of restricted access as the patient’s formal medical notes. They should not be
taken home after work, must not be left where others could read them, and must never be
disposed of without being destroyed.
It is sad reflection on today’s society that many caring staff feel the need to leave the door
ajar as protection against allegations of impropriety when delivering personal care to a
patient. Others welcome the presence of a chaperone. In both cases, there is a risk to the
patient’s privacy. Carers should judge the risk to privacy against the risk of being accused of
misconduct and find a balance that the patient can accept.
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4.3 Patient dignity
Dignity has become a popular buzz word for those looking for what is amiss in the care
sector.
Most dictionaries define dignity in terms of “self-esteem” or “self-respect”. This means that it is
a feeling within the patient, not something that can be delivered but something that can be
affected. Every carer should know that their actions influence how the patient feels about
themselves, whether or not they show it.
In care work, dignity is fostered by showing respect for the patient during all aspects of care
from verbal communication to personal hygiene or toileting. Consideration of a person’s
dignity should be fundamental to the carer’s dealings with everyone – colleagues, patients or
their visitors.
Respect starts with the way that people are addressed. The widespread practice of using first
names without being invited to do so is potentially disrespectful. The use of first names
usually indicates a friendly relationship and while this is a legitimate goal, it should not be
presumed.
Before friendship, the aim is to have a professional relationship. The carer is generally being
paid to deliver the care they undertake and the patient has usually paid national insurance
and taxes, therefore pre-paying the carer’s wages. Until and unless the patient indicates
otherwise, the carer has no right to address the patient in a familiar way. They should not use
the patient’s first name or familiar terms such as “dear”, “love”, “darling”, “duckie”, etc. All too
often these terms are used when a carer cannot be bothered to find out or remember the
patient’s name, which is entirely unacceptable. Some people do have problems remembering
people’s names and may have many patients to remember. They might start the exchange
with a smile and a glance at the patient’s notes where their name is written, or keep a list of
names in a notebook.
When the relationship between the carer and the patient develops, the patient will tell the
carer how they would like to be addressed and, even if that seems rather formal, it must be
respected. Until then, the patient and their relatives must be shown courtesy and respect in
what is a professional relationship. Generally, this will mean calling them Mrs, Mr, Ms or Miss
– or of course a military or religious title when appropriate.
Each situation will be different. Each person being cared for will be different. Each carer will
approach each patient from a slightly different perspective and all will have a slightly different
set of values. But showing demonstrable respect throughout every aspect of both contact and
care is the minimum standard of care expected. No matter what the situation, it is never
acceptable to speak to or about the patient with any hint of derision. Every aspect of care
delivery should demonstrate that the carer has respect for the patient, their abilities and their
beliefs. There are no exceptions. Ever.
Within all types of ”care” training the use of “self-directed” or “guided training” is often used
when considering “dignity”. This can be a box ticking exercise without the underlying need
being taken seriously. Until recently, concern for a patient’s dignity did not appear to be very
high on the teaching agenda at all. Hopefully the practice of discussion and debate around
issues of dignity in care will increase, so encouraging individual responsibility for
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understanding just how the preservation or building of “Patient dignity” can be achieved by
every carer at all levels in the profession.
4.4 Infection control
In the caring profession, managing the risk of infection is known as “infection control”. At its
simplest, “Infection control” means taking measures that reduce the risk of introducing or
transferring infection to or between people. “People” in this context includes carers, patients,
relatives, visitors and the general public.
Usually an infection involves an unwanted bacteria, virus or yeast entering a new host
(person) and reproducing within them in a way that causes unwanted symptoms.
Bacteria are vital to our wellbeing but the wrong bacteria in the wrong place can be life
threatening. Viruses or yeasts from within the environment can also be absorbed into the
body with undesirable consequences.
Any of these infective agents can enter a person’s body in several ways – breathing, passing
through the skin, via wounds, or by ingestion in contaminated food and water, etc. When this
happens to a healthy and fit person, the body’s defences often manage to destroy the
invaders. However, when someone is weak, already ill, or receiving medication, their
response to these invading bacteria / virus / yeasts can be far less effective. The infections
that result can lead to very unpleasant symptoms, do permanent damage and even be fatal.
It is every carer’s responsibility to reduce the risk of infection to their patient(s) to a level that
is as low as is reasonably possible.
Every aspect of care delivery should automatically include the application of infection control
techniques, some of which are introduced below.
4.4.1 Reducing the risk of infection
The simplest and most effective method of reducing the risk of infection is by using old
fashioned soap and hot running water. As ever, a commercial opportunity has been spotted
and alcohol gel is now widely available to “kill” infections. Alcohol gel is certainly useful when
hand washing facilities are not readily available and is far better than no hand washing at all
but alcohol gel is not usually better than washing your hands. It is still better to wash hands
thoroughly with liquid soap9 and hot running water and dry them thoroughly on a clean towel.
Carers should also be aware that wristwatches and hand jewellery can harbour infection, so
should not be worn when engaged in any activity that involves contact with a patient. This not
only prevents the carer infecting the patient with something they have brought from outside, it
also prevents any infection that the patient may have being able to “hide” on the carer and so
be transferred to another patient. It is in the carer’s personal interests as well, because they
do not want to take the infection home and put it in their family’s sandwiches.
Infection control should also be applied to all equipment used with the patient. Not all
equipment is disposable after being used once. Equipment is often “single patient use”. This
often means that it can be washed (in hot soapy water) then rinsed and thoroughly dried
9 Use liquid soap because no one else has touched it. Shared bars of soap can transfer infection from one user to another.
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before being reused for the same patient. The drying is as important as the washing because
bacteria love to grow in warm moist conditions.
Other equipment needs to be sterile to control the risk of infection. This equipment is usually
provided by the caring authority (G.P., Hospital, etc.). Whatever this equipment might be, it
must not be contaminated before use so the carer must know how to use it in an acquired
“sterile technique” or “no touch” technique. This should have been covered in the carer’s
training but if not, the carer must ask to be taught it before using sterile equipment. Failure to
use sterile equipment in the right way adds risk of infection instead of controlling it. Many
carers responsible for the day to day care of their relatives undertake sterile technique tasks
regularly and must know how to do it safely.
If the equipment may have become contaminated, before being used it must be discarded.
The carer must be strict about this, acknowledging error when necessary and never exposing
their patient to an infection risk that could be avoided.
The Health Protection Agency publishes a poster10 showing how to wash hands thoroughly.
There is more to it than many realise.
4.4.2 Hidden infections
Any patient who develops an infection is potentially infectious. Any carer who develops an
infection is potentially infectious. Any relative who develops an infection is potentially
infectious. And unfortunately, when we develop an infection we are often at our most
infectious before we develop any symptoms.
10 Health Protection Agency, http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947384669
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To control the risk of spreading an infection that you do not know you have is best achieved
by ensuring personal cleanliness and regular, thorough hand-washing. Thorough hand
washing greatly reduces the risk of spreading infection, no matter what the infection is.
Sometimes patients are found to ‘harbour’ the MRSA type of bacteria without showing any
symptoms of illness. The bacteria are present and could eventually wreak havoc on the
patient if they become weak or have open wounds. And even while apparently dormant, they
can be transferred to staff and other patients. MRSA is an infection that can be particularly
problematic because it is resistant to many antibiotics and often only responds to particularly
strong, potentially toxic, antibiotics. A strict regime of hand washing (including the use of gels)
has been shown to control MRSA.
The carer owes it to their patient to wash their hands routinely, regularly and
thoroughly – and always when moving between patients.
4.4.3 Infection control by isolation
Anyone who is found to have a potentially infectious ailment must be taken out of contact with
other patients to reduce the risk of cross infection. They should be cared for in a separate
room or cubicle (“isolated”) and their movements restricted so that they do not leave the room
without precautions being used to reduce the risk of transmitting the infection.
All carers of patients in isolation (and sometimes their visitors) must wear protective clothing
(PPE11- usually gloves, a plastic apron, and sometimes a facemask) before entering the room
and must follow a strict hand washing routine when they discard these and leave the room.
Ideally the carer responsible for looking after an isolated patient should not also be looking
after other sick patients – particularly those who are at increased risk of “picking up” the
infection. While the wearing of disposable plastic aprons and gloves (and sometimes a
facemask) is designed to reduce the risk of infection transfer, it does not eliminate it. The
carer can inadvertently carry the infective agent on their clothes or shoes, or in their hair. Of
course, the risk of infection transfer is greatly increased if the carer does not remove the
apron, facemask and gloves appropriately and follow this by thoroughly washing and drying
their hands. Any carer who does not know how to use PPE appropriately must ask for
instruction.
The psychological impact on a patient who is isolated and only touched with “gloved hands”
by carers wearing plastic aprons and facemasks can be utterly demoralising. Patients who
have been isolated often report having felt rejected, lonely, frightened and a social outcast.
The patient’s dignity should not be sacrificed to infection control, but the infection must be
controlled so the carer must do what they can to reduce the impact of isolation. It can often
help to find time for a conversation that is not treatment related, reminding them that the
isolation is temporary, not their fault, and so on.
4.4.4 Preventing infection via clinical waste
All carers should know that the correct disposal of equipment and consumables that may
carry infection is an essential part of preventing its spread. Any potentially infected material
11 Personal Protective Equipment – specific equipment worn by the carer to reduce their risk of becoming contaminated
while delivering certain aspects of care to the patient.
27
must be put into clinical waste for incineration. They can be very expensive to dispose of but
cost should never be a consideration.
Clinical disposable equipment should be disposed of in special clinical waste bags or
containers. Any used sharp items (“sharps”) must be disposed of in special sharps containers
that must all be sealed after they have been filled to the designated line on the bin then taken
for incineration.
There is a universal colour for clinical waste bags in the NHS (orange at the time of writing)
and sharps containers. It is obviously important that the correct bag or container be used so
that they are disposed of appropriately.
Gloves and aprons used in the routine delivery of care to patients without infectious diseases
need not be disposed of in clinical waste.
When a carer is looking after a relative at home, their local GP practice or care provider
should provide guidance on the disposal of Clinical waste, often via their nursing support
team.
4.5 Patient consent
Consent means “agreement” or “approval” and the carer should have the patient’s consent or
approval for everything that is done for or to them. The only exception is when a patient is
unable to communicate and needs emergency treatment.
I have heard it said that admission to hospital or attendance at a clinic indicates the patient’s
tacit approval for any treatment or investigations that may take place. It does not. If it did, the
hospital of clinic would have carte blanche to do anything to the patient without asking, even
when the patient is perfectly capable of having a preference and making it known.
For example, if I attended my dentist and he elected to remove all of my teeth because he
thought it was in my “best interests” without asking my permission, this would obviously not
be okay. To extract my teeth without my consent would be a form of abuse. The dentist would
be open to prosecution unless I had been demonstrably unable to make the decision myself,
and unless he could present a medically compelling case for the emergency removal of my
teeth being essential.
When a patient is lucid, orientated, communicative and conscious, there is never any excuse
for not asking their permission before the carer does anything to them. From washing their
hands to taking blood samples, this is always true.
Carers should avoid telling the patient anything when they could just as easily ask for their
consent. For example, it is not acceptable to say “‘I am just going to take some blood from
you” when it would have been just as easy to ask, “Could I take some blood from you?”
Whenever a patient can respond – Ask them, don’t tell them.
Asking is not only likely to increase patient compliance, it is also common courtesy – and
maintains patient dignity. Consent implies choice, so the carer should always find enough
time to be confident that the patient does have a choice. This requires communication and a
willingness to put themselves in the patient’s position.
A common use of the word “consent” is when the patient has to sign a “Consent Form”
agreeing to an intervention (usually surgical). Getting their consent is a legal requirement
28
whenever possible, but is often asked of patients who are not in the right condition to fully
understand what is being asked of them and what their options may be.
I can remember many cases involving older patients, often anxious and afraid, who I have
spoken to after they have signed their “Consent forms”. When I have asked what they have
just signed they frequently have no idea. Some say they could not hear, other’s that they did
not understanding what was meant but they all signed anyway because “doctor knows best”.
The older generation often have a reverence for medical professionals that results in total
trust. This should never be taken advantage of for the convenience of the timetable or
targets. The carer should ensure that they really do understand what is proposed, what the
options are, and what the risks are – because every intervention involves some risk and every
effort should be made to ensure that the patient really does decide. This information is known
as a ‘duty of candour’ and should be provided simultaneously considering and
accommodating both the capacity and condition of each individual patient.
4.5.1 Unable to give informed consent?
Gaining genuine consent is obviously complicated when a patient is disorientated or unable
to understand and communicate because of their condition. The carer should consider
alternative communication techniques before deciding that they cannot communicate.
In some situations the patient might have had an assessment of their mental capacity and a
legal guardian appointed. The legal guardian should be asked for their consent and their
approval recorded and signed. Such decisions are made in ‘the best interest’ of the patient.
Any such decisions can be potentially subject to subsequent scrutiny and justification.
The unconscious patient cannot consent but any carer, nurse or medical practitioner should
still talk to the patient and tell them what is being done. For example, the carer should tell the
unconscious patient that they are going to wash them and the medical staff should warn the
patient of the impending “sharp scratch” if they are going to insert a needle to get a blood
sample. For good carers, this should be second nature and automatic.
Consent with the disorientated patient can be assumed when the action or procedure is
considered to be in their “best interests”. Any “best interest” actions”must be recorded and
justified – and the carer should still explain to the patient what they will do before undertaking
the intervention whenever possible. The only time this can be neglected is when the
intervention is an emergency life-saving intervention that must be conducted without a few
second delay (such as Cardio Pulmonary Resuscitation) ).
4.6 Respecting the patient’s culture and religion
In Britain, our multicultural society means that the range of patients who may need care is
global. Similarly, very many carers were not born and educated in Britain and may have
varied faiths and varied cultural backgrounds. We must respect that in our patients and in our
colleagues, but not allow any variation to affect the quality of care that is provided. There is
no conflict. The other five fundamentals of delivering quality care, Communication, Privacy,
Dignity, Infection control and Consent all allow for the diversity of the patient’s Religious and
Cultural background. It is a carer’s responsibility, whatever their own background, to deliver
these fundamentals to the patient in way that is appropriate to that individual.
29
The terms “cultural diversity”, “ethnicity” and “race” are often used without the difference
between them being clear. Broadly speaking, “cultural diversity” refers to a series of shared
customs or beliefs. “Ethnicity” refers to those shared meanings developed within a social and
economic context with a particular historical and political background. “Race” refers to a
group sharing defined physical characteristics. None are superior to another and all are
constrained by the laws of Britain while in Britain. And all carers must seek to deliver excellent
care that is tailored to the patient whatever their own background.
The only way for a carer to achieve this is by communicating with their patient – asking them,
respecting them, and fostering their dignity. The carer must avoid passing judgement or
applying their own values on the patient, their culture, ethnic background or race.
Many hospitals and institutions have a pamphlet or folder containing advice about what
should be done to accommodate various religious beliefs. These may include chaperoning,
providing specific foods, designating prayer areas, and acceptable medical practices such as
organ donation, blood transfusion etc. If a carer is working in an institution that does not have
such a resource, I can only suggest that they remind their managers of their duty of care and
suggest that one be compiled as soon as possible.
A good carer must do everything they can to understand, respect and accommodate the
religious and cultural needs of their patient. When a carer finds out anything that was not
obvious about a patient’s cultural or religious needs, they should write it in the patient’s
personal records so that other carers can share that knowledge.
30
5 Applying these Six Principles
Having introduced the Six fundamental principles of nursing care on which the delivery of
competent care delivery relies, it may be helpful to show how these fundamentals can be
applied during basic activities. The range of possible activities is too broad to cover them all,
so I have limited my advice to areas of frequently required care skills. While these broadly
represent the range, others could easily have been included and their exclusion does not
imply any kind of judgement about their value.
Best practice in delivering every aspect of care is influenced by fashions and fads as well as
new equipment, drugs and discoveries that lead to improvements. The details given in this
part of the book about the equipment to use and the procedure to follow represent best
practice at the time of writing and in the eyes of the author. When a reader has other
experience and disagrees about detail, that is as it should be because there is rarely a single
way of doing something or a single piece of equipment that could be used. During the rest of
this book, I sometimes refer to equipment or resources by name. Alternative equipment or
resources are provided in some places and the “norm” is constantly changing, so no preference
on my part should be presumed. While the equipment or resources may differ, the fundamental
principles still need to be applied to the delivery of care.
While reading on, I suggest that readers work out how the application of the Six fundamental
principles would apply to the caring requirements described. They should also consider how
that would vary in the unique context of their own daily caring acts. It will vary because each
care situation is unique and every aspect of the context impacts on the competent delivery of
appropriate care.
The common caring requirements that I discuss below are presented under the headings:
1. Providing appropriate personal care / hygiene
2. Managing nutritional needs / feeding
3. Managing toileting (professionally known as “elimination”)
4. Managing pain relief
5. Making clinical observations
6. Caring for the unconscious and/or dying patient
Whichever caring activity is underway, all carers will be part of a system that has its own
reporting requirements. It is essential to record the care properly and with enough detail to
ensure that others in the system know what has been done, what has not been done, and the
relevant patient specific detail. These reports provide an audit trail that protects the patient
and the carer against misunderstandings. Carers have a responsibility to keep records
properly for the sake of the patient and also themselves.
When a relative is acting as the carer, they should still have someone to report to, recording
their activities and discussing their concerns. When a home carer has urgent concerns, they
should contact the relevant medical professional and keep a record of that contact.
In Britain, the carer has a legal responsibility to deliver excellent care. When the carer is
unable to deliver the required care because of budget constraints or inadequate provision of
resources – the only protection the care staff have is a written audit trail of reports. They
31
should report the level of care provided and the actions they have taken to resolve any lack of
resources.
Despite the fact that senior management appear to have been treated as immune from
prosecution in recent high profile cases of patient neglect12, they are responsible and could
be held liable for any edicts passed down to caring staff or any reports from caring staff that
were ignored to the detriment of the patient(s). Morally, that responsibility extends to
politicians who presume to dictate the use of management systems that sometimes appear to
work to the detriment of patient care.
5.1 Providing appropriate personal care / hygiene
Personal hygiene helps to maintain a patient’s health, comfort, safety and feelings of “well
being”. It covers:
Assisted hygiene. This is helping the patient to wash themselves thoroughly.. When a
patient can do some of the washing themselves, they must be encouraged and
helped to do so.
Freshen-up care. This involves cleaning of hands, face and teeth and is conducted
frequently as a “freshen up”. When appropriate, it should include provision to shave
and brush hair. The carer should also consider making it easy for the patient to use
their own cosmetics or perfume.
Full wash or blanket bath. This is a full body wash for patients in bed who are unable
to wash themselves. When they can do some of it, they should be encouraged to do
so even if that makes the procedure take longer.
Spot washes. This involves the cleaning of specific areas of the body that have
become soiled, as occurs following an episode of incontinence, for example.
Bath or shower. This involves helping the patient take a bath or shower in safety.
Passive movements. This refers to the regular movement of an immobile patient so
that pressure sores and other problems are avoided.
Oral and hair care. Brushing teeth and hair as part of a “Freshen up” routine or on
their own when it would help the patient to feel more comfortable.
Care of nails on feet and hands. This involves trimming finger and toenails for the
patient’s comfort. Even when a patient may be able to do this, the movement involved
in cutting toenails may be undesirable and the carer should help.
Care of nose. This refers to the nostrils, their cleanliness and comfort.
Care of eyes. This refers to the care and treatment of eyes that may have become
infected, dry or encrusted.
After helping the patient with any aspect of personal hygiene the carer should ensure that the
patient is comfortable and has full access to their potential requirements. Doing this may
include elevating their feet, ensuring that their legs are warm, putting the call bell, spectacles,
drink, functioning hearing aids, reading material, radio etc., within easy reach. The carer
12Patients First and Foremost, the Initial Government Response to the Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry, March 2013.
32
should avoid rushing to next job without ensuring that the predictable needs of the current
patient have been met.
Anyone who is weak or debilitated may require help with their personal hygiene but the carer
has no right to force a reluctant patient to comply. Non residential carers who visit a patient
may be working to a tight timescale that does not allow time to gently persuade a reluctant
patient. The carer should try to negotiate a compromise if they refuse a full body wash,
suggesting just a hands and face wash and a change of clothes might work. The failure to
conduct the expected intervention should be documented, with reasons noted. If possible, the
carer should try to persuade the patient later in the day when their attitude may have
changed.
A patient’s reluctance to fit in with the carer’s personal care regime is acceptable as long as it
does not compromise other aspects of their care. This may be the case when the patient has
incontinence or is at risk of developing pressure ulcers, etc.
Religious, cultural, family, social and economic influences may all affect the patient’s wishes
with regard to their personal hygiene and how and when this is carried out. Negotiation with
the patient usually works – often because it allows the patient to feel able to make the
decision themselves, not simply falling into whatever is easiest for the carer.
Negotiating consent is important and generally makes everyone’s life easier. Attempting to
remove clothes and wash an uncooperative patient can be cruel, humiliating and very hard
work. It is no excuse for the carer to say “it’s what I am being paid to do and I don’t have
much time”. The good carer should be able to avoid this in most cases by negotiating an
agreed outcome.
So it is important to obtain consent from the patient before assisting them with their hygiene
and this includes getting their consent to access their personal belongings such as toiletries
and clothes. The equipment might be already visible and therefore accessible, but the carer
does not have the right to search through a patient’s personal belongings without first asking
for permission. The only exception would be when the patient is unconscious or unresponsive
to any interaction but the carer can still tell them what they are doing. If a relative is present
they might prefer to find things for the carer, so should be given the opportunity.
Remember, the carer must ask for consent but also respect the privacy of the patient and
their personal effects as much as is possible.
The carer must ensure that patient dignity, independence and autonomy is encouraged by
giving the patient the opportunity to conduct their own hygiene routine as much as they are
able. Even when that slows the carer down, it is the needs of the patient that matter, not the
convenience of the carer.
The assistance with personal hygiene that is required will depend on the patient’s general
condition and what, if anything, they are recovering from. Patients do not only recover from
illnesses or conditions, they also need to recover from the medical procedures that may have
been conducted. Following any operation there may be wounds to care for and the patient
may be feeling the after effects of an anaesthetic. Even the use of a local anaesthetic can
make a patient feel pretty awful. Older patients, or those with a concurrent disease such as
diabetes or arthritis, may feel even worse, and can take far longer to recover than a younger
patient.
33
Young or old, few patients feel 100% following any medical procedure. The carer should
anticipate that they might benefit from a “Freshen up”. This might only involve washing hands
and face, cleaning their teeth and brushing their hair. This should be the minimum offered to
any patient who is recovering from a procedure. The patient might decline, but it should be
routine to offer this.
The carer’s involvement in meeting a patient’s personal hygiene needs will depend on the
patient’s ability to do it themselves. If the patient is able and willing to wash their own torso,
hands and face, this should be facilitated. It may take far longer than being washed by an
efficient carer, but the carer must allow the patient to do it themselves when they want to
because the maintenance of a degree of independence can lift the patient’s morale, bolster
their self respect and dignity and have a very beneficial psychological impact that assists their
recovery. When a patient has opted for assisted hygiene, the carer should return to them
when they are ready and complete the care by washing those areas the patient could not
reach, which is usually their back, legs and feet.
Whatever personal hygiene method is used, after it has been completed, it is often
appropriate to encourage the patient to dress in their own clothes during the day and
nightclothes at night. This will help to encourage normality and independence whilst
maintaining dignity and giving a “shape” to their day.
5.1.1 Equipment necessary for both full and assisted hygiene
If the patient is not in a bathroom, some or all of the following equipment will be needed. The
list is not exhaustive. The carer should think about the patient and include anything specific to
their needs.
1. Bowl of Hot water (the water should be changed half way through in all body washes).
2. Two flannels or sponges (whatever the patient uses). One is for the face and the
other for the rest of the body.
3. Two large towels. One is for covering those parts not currently being washed.
4. Soap.
5. Clean clothes (and a continence pad when required).
6. Talcum powder / deodorant / Aftershave, as required by the patient.
7. Any prescribed skin creams or ointments.
8. Dressing gown and slippers if not getting dressed / clothes if getting dressed.
9. Teeth cleaning equipment.
10. Hairbrush / comb including access to a mirror.
11. Cosmetics if desired.
12. Shaving equipment when appropriate.
13. Cloth to clean spectacles, when required.
14. Clean bed linen.
When the patient has a catheter, an alternative type of catheter bag for day use (known as a
day bag) may be required.
If the patient has any other drainage bags they will also need to be changed.
34
5.1.2 Principles applicable to all types of personal care delivery
Prior to all patient contact, infection control considerations mean that carer must thoroughly
wash their own hands with liquid soap and hot running water, drying them thoroughly. They
should only use alcohol gel only when hand washing is not possible.
The carer need not normally wear gloves unless they are dealing with vomit, blood, urinary or
faecal matter, all of which present a risk of infection to the carer. If the carer is likely to be in
contact with bodily fluids, they should protect themselves by using gloves, aprons and, when
appropriate, goggles while they are or may be in contact with the body fluid only.
Whatever the type of personal care the carer is supporting, it is important that this opportunity
is used to communicate with the patient. Whenever communication is possible, the carer
should gain their consent before starting. Consent should never be presumed.
While helping with personal care, the carer can take the opportunity to discreetly assess the
patient’s skin integrity, looking for signs of damage, bruising, cuts, pressure ulcers etc.
Patients can feel exceptionally vulnerable during this care. The carer must be vigilant about
preserving personal dignity, privacy and any cultural or religious requirements.
Any soap used should be rinsed off the skin because if left it can make the skin more
susceptible to dryness, cracking and irritation. Use of emollients, such as aqueous cream, as
a soap substitute may be appropriate because they provide both a cleansing and a
moisturizing effect. Never rub the skin dry, pat with the towel gently – rubbing can damage
the protective outer layer of the patients’ skin.
If the patient has any tubes attached to them and the carer is not fully aware of their purpose,
they must not be touched. Knowing what the tubes are is NOT the same as knowing the
appropriate way of managing them to reduce the risk to the patient. Above all, the carer must
ensure that they do not do the patient harm. It is the carer’s responsibility to ensure that any
such tubes are examined and appropriately managed. When the carer cannot do this, the
requirement for their management must be recording in writing and the carer must contact
their senior nurse / manager to ensure that the need is known,
Following every type of delivery of personal care, the carer must clear away used articles and
clean them in accordance with the rules of the establishment. If there are no specific rules,
then washing any non contaminated equipment with soap and water then drying it thoroughly
will usually suffice. Electric or battery operated equipment should be switched off, unplugged
and can usually be wiped with a dilute hypochloride (bleach) solution, then immediately dried.
Bars of soap should never be shared between patients or staff. Liquid soap from a dispenser
is required because wet, slimy bars of soap provide a perfect medium for bacterial growth and
the spread of infection.
Any potentially infected linen or clothes, such as those that may have been soiled with faecal
matter, should be sluiced using gloved hands then washed in the hottest temperature
possible for the material.
5.1.3 Assisted hygiene (partial self-wash)
The following describes a fairly typical assisted hygiene procedure. It will vary according to
the patient and their context, and will be rather different in their own home.
35
1. Ask the patient if they want to use the toilet / bedpan / commode and assist them to
do so when necessary. Empty any used catheter or stoma (colostomy) bag and
document that as appropriate.
2. With the patient’s consent, gather together the washing requirements including
disposable flannels, toothbrush, hairbrush, razor etc and put them easily within the
patient’s reach.
3. Identify clean night / day clothes as appropriate and make them accessible to the
patient.
4. Prepare a bowl with sufficient water at the correct temperature. The default
temperature is 42ºC but it should be varied when that is what the patient prefers.
When there is no access to water nearby, it can be convenient to prepare two bowls
in readiness.
5. Remove the bedclothes and put them aside where they will not get dirty. Leave either
their top sheet loosely covering the patient or place a large towel over them. When
using a large towel, try to have it pre-warmed.
6. Help the patient to remove their bed-wear, top and bottom, maintaining their modesty
throughout with the judicious movement of the sheet or towel.
If the carer does not know otherwise, they should presume that the
patient is very shy because many are.
7. Remove any incontinence pads, leaving a dry incontinence sheet beneath their
buttocks if it makes them more confident to do so. There is no reason for unwanted
exposure. The sheet or towel can keep them covered throughout.
8. Remove any anti-embolic (TED13) stockings from the patient’s legs and feet.
9. Ensure that the patient has easy access to a dry towel.
10. Confirm that the patient can make contact when then need further assistance, then
leave them to wash all that they can, ideally their face and top half of their body and
their genitalia.
11. When they have completed all that they can, confirm how much they have managed
and help to wash their genitals if they have not done so themselves
12. Remove the bowl and change the water.
13. Then wash and gently pat dry any areas that they were not able to do. This often
includes their legs and feet, back and buttocks.
14. Use any perfumes or deodorants indicated by the patient but avoid applying talcum
powder to skin creases because it can cause soreness.
15. Assist with dressing as required by the patient, encouraging them to undertake as
much as they wish. Do not do more than necessary because this imposes a
13TEDS are a specific type of stockings designed to apply pressure on the deep veins of the legs so reducing the risk of a
deep vein thrombosis or subsequent pulmonary embolus. These have to be prescribed and should never be wrinkled or
cutting into the patient’s skin.
36
dependency that can be demoralizing. Assist them to dress in or out of bed, as
appropriate for each patient. While it may be quicker for the carer to do things for the
patient, it does not help recovery and can erode confidence.
16. Don’t forget to reapply anti-embolic stockings if they have been prescribed.
17. Put the equipment for mouth care, hair care and shaving, as required, either by their
bed or on a bed table beside the chair when they are sitting.
18. If the patient cannot undertake any of these tasks for themselves the carer should do
it for them gently and without undue haste.
Sometimes this whole wash is undertaken with the patient sitting in the chair. When this is the
case, their feet can be placed into the bowl of water. Ensure that feet are dried thoroughly
afterwards, especially between the toes.
It can be a real comfort to the patient to have their feet in a bowl of warm water. Every patient
can enjoy this when they are sitting out in the chair. This need not add unduly to the time
taken because their feet can be soaking while the carer makes their bed and clears away the
other washing equipment.
Before the carer leaves they must ensure that they have cleared everything away, put away
the patient’s personal effects and placed all used equipment in the right places for
subsequent washing or for disposal as appropriate.
5.1.4 Full wash / blanket bath
A full bed wash used to be known as a “blanket bath”. This was because the patient was
covered with a soft fleecy bath blanket throughout the procedure, with only the ‘bits’ being
washed exposed at any one time. This kept them warm, and ensured modesty throughout.
Even though these blankets are no longer used, the same care should be considered – allow
modesty and stop the patient getting cold. Use a large towel (or several small ones) or the top
sheet from their bed to cover the patient and only expose the parts actually being washed or
dried at any one time.
The following describes a fairly typical full wash procedure for the patient who is in bed and
unable to assist. It will vary according to the patient and their context. At all time, the patient
must be asked for their consent, informed about what is happening and have their right to
privacy protected.
1. Ask the patient whether they want to use the toilet / bedpan / commode. If they are
responsive, assist them as appropriate. Empty used urinal / catheter / stoma bag and
document appropriately.
2. Ask the patient if you can give them a bed bath and explain why it is needed.
3. Identify clean bed wear and place it to hand.
4. Prepare a bowl with sufficient water at the correct temperature. The default
temperature is 42ºC but it should actually be varied when that is what the patient
prefers. When there is no access to water nearby, it can be convenient to prepare two
bowls in readiness.
37
5. Remove the bedclothes and put them aside where they will not get dirty. Leave either
their top sheet loosely covering the patient or place a large towel over them. When
using a large towel, try to have it pre-warmed.
6. Remove the patient’s bed-wear, maintaining their modesty throughout with the
judicious movement of the sheet or towel.
If the carer does not know otherwise, they should presume that the
patient is very shy because many are.
7. Remove any incontinence pads without any unwanted exposure. The sheet or towel
can keep the patient covered throughout.
8. Remove any anti-embolic stockings (TEDS14) on the patient’s legs.
9. Tell the patient what you are doing and start the washing sequence with the face and
neck, then the arms, chest, abdomen, and then the genitalia. Expose each part of
their body to wash it separately. Cover whatever is not currently being washed.
10. Use the towel to pat each washed area dry – DO NOT rub because this may remove
the epidermis of the skin. Removal of the epidermis removes a protective layer of the
skin, so making the area more vulnerable to sores or pressure ulcers.
11. Change the water and then wash the patient’s back and buttocks, legs and feet. It is
advisable to have help washing the patient’s back – but if assistance is not available,
take care that the patient does not roll or accidentally get “pushed” out of bed.
12. Use any perfumes or deodorants as indicated by the patient but avoid applying talcum
powder to skin creases because it can cause soreness.
13. Apply any skin treatments that may have been prescribed and replace the patient’s
anti-embolic stockings if they have been prescribed.
14. Dress the patient as required, taking care not to expose more of their body than
necessary while doing so.
15. Bring the equipment for mouth care, hair care and shaving, as required. The carer
must conduct these procedures gently, explaining what they are doing at each stage.
If the patient is capable of doing any of these things for themselves, they should be
encouraged to do so.
While the carer is washing the patient, they should be talking with the patient and also noting
any sores, abrasions, swelling, bruising etc. Talking gives the carer the opportunity to find out
or confirm essential care information – how the patient is feeling, whether they have pain, if
they have any worries or concerns, or even whether they are aware of their surroundings and
what is going on. If the patient is not responsive or not conscious the carer must still talk to
them, explaining what is happening in a way that is calm and unthreatening.
All patients confined to bed should have their bed linen changed at least every 24 hours, and
as required when sweating or incontinence has left the linen wet or soiled. All bottom bed
sheets or draw sheets used must always be wrinkle free. Ensure all creases have been
14TEDS are a specific type of stockings designed to apply pressure on the deep veins of the legs so reducing the risk of a
deep vein thrombosis or subsequent pulmonary embolus. These have to be prescribed and should never be left wrinkled or
cutting into the patient’s skin.
38
smoothed away as the sheet is tucked in. Wrinkled sheets increase the risk of the patient
developing pressure ulcers.
5.1.5 Bath or shower
Within the NHS or in private care homes, ordinary household baths are rarely used because
of the difficulties found in getting many patients safely in and out of a household bath. Some
specialist baths include lifting devices that the carer should be trained to use. While some
advice about using specialist devices is given below, there are too many designs of baths and
showers in medical facilities to cover here. However, some basic rules must be applied
whatever the equipment.
1. The carer should not use the equipment until they feel competent and confident to do
so without endangering their patient. However simple or complex the device, there will
be safety factors to consider. The carer must know them. In many instances the use
of the equipment may be obvious or explained in documentation, or another carer
may be able to demonstrate its use.
2. When assisting a patient to wash in a bath or shower, the familiar principles of gaining
their consent, communicating their preferences, maintaining their privacy and
avoiding any affront to their dignity and respecting any Religious or Cultural
preferences must always be applied.
3. Showers and baths almost always involve standing or sitting on wet surfaces, so non
slip mats should always be used.
4. When the patient has finished, the carer must ensure that all the equipment used has
been cleaned, dried and disposed of, as appropriate .
Home carers whose patient has been assessed by an Allied Health Professional (AHP15) as
being in need of an alternative type of bath or shower may find themselves presented with an
unusual looking facility designed to make patient access safer. They should ensure that they
are confident and competent in its use before doing so.
5.1.6 After the patient has completed any type of personal
hygiene
There are things that every carer should ensure that each patient has access to before they
leave them. This applies after any patient contact, but especially after personal hygiene
routines because they can disrupt the patient’s bed space.
What follows is a very incomplete list of questions that a carer should consider before leaving
their patient. The real list will be patient specific and far longer. These are not questions the
carer should ask the patient, but questions the carer should ask themselves.
Does the patient wear spectacles, and if so, are they within easy reach?
Have they got hearing aid(s)? Are they working? Are they in the patient’s ears?
Have they got access to a TV? Have they a functioning remote control?
15AHP Allied Health Profession. These are highly trained Registered Professionals who are not nurses or doctors but who
work within the health and social care sector – all of whom are Registered and therefore accountable for their own practice.
Most are autonomous practitioners. Examples include Physiotherapists, Occupational Therapists, Social Workers,
Dieticians, Pharmacists etc.
39
Has the patient got something to do – magazines, knitting, cards – the radio?
Are any radio ear-pieces clean?
Does the patient know how to operate the radio, TV, etc?
Has the patient got their call bell? Do they know how and when to use it?
Is the patient comfortable, warm enough, should their feet be elevated?
Would the patient benefit from seeing a clock with the date and time on?
Has the patient got easy access to a drink (as long as they are not denied fluids for
medical reasons)?
Has the patient got a weak or injured side? If so, are all of these resources on the
appropriate side so that they can access them?
Is all tubing (such as catheter tubes) discreet?
Are all drainage bags out of sight but in a position to drain and out of contact with the
floor?
A good carer will have a list in their head for each patient and update it regularly.
5.1.7 Passive movements
Strictly speaking, passive movements refer to the movement of a joint without participation or
effort on the part of the person moving. In many hospitals this definition is extended to include
those movements made by a recumbent patient because they are asked to move in that way.
The patient is asked because the movements reduce the risk of deep vein thrombosis
(DVT16
), pulmonary embolism17
, pneumonia, chest infection, muscle spasm and muscle
wastage.
Passive movements of any unresponsive patient’s limbs should be conducted by the carer at
not longer than four hour intervals, generally when they turn any patient who cannot move
themselves. Patients who are at high risk of developing pressure ulcers because of their
being thin and unable to move themselves should be turned more frequently, at least every
two hours. Again, passive movements can be undertaken as part of this two hourly routine.
All patients confined to bed, or who cannot move much, should be encouraged to make
“passive movements” every hour. Common examples of four hourly Passive movements for
conscious patients who can move are:
Deep breathing – slow and deep, not panting or hyperventilation!
Rotating each foot in circular motion, and
Bending the knees and extending the legs.
Whenever a patient can do this themselves, it must be encouraged by the carer. When the
patient can understand, the reason for doing it should be gently explained. The carer should
avoid over-dramatising the need because that might cause worry and distress. These
movements reduce the risk of undesired events and are simply part of the patient’s treatment.
16 DVT – deep vein thrombosis, a blood clot in the deep veins, commonly of the lower leg. This blood clot can break away
and be transported around the patients body, commonly lodging in the lung causing….17 A pulmonary embolus (a blood clot in the lung) which can be life threatening.
40
5.1.8 Oral care – mouth care
Oral care is necessary for any patient with a restricted fluid intake – whether that restriction is
self imposed, a result of their condition or a medical requirement.
Because the mouth (oral cavity) is a natural environment for many bacteria, infections arise
when the natural state changes and the mouth becomes dry. Mouth infections can cause
localised soreness that may spread to cause serious systemic (large parts of the body
system) infections, so their avoidance is important.
Oral care is conducted to keep the mouth clean, soft and moist, so avoiding cracking and
preventing infection. It can also increase patient comfort dramatically. Mouths are sensitive
and intimate, so mouth care should always be conducted gently and with respect for the
patient’s privacy. Unless the patient is not able to rationalise, the carer should always have
the patient’s consent before starting.
Generally, the carer should make mouth care regularly available when:
1. Any patient is not taking fluids by mouth for whatever reason. Mouth care should be
conducted every two hours for maximum patient comfort, and never less than at four
hourly intervals to avoid infection.
2. If the patient is taking oxygen via a mask, has an infected mouth, or is unconscious,
mouth care should usually be conducted at not less than two hourly intervals,
3. Mouth care should be continuously and discreetly available to all compliant, lucid
patients and “delivered” by the carer to the confused or unconscious patient. Watch
the patient. If their mouth hangs open and they cannot drink, mouth care will be
needed regularly. Generally, mouth care gives such relief to those with a dry mouth
that even the non-compliant or disorientated patient will not object.
4. When any patient is not able to walk around independently or freely, the carer should
facilitate tooth brushing (in mouth or as dentures) night and morning and after every
meal. The amount of toothpaste used should be limited because too much can have a
drying effect. The carer must encourage the patient to rinse the mouth if possible
because this will wash residual toothpaste away and so reduce any drying effect.
The purpose of mouth care can be achieved in any way that keeps the mouth clean, soft and
moist and is acceptable to the patient. The equipment and procedures vary between
institutions. They usually involve the gentle use of a purpose made disposable sponge-stick
or soft toothbrush, moistened with water. There are many mouthwashes available, but water
may be safest agent to use18. There are various oral assessment and recording tools
available if the patient is considered to be at a high risk of oral problems19.
The simplest foam-stick has a plastic handle and an open-cell foam or cotton head. The head
is dipped in water or the preferred mouthwash solution. Some already have a liquid content –
such as lemon and glycerin foam-sticks. The foam on these is soaked in lemon, honey and
glycerin that is brushed over the tongue, gums and mouth lining.
18 Manufacturers of mouthwash products may claim otherwise, but current research suggests that water is the safest and
most effective moisturising agent for oral care. See: http://www.geriatricoralhealth.org/topics/topic07/art/qualified-nurses-
lack-adequate-knowledge.pdf. If antibacterial mouthwash is required chlorhexidine gluconate is an effective antibacterial
agent – Royal Marsden 9th ed. 2015 page 495.19 Use of a single validated tool is recommended by the Department of Health, this ensures consistency of assessment.
41
Foam - or cotton -sticks are not used in some care institutions because there is a risk that the
patient may bite the foam off and choke on it. The carer should assess the patient and
consider whether this is likely. If they think it is, the problem should be resolved by the use of
a soft toothbrush. Institutions that do not use foam-sticks usually use soft toothbrushes to
conduct mouth care, again soaked in the preferred liquid. A soft toothbrush is usually more
effective than foam or cotton sticks.
Many institutions have a preferred mouthwash, or the patient may have their own. Rather
than argue about the advantages of using water, the carer should respect the patient’s or
institution’s view and keep the mouth moist. The important thing is that the oral care must be
undertaken before the patient develops a dry, sore or cracked mouth, not which mouthwash
is best.
When a patient is compliant and able, they may be able to use a mouthwash themselves.
They may have their own, or may accept the mouthwash favoured where they are. Common
mouthwashes used in the NHS include:
The mouthwash Corsodyl which has antibacterial and antifungal properties but the
high alcohol content can make it sting uncomfortably.
The mouthwash Chlorhexidine Gluconate 0.2% which should be diluted 5ml in 100 ml
water, and retained in the mouth for one minute before spitting it out. While mouth
care may be needed far more often, Chlorhexidine mouthwash should only be used
twice a day.
There is evidence (and it is obvious) that the use of a toothbrush is actually more effective
than the use of a sponge-stick but it can be hard to brush a patient’s teeth without introducing
distress or discomfort, so the carer should generally only use a toothbrush with the patient’s
consent. If the patient can use a toothbrush themselves, that should be encouraged.
While conducting mouth care, the carer should pay attention to the following:
Respect the patient’s right to privacy and ensure that no one else can see what is going
on. This can be critical when a patient wears dentures and is self-conscious.
Examine the patient’s lips. If they are dry, cracked or bleeding, the appropriate treatment
should be applied. While vaseline is generally effective, the carer should know that it must
not be used when a patient is receiving oxygen therapy. E45, aqueous cream or aquagel
are suitable alternatives
If the patient’s tongue looks coated and there are signs of a fungal infection, the carer
must report the problem so that a Registered Practitioner or doctor will examine the
tongue and prescribe any antifungal treatment that may be required.
A coated tongue that is not infected can be cleaned with a soft toothbrush and a Corsodyl
50/50 with water or similar mouthwash.
Examine the patient’s mouth for problems such as decay, excess tooth-plaque or rubbing
dentures. If there may be evidence of dental disease or denture problems the carer
should record the problem so that a Registered Practitioner or doctor can make an
examination.
42
When a patient wears full or partial dentures, these must be removed to clean the
underlying areas. While the denture(s) are removed, give the patient water or a
mouthwash to rinse the mouth. Generally, dentures should be removed at night and
placed in water or a suitable cleaning solution, but only with the patient’s consent.
Removing a patient’s dentures can affect their self-image, dignity and self respect, so
always requires their consent whenever the patient is conscious and rational unless there
are compelling medical reasons to remove them.
If the patient has a dry mouth, the carer should prevent this by ensuring that the patient
drinks frequently or has more regular mouth care. If the patient is unable to drink, the
carer may consider whether it is safe for them to suck ice. Regularly irrigating their mouth
with water that is not swallowed will effectively moisten it but spillage must be mopped up
immediately. The carer should also consider using a saliva spray or pastilles. If the
approaches suggested are not safe because the patient cannot swallow properly,
consider thinly smearing a moistening gel such as “Aquagel” thinly onto the patient’s
tongue and gums. Whatever the carer decides is appropriate, they should consult the
patient and get their agreement whenever the patient is conscious and rational.
When the patient may have ulcerated or bleeding gums or mucosa20, the carer might try
cleaning the areas with small, soft, round-ended toothbrush and a smear of fluoride
toothpaste. Any toothpaste used should be rinsed away, then apply a thin layer of
aquagel or similar to the affected areas regularly.
When the patient complains of soreness or mouth pain, the carer may consider the use of
a topical analgesic (pain killer) such as ‘Difflam’ or ‘Bonjela’ which can be bought from
most chemists. Bonjela is rubbed gently onto the affected area. ‘Difflam’ is a mouthwash
that should be diluted 50/50 with water. A simple and effective aspirin mouthwash can
also be made using 2 x 300g soluble tablets and repeated four times a day, but the carer
must always check with the Registered Practitioner or doctor to ensure that the treatment
used is acceptable. Mouthwashes should not be swallowed, of course.
Some patients suffer from the opposite to a dry mouth. They hyper-salivate and cannot
swallow it all. This can result in dribbling, choking or sore skin. The carer should apply a
barrier cream to the area affected by saliva. ‘Cavilon’, ‘diprobase’ or ‘vaseline’ can form an
effective barrier to protect the skin. When a patient’s oral moisture loss is excessive, the fluid
loss should be estimated so that it can be replaced in the calculation of the patient’s required
fluid input. The carer should report the fluid loss in writing so that a doctor can prescribe
medications to reduce the fluid loss. The products suggested here are only suggestions, a
healthcare professional may well advocate alternatives.
When an antifungal mouthwash has been prescribed, it should be used when nothing else
will be delivered via the mouth for a reasonable time (at least an hour). This allows the
antifungal mouthwash time to destroy the fungus and reduce the discomfort. When an
antifungal mouthwash is given to an unconscious or immobile patient, the carer must deliver
the solution with the patient lying on side to reduce the risk of choking. Obviously, place a
towel under their head before using the mouthwash which may be squirted into the mouth or
applied using a sponge-stick. Turn the patient and deliver the mouthwash on both sides, so
increasing the likelihood of it being effective all around the mouth and tongue.
20 The mucosa in this context refers to the inner lining of the cheeks, roof and floor of the mouth.
43
When the mouth care has been completed, the carer must ensure that all equipment used
has been cleaned and dried or disposed of, as appropriate, and that the patient is
comfortable.
5.1.9 Shaving
Shaving can be done using an electric razor or a “wet shave”. Generally, the carer should
encourage any patient who can do this themselves to do as much as they can. The carer can
then complete any bits they have “missed”. Doing more for the patient than is necessary can
affect the patient’s self esteem and increase dependency, instead of promoting recovery.
Generally shaving should be a regular part of the patient’s daily personal hygiene routine
unless the patient does not want to shave or there are medical reasons for not shaving.
The shaving requirements will vary, but all wet shaves will involve having access to hot water,
soap or foam, a mirror, towel and, when wanted, aftershave lotion. Either the patient’s own
razor should be used or a disposable one provided. When the carer shaves the patient, they
should talk to the patient explaining what they are doing and flattening the skin when
necessary to ensure an even shave. Most disposable razors are designed to be used at
limited angles. Holding the razor at the wrong angle can make it likely that the skin will be
damaged. When a carer has never used a wet razor, they should practice on themselves
before approaching a patient with a razor. Shaving someone is easy, but there is a knack and
it should never be rushed.
For all electric shaves, the patient will need access to both a mirror and their own functional
electric razor. Following use it may need to be recharged and the shaving head may need to
be cleaned. The carer should ensure that this happens, and do it for the patient when they
cannot do it themselves. Shaving a patient with an electric razor is easier than giving a wet
shave but should still be done slowly and gently, taking instructions from the patient
whenever they can give them.
When the patient has shaved, the carer should offer to help with any areas that have been
missed, then ensure that all shaving equipment is cleared away, washed and dried or
disposed of, as appropriate.
5.1.10 Care of nails on hands and feet
Care of finger and toe nails is important because, particularly in diabetic patients, the nails
and areas around them can easily develop sores that do not heal readily. This raises the risk
of infection and causes discomfort to the patient.
Nail care should be included as part of the patient’s personal hygiene routine. It covers not
just cutting nails, but also cleaning under and around them so is a daily requirement. When a
patient does not want their nails to be cut, their preference must be respected unless there is
a compelling medical reason to cut the nails. Generally, the patient will allow their nails to be
cleaned even if they are reluctant to have their nails cut. If a patient wants the clippings
collected, the carer must do this without comment.
Whenever a patient can clean and cut their own nails, they should be encouraged and helped
to do so. Many patients cannot comfortably bend to reach their feet and clean or cut their own
toenails, so the carer will often have to do this for them. If a patient has a preference for the
shape of their nails, their preference must take precedence over default advice, of course.
44
Soaking the fingers or feet in warm soapy water before cleaning and cutting nails can make
the process easier and more efficient.
The area around nails should be cleaned using a nailbrush. The nailbrush should never be
shared with other patients because they can harbour bacteria and be a cause of infection
transfer.
The area beneath the nails can be cleaned using a nail file. Cut or clip finger nails level with
the tip of the toe or finger. The corners of a fingernail can be shaped using an emery board.
Toe nails should be cut/clipped straight across. The emery board must never be shared
between patients because it can be a cause of infection transfer.
Patients who have diabetes may have an increased risk of circulation problems in their legs
and feet. They should always have their toenails cut by a podiatrist (chiropodist).
During the care of finger and toe nails, the carer must examine the areas and record any
area(s) of skin dryness, inflammation, or calluses in the patient’s personal notes. Any
indication of infection should be brought to the attention of appropriately qualified medical
staff as soon as possible.
After caring for finger and toenails, the carer must ensure that all the equipment used has
been cleaned and dried, or disposed of, as appropriate.
5.1.11 Care of the nose
The carer should consider, offer and include nasal care as part of the patient’s personal
hygiene routine. When a patient has access to tissues and can blow their nose, it may not
often be necessary, but in some cases it is essential. When a patient has tubes inserted via
their nostrils or is receiving oxygen through nasal prongs, they frequently develop a sore or
encrusted nose.
Before providing nose care, the carer must explain what they are doing and why. Noses are
sensitive, so the care must be conducted with patience and with respect for the patient’s
privacy.
Each nostril should be cleaned using a gloved hand using warm water and gauze soaked
with saline21 solution, then apply a gel such as Aquagel (not vaseline) to reduce dryness. Any
areas of soreness should be recorded and reported appropriately.
Feeding tubes require very specific assessment before changing the dressing / securing tape,
so this should only be conducted by appropriately qualified staff. If the carer thinks it is
needed, they should report the need and record it in writing.
5.1.12 Care of eyes
To maintain healthy eyes and preserve sight, eyes must be kept moist and free from infection.
Most patients will need no special eye care but there are several regularly used drugs that
can increase the risk of the patient’s eyes become dry and prone to encrustation that can
cause infection. The unconscious or dying patient is also significantly at risk of eye
encrustation.
21 A teaspoonful of salt dissolved in a pint of cool boiled water could be used in this instance.
45
Eye care can be divided into two activities - washing and irrigation. All carers should be
competent to wash a patient’s closed eyes but the irrigation procedure should not be
conducted by any carer who has not been trained and assessed as being competent to
undertake it.
As with each aspect of care, the carer should explain to the patient what they plan to do –
asking for the patient’s consent before starting.
If the patient has an infection in one eye, the eye without an infection should be cleaned
before the infected eye. This reduces any risk of spreading the infection.
To clean sticky matter and encrustations from a patient’s closed eyes, the carer should use a
solution of 0.9% sterile saline solution (salty water) or sterile water22 to wet a low lint soft
gauze. Using a gloved hand, wipe the gauze gently from the nose outward, then turn the
gauze to repeat with its clean side. Wipe gently – applying no pressure to the eyeball. Repeat
the wiping action until any encrustation has been removed, never using the same piece of the
saline soaked gauze more than once. Make sure that the lid stays closed and that the gauze
does not come into contact with the eye, and always use separate gauzes for the right and
the left eye.
After caring for the patient’s eyes, the carer must ensure that all the equipment used has
been cleaned and dried, or disposed of, as appropriate.
Some patients have an artificial eye. This may be removable or implanted. All removable
artificial eyes should be removed daily and cleaned. Artificial eyes can be cleaned using
sterile water, or a proprietary solution that the patient may have. Usually the patient will be
able to either remove the eye themselves or tell their carer how to do it. When the patient
cannot do this, the carer should document the problem and seek advice
5.1.13 Care of hair
When a patient is lying in bed, their hair can become knotted and matted. This can be
uncomfortable and can embarrass the patient, lowering their self esteem. If hair is dirty it can
harbour infection and present a health risk. The same can be true of bearded male patients
who must be offered the same hair care facilities for their beards.
Generally, each patient’s hair should be combed or brushed thoroughly at least once a day.
Whenever a patient cannot do this for themselves, it is the carer’s responsibility to assist. As
always, if the patient can do part of the task themselves, the carer must facilitate this. As with
each aspect of care, the carer should always explain to the patient what they plan to do and
get their consent and assistance whenever possible. Hair care is generally a private activity,
so the patient’s privacy must be respected whenever possible.
The carer should not use the same brush or comb for more than one patient.
Patients should be given the opportunity to wash their hair whenever it looks as though it
needs it, or when the patient asks. When a patient cannot do this themselves or has
restricted movement, this can be challenging but the carer must find a way. Some institutions
will have equipment and a process to follow, in other places the carer may need to use a little
22 Sterile water may be preferable a saline solution when a patient is aware – because it is less likely to sting.
46
ingenuity. When caring for a long-stay patient, it can become part of a routine that the patient
can look forward to.
Hair washing is always worthwhile because, for many patients, having clean and tidy hair can
provide a huge morale boost.
In nursing, rest and private care homes, there is often an arrangement with a mobile
hairdresser who will visit at pre-arranged times. This service is usually (but not exclusively)
only available to patients who are not confined to their bed. If it is available, the patient must
be made aware of it and encouraged to take advantage of it when appropriate.
While it may not be possible to accommodate a patient’s desire for frequent hair-washing,
regular brushing and combing is part of basic nursing care and failure to offer it with as much
assistance as necessary would constitute neglect.
5.2 Managing nutritional needs – feeding
Some conditions or diseases increase the risk of the patient developing a poor nutritional
status which raises the risk of unnecessary complications such as pressure ulcers (bed
sores), poor tissue regeneration (healing), infection and unnecessary patient suffering.
Examples of patients with a higher than average risk of having a poor nutritional status are:
Those who have suffered a stroke and have difficulty swallowing as a result
(dysphagia).
Those who have been recently diagnosed as diabetic and their condition has not yet
stabilised.
Patients who are receiving enteral feeding (enteral feeding is feeding via a tube into
the stomach and is discussed below).
Patients with any malabsorbtion syndrome, whereby their gut cannot absorb or
metabolise food thoroughly.
Patients receiving what is known as “Parental nutrition” (usually through a central
venous line). Parenteral nutrition is a liquid food, comprised of specific nutrients and
vitamins that are delivered into a large central vein of the patient.
Patients with known liver (Hepatic) disease.
Patients with known kidney (Renal )disease.
Patients who are grossly obese, known as “morbid obesity”.
Patients with anorexia nervosa.
Patients with pancreatic disease.
Patients who are or who have recently been nursed in a critical care unit.
Patients who have had major gastrointestinal surgery.
Patients with advanced stages of dementia.
Patients who meet the above criteria will not necessarily have a problem with their nutritional
status, but the carer should be aware of the increased risk.
47
When the carer suspects a patient may be malnourished, specific assessment is required that
will identify both whether this is correct and whether there are other factors that require
special dietary supplements to be administered
Most patients eat normally through their mouths, known as “Oral Feeding”. Their carer must
ensure that the food provided meets any religious or cultural requirements. They must also
ensure that the food is presented to the patient in a position that makes it easy for them to
reach and provide assistance when required. Some may need the food cut up for them,
others may need help moving the food to their mouths. When a patient takes oral sustenance
with assistance, the carer should never try to make them eat faster than their natural speed.
When the patient has not eaten much it can be appropriate for the carer to encourage them to
continue, but the carer must not oblige or bully the patient.
The portion should be agreed (consent) and adjusted to suit the patient. An elderly anorexic
will be unlikely to want to even look at an enormous plate of fish and chips while a ravenous
young man will not want a paltry portion. The carer should know their patient and ensure that
the size of portion meets their needs.
Some common physical infirmities, such as arthritis may make it impossible for a patient to
use normal cutlery. If this is the case, an Occupational Therapist should be asked to assess
the patient’s needs and provide appropriate eating utensils. When the carer thinks there is a
problem, they should report it and ensure that the problem is satisfactorily resolved.
Some patients are thin, frail, and have a low body mass. Their diet is commonly
supplemented with nutritional drinks. These are prescribed by a dietician / doctor and their
ingestion is important, so the carer must record their use accurately. The carer should also
encourage the patient to drink them. Patients with a low appetite may be reluctant so the
carer may need to remind them that they are part of the treatment and will improve the way
they feel. Nutritional drinks are often quite large and may be too much for the patient to drink
in one go. The carer should ensure that they are not left on lockers or bed-tables for hours
because they can easily grow bacteria. Refrigerate an opened drink supplement. In warm
conditions, record approximately how much was drunk and then dispose of the partially
consumed drink.
The carer must only ever encourage, not oblige the patient to eat or drink. The patient has the
right to decline. If the carer is concerned that they are not eating enough or they are not
eating prescribed supplements, the carer must record this reluctance.
Eating should be an enjoyable process for the patient. When they require help, that can be
demoralising so the carer should make the process as easy as possible
Before serving any meal the carer should:
Offer toileting to any patient who may be in need. When patients have been given a
diuretic (medication to make the patient pass a lot of urine), their needs can be
sudden and urgent. Then ensure that any toileting equipment has been removed
Remove any aprons or gloves that have been used to deliver other aspects of care,
then wash their hands thoroughly. Some institutions require the use of a specific
apron for delivering food and the rules of the institution should be followed.
Ensure that the patient is comfortable, usually in a sitting position.
48
If the patient has dentures, check that they are wearing them, or if they want to wear
them.
When protection for the patient’s clothes is required, ensure that it is clean. It is not
acceptable to use protection that has previous stains.
Ensure that there is a suitably positioned bed-table or other surface on which the food
can be placed.
When providing assistance with eating, the carer should:
Sit in front of the patient or slightly to their side.
Interact with the patient, encouraging discourse as if dining together.
Ask whether the food is suitable and to their liking.
Offer the food in small amounts. Each mouthful must be chewed properly and
swallowed before the next is offered.
Offer frequent drinks – preferably not using a feeder cup. Feeder cups have a place in
helping a patient to feed themselves but whenever possible the carer should use a
normal cup, adding a drinking straw when necessary. Feeder cups emphasise the
patient’s vulnerability and can be a degrading affront to their dignity. They are not
often necessary provided the delivery of fluid is not being rushed.
Do not appear to be in a hurry. A patient should not feel obliged to hurry or say they
have had enough because their carer is busy. Rushing feeding causes poor chewing,
poor digestion, indigestion, constipation or worse still, choking and possibly death.
A pleasant, satisfying meal can make a great difference to patient morale, and mealtimes can
become highlights in their day.
Every carer should be aware of the appropriate action to take if a patient chokes while eating.
This should have been covered during their training. It is the carer’s legal responsibility to
ensure that they know what to do if choking occurs.
When the meal has been completed, clear the equipment away and document it when
required. It is usually appropriate to offer the patient a freshen up wash, including oral care.
Why some patients are reluctant to eat
There is always a reason for a patient not eating and it is part of their carer’s responsibility to
communicate with the patient, identify the cause and rectify it whenever possible.
Common reasons for a reluctance to eat include:
1. The patient is feeling anxiety.
2. The food offered is inappropriate, either in consistency or by failing to conform to the
patient’s religious or cultural requirements.
3. The food looks unappetising.
4. The patient is in pain.
5. The patient needs to go to the toilet.
6. The patient has no teeth, painful teeth, or a sore mouth.
49
7. Physical infirmity, unable to cut up their food or handle the cutlery easily.
8. The patient is suffering from depression.
9. The patient cannot reach the food easily. The plate may not be at an appropriate
height for the patient’s position.
10. The patient cannot see what they are eating or what is on the plate – those with visual
problems might like to be told what they are being given and their hands guided to
their cutlery and drink.
11. The patient is confused and does not understand what they are expected to be doing.
12. The patient is anorexic.
13. The patient is feeling nauseous.
14. The patient has been given too large a portion.
15. The patient does not like what they have been given.
Many of these can be rectified and all should be recorded and reported because they can be
critical to a patient’s welfare.
Why some patients are reluctant to drink
Getting patients to drink enough can be a problem because the more they drink the more
they want to go to the toilet. Many patients don’t drink much because they don’t want to have
to keep going to the toilet. They may want to avoid the effort and discomfort of making their
way to the toilet independently, or they may want to avoid asking for help and the loss of self
esteem involved in needing toileting assistance.
This is a serious problem because if they don’t drink enough they risk developing a urinary
infection. This may be a low grade infection but it is unpleasant, makes the patient need to
pass urine more and makes urinating painful,. Untreated, the infection can develop into a
significant infection that can make the patient confused and even more reluctant to drink. It is
not uncommon for this to lead to the patient being hospitalised to receive intravenous fluids
and intravenous antibiotics. Admission to hospital can lead to the patient being encouraged
into a “dependency mould”. Their bed may be a long way from a toilet. They may rarely be
offered the opportunity to be escorted to the toilet and so become dependent on bedpans or
commodes. Their confidence in their ability to walk can be eroded, reducing their ability to
cope independently in a way that leads to them eventually being institutionalised.
The solution is very often to remove the problems that a patient has about urinating
frequently. This is not as simple as regularly offering a commode or a bedpan. Whenever a
patient is capable of walking to the toilet, the offer should be to escort them to the toilet so
that their confidence in their own ability is enhanced rather than eroded. This may take a little
more time, but can pay great dividends to the patient.
To encourage fluid intake, all patients should have access to drinking water at all times
unless there are medical reasons to restrict fluid intake. Easy access to a toilet will often
encourage compliance.
5.2.1 Swallowing difficulties (dysphagia)
Patients with known swallowing difficulties should have a “swallow assessment” to ensure
they are not at risk of food going the “wrong way” and ending up in their lungs. The
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assessment is often conducted by a Registered Practitioner or a Speech and Language
Therapist. (SLT23). If food does “go down the wrong way”, the patient can develop a
pneumonia which can be fatal. The assessment will determine whether the patient can safely
eat and drink.
When it is not safe for the patient to eat and drink, the patient will be declared “Nil By Mouth”
(NBM) and need alternative methods of feeding. This decision requires a significant life style
change and will have a major impact on both the patient and their relatives.
Any patient declared NBM will require frequent oral care (mouth care).
Sometimes it is decided that a patient can eat but that the food must be mashed or pureed.
Sometimes a decision is made that all fluids must be thickened. Thickened fluids are used to
reduce the risk of choking because they are easier for the patient to control in their mouth.
Effectively, nothing slips down their throat until they decide to swallow. Thickened fluids are
made by adding a thickening powder to everything that the patient drinks – cold drinks, hot
drinks, soups and nutritional supplement drinks. The consistency can be varied and the
correct consistency should be indicated by those making the assessment.
The consistencies are generally known as:
Stage 1: syrup consistency
Stage 2: custard consistency
Stage 3: pudding consistency
Those conducting the assessment will also advise on the type of drinking cup that is best for
an individual patient. Open cups are often better because beakers can send the fluid to the
back of the throat too quickly.
5.2.2 Enteral Feeding
When a patient has had a “swallow assessment” and is found to be at significant risk of
choking on foods and fluids of any consistency, an alternative means of feeding is required. If
the problem is expected to be very short term, the patient may have an intravenous line
inserted through which a special feed is delivered intravenously.
When the patient may be expected to need longer term feeding, enteral feeding is commonly
used. This involves passing liquid feed directly into the patient’s stomach. Enteral feeding is
achieved either by using a tube inserted into the patient’s nose (known as an enteral feeding
tube24) which ends in their stomach, or by passing a tube through their abdominal wall and
into their stomach (known as a Percutaneous Endoscopic Gastrostomy or P.E.G.25 tube). The
liquid feed delivered through the tube contains the patient’s complete nutritional
requirements.
23SLT – an Allied Health Profession whose skills include the ability to undertake a “swallow assessment’” and identify any
risks inherent with patients who may have swallowing difficulties.24 An NG is a tube that is delivered “Naso” (in the nose) and passes into the stomach (Gastric).25 P.E.G – Percutaneous Endoscopic Gastrostomy – through the abdominal wall directly into the stomach (gastrostomy),
51
5.2.3 Enteral feeding tubes
An enteral feeding tube is often used when the patient’s need for this method of feeding is not
expected to continue for more than a few weeks. It may also be used while waiting for a
P.E.G. tube to be inserted.
Delivering nutrition by an enteral tube can be very demoralizing for the patient who may have
just experienced a life changing event such as a stroke or receipt of a serious diagnosis. In
these situations, both the patient and their relatives should be expected to be upset, angry or
grieving. The presence of a feeding tube will not be reassuring. The carer must provide plenty
of that.
The carer should regularly and discreetly examine the enteral tube’s securing method and the
nostril through which the tube passes. Using a gloved hand, treat any sores or dryness using
a lubricant such as aquagel or vaseline. Replace the means of securing the tube to the
patient whenever it could be become detached. Make sure that the tube never passes in front
of the patient’s vision. There is no reason why it should, so obstructing the patient’s sight
would be thoughtless and inconsiderate. The carer should remember that when a patient’s
condition is such that they need enteral feeding, that patient needs the utmost support and
consideration as a person as well as a patient.
When inserting the enteral tube up a nostril it is possible to accidentally push the tube down
“the wrong way” into their lungs. A patient with a normal swallow reflex would know this and
could be relied on to cough, but in the patient who has difficulty swallowing they may not feel
this incorrect insertion and not cough – resulting in the tube being incorrectly inserted26.. The
enteral tube has a thin guide wire inside it. After the tube has been inserted, the guide wire
must be left in place until the patient has had an x-ray of their chest. The guide wire will show
up on the x-ray, so providing confirmation that the end of this tube is in the stomach and not
in the bronchus or lungs. The guide-wire is then removed, the tube is secured to the patient’s
cheek or nostril and liquid feeds delivered. The feed is usually pushed through the tube by a
feed pump that slowly delivers the feed into the patient’s stomach.
Not only do feeding tubes potentially demoralise the patient they also increase the risk of
nasal sores and most importantly, they require extreme vigilance to ensure that the tip of the
tube remains in the stomach and does not move from the stomach into their lungs – known
as tube misplacement. That may sound unlikely but it can occur.
Vomiting or coughing can be the cause of tube misplacement. So can securing the tube to
the patient’s nose or cheek in a way that becomes loose. When a tube appears to be “coming
out” the carer must never simply just push the tube back down again because there is a high
risk of accidentally pushing the feeding tube into the patient’s lungs instead of their stomach.
There are markings on the outside of the tube, the number written on the tube where it exits
from the nose should be recorded at the time of satisfactory insertion. This number should
remain the same and be checked prior to starting any enteral (tube) feed.
26 The risk is very high and is recorded by the Department of Health as being a “never” event, of such magnitude that it
should never happen.
52
5.2.4 Testing for enteral tube misplacement
In order to ensure that the tip of the feeding tube has not become misplaced a test must be
conducted before any feed is attached to the nasal feeding tube.
This test involves using a clean syringe that is attached to the end of the enteral tube using a
gloved hand. The syringe plunger is withdrawn just enough to draw back a small amount of
fluid into the syringe body. A few millilitres is all that is needed.
The syringe is then disconnected from the enteral tube and the content squirted directly onto
a piece of pH paper. If the result shows a pH result of 5.5 or less, this indicates a very acid
result and means that the tip of this tube is safely in the patient’s stomach. It is important that
pH paper is used, not litmus paper. This is because some people have acid secretions in their
lungs, caused by some lung diseases or medications. If litmus paper were used it would not
provide the information required for best, safe practice. When a carer has any concern that
the enteral feeding tube may have become displaced, such as when the patient has been
coughing violently or vomiting, they must not attempt to deliver any feed through it. The carer
must report their concern, recording it in writing and seek advice from a suitably qualified
Registered Practitioner or doctor. Another x-ray may be conducted to confirm that the tip of
the enteral feeding . tube is placed in the patient’s stomach and not their lungs.
5.2.5 P.E.G. (percutaneous endoscopic gastrostomy)27 feeding
tube
When enteral feeding may be required for longer than three or four weeks, a P.E.G. tube is
often used instead of the enteral feeding tube.
The P.E.G. tube is inserted while the patient is either under a general anaesthetic or under
sedation, so this usually occurs in a hospital or clinic setting. The tube is guided directly into
either the stomach or jejunum (a specific part of the small intestine) using an x-ray type of
imaging. When correctly in place, a type of balloon or “button” is inflated to prevent it falling
out again. This means that a P.E.G. is unlikely to become displaced, but the site where it is
inserted into the abdomen can become sore or infected.
5.2.6 Care of the P.E.G. insertion site
The carer must regularly clean the tube insertion site using sterile low lint gauze soaked in
saline. While doing this they should look for any encrustation, swelling or signs of infection.
The carer must report any indication of swelling or infection immediately.
Sometimes the P.E.G. tube is secured to the patient’s abdomen by a dressing or tape fixing.
When this is the case, the carer must ensure that the patient’s skin is not sore or dirty
underneath this. Before removing the tape fixing, the carer should note the number on the
outside of the tube – this will be indicated in millimetres or centimetres. The skin underneath
the tape fixation can be examined, cleaned and dried if appropriate The measurement should
be the same when the tube is reattached to the tape fixation device..
27 P.E.G. or percutaneous endoscopic gastrostomy is sometimes referred to simply as a “gastronomy”.
53
When checking the insertion site, the carer should gently rotate the P.E.G. tube through a full
turn (360°). This can help to prevent the tube becoming stuck to the stoma track inside the
patient.
In some cases the tube exit area may have been sutured. If sutures are present, the carer
must check that they are secure and report immediately if they seem to be insecure, are
moist, look red or infected
The carer should not cover the P.E.G. insertion site with a dressing unless it is leaking
because leaving it uncovered promotes healing and prevents infection.
The carer should not use talcum powder or skin creams around the tube insertion site.
5.2.7 Feeding using enteral or P.E.G. tubes
Whichever tube is used, the feed is delivered using a slow feeding pump that delivers a
specific amount every hour. The amount delivered can be adjusted to suit the patient’s needs.
The feed can be delivered continuously, intermittently or in specific volumes over a set
timespan.
Continuous feeding has the advantage of maintaining a constant blood glucose level in the
patient. This is generally well tolerated by the patient’s body but it can restrict patient
movement because they are attached to the machine most of the day.
Intermittent feeding can be delivered by gravity (a large syringe is attached to the end of the
feeding tube, filled with the liquid feed and elevated to allow the liquid feed to drain by gravity
down the tube into the patient) or by using a feed pump. This intermittent approach generally
has the advantage that the patient can choose when to be fed, so have the opportunity to get
out of bed and do other things. Each pumped feed may be delivered over an hour or two but,
because the feed is not continuous, a larger volume must be delivered in a shorter time. If the
patient feels too full or uncomfortable the feed must be stopped. If they allow their stomach to
become too full, they may vomit. Whether the feed is stopped or ejected, the patient is not
getting the required sustenance and this must be recorded and corrected.
Giving a specific volume of food in a limited time is known as “Bolus” feeding. While this has
similarities to eating at mealtimes, it can be very intensive and because of the ‘richness’ of the
food it can result in poor digestion and absorption of nutrients.
The content of the patient’s feed will be prescribed by a dietician who must take note of any
religious or cultural requirements and preferences. The content should be discussed and
agreed with the patient or their legal representative whenever possible. When discussion is
not possible, the dietician must consult the patient’s notes to ensure that any religious or
cultural requirements are accommodated.
All feeding equipment should be sterile when starting a feed. The carer should remember,
that the care environment is generally warm and the feeds are full of nutrition, so providing an
ideal environment for infective agents to flourish if they can gain access. It is up to the carer
to ensure that they do not.
The carer should wash their hands thoroughly in liquid soap and under hot running water
before setting up the feed.
54
After a feed, the tube should be flushed with water to prevent any food residue blocking the
tube.
After use, the feed pump should be wiped with an appropriate disinfectant wipe28, never
immersed in water.
5.2.8 Other enteral feeding notes
The carer should reduce the risk of aspiration of the feed into the lungs by ensuring that the
patient is at a 45° angle (or more) throughout the feed whenever possible.
If nausea or vomiting occur at any time , this must be recorded in the patient’s record and the
dietician informed. Sometimes reducing the duration of delivery may reduce nausea.
Feeds can give patients loose stools or diarrhoea. This can be reduced by delivering the feed
to the stomach at a slower rate. All enteral and PEG feeding is prescribed and therefore must
be delivered as prescribed by the dietician.
When a patient receiving enteral or PEG feeding becomes constipated, the carer should
examine the amount of water that has been delivered via the tube. Water is usually
prescribed as part of their nutritional regime and should be sufficient to reduce the risk of
constipation. Again, this should be reported to the dietician who may prescribe an apperient
such as senokot liquid which can be delivered via the feeding tube. When a feeding tube
becomes blocked, this is always caused by the carer having failed to flush the feeding tube
adequately following the feed. Whenever a feed is completed, the tube should always be
flushed with water to prevent it blocking. When a tube is blocked, flushing with warm water
can sometimes push through the blockage, but it should never be forced through the tube
because that could make the tube burst.
Patients receiving enteral feeding of any type have a significant risk of developing a sore or
dry mouth – but generally this will only happen when the carers have not ensured adequate
and thorough oral care.
5.3 Managing toileting - elimination
This most basic animal requirement frequently causes the most distress to patients and / or
their relatives. Many patients feel embarrassment and a loss of dignity because their toileting
needs are suddenly the concern of others. The carer should anticipate this and do all that
they can to help the patient conserve their self-respect, dignity and pride. This involves
anticipating and respecting the patient’s needs.
A previously healthy person may have never discussed their toileting habits in their entire life,
considering it indelicate, personal and ultimately private.
Another patient may have managed to be independent in their own home where they were
close to a familiar toilet that they could access using various pieces of furniture as hand holds
to negotiate their way there and back. In a hospital or other institution they will suddenly be in
unfamiliar surroundings. The toilet may be far away and will almost certainly be functionally
impersonal. They can no longer get to the toilet and can feel totally dependent on others.
28 The type of wipe will often vary. When no wipes are available, a clean cloth soaked in a mild soap and water solution will
generally be sufficient.
55
Loss of one’s independence, dignity and familiar surroundings at the same time as having a
medical condition is not easy for them. The carer should anticipate this and do all they can to
make toileting an issue of little concern. This does not necessarily mean using commodes or
bedpans. These are often for the carer’s convenience, not that of the patient. A sick patient
may appreciate no longer having to negotiate their way to the toilet but as they get stronger,
walking to the toilet can be a vital part of their rehabilitation, so the carer should assist with
that. .
Many elderly patients may be prescribed diuretic tablets that make them increase their urine
output. If patients are receiving these diuretics intravenously (via a drip into a vein) these
drugs will work fast. The carer should presume that the patient will need frequent and
URGENT bedpans or commodes, without which the patient may have an “accident”. The
“accident” may not be of great significance to a carer who was slow to respond but it can be
devastating to the patient who is suddenly labelled “incontinent” for the first time in their lives.
Carers should predict and respond to toileting needs efficiently and never show irritation or
judgment following “accidents”.
Many elderly patients have a history of urgency or stress incontinence, a condition that often
affects women after the birth of their children. When a carer finds that a patient has a long
history of this they should consider (with the patient’s consent) asking for the patient to be
referred to the specialist nurse, via the G.P. or hospital. There are specialist nurses working
with continence problems and they can sometimes help.
Similarly, many elderly (and some younger) men suffer prostatic (prostate gland) problems
resulting in frequent and urgent needs to urinate and / or poor urinary output. These men may
lose their toileting independence if their bed is a long way from a toilet. The fact that men can
use a bottle urinal often reduces this problem but the bottle urinals may introduce other
problems. They are often stacked up on the locker or bed-table – a practice that is neither
aesthetically pleasing nor hygienic. The carer should imagine how they would feel if a
neighbour visited them at home and there was a bedpan full of urine on the floor or table
beside them. Leaving these toileting essentials on public display is potentially embarrassing
to the patient and / or their visitors – so their carers should avoid that. And it is also
unhygienic.
Most patients cope very well, especially when they have considerate and respectful carers.
Carers should consider the following problems and minimise them whenever possible:
1. The patient’s position in relation to the toilet can have a significant impact on whether they
remain independent, and so may affect whether they are ever able to go home. The beds
of those with a predictably frequent need should be positioned conveniently for the toilet.
When that is not possible, the need for a bedpan, bottle urinal or commode should be
presumed and offered.
2. Calls for toileting assistance should always be answered promptly.
3. Communication about toileting should be especially discreet. The patient’s dignity and
privacy are rights that the carer must respect.
4. The gender of the carer may influence the patient’s acceptance of the carer’s involvement
in facilitating their toileting requirements. This is not silly. It may be “coy”, but that is the
56
patient’s right. Whenever possible the carer should facilitate it. When a patient insists, the
carer must respect their needs.
5. The drugs that the patient is taking may make them need frequent bedpans, bottle
urinals, commodes or visits to the toilet. This should be predicted and provision made to
meet their needs.
6. The patient may be terrified of being in hospital and “doing things wrong” so they just do
as they are told, even though that leaves them humbled and embarrassed. The carer
should not take advantage of their compliance but should try to find out what they need
and deliver it whenever possible.
All of this must be considered for every patient. Those who have urinary or bowel problems
may have more intense needs for toileting assistance and this should be predicted and
catered for by their carers.
Urinary Tract Infections (U.T.I.) do not always cause a temperature (pyrexia) in patients in the
way that many infections do29. However even mild U.T.I. frequently makes it painful to pass
urine (a condition known as dysuria) and makes the patient want to pass urine frequently.
The urine may smell unpleasant and the elderly patient may display signs of confusion. The
carer should always consider the possibility that the patient has a U.T.I. if the patient has
become confused. Check for the symptoms mentioned, document the problem and ensure
that the relevant senior staff respond appropriately.
5.3.1 Screening urine samples
In many medical institutions, every new patient will have their urine routinely screened using a
“reagent strip”. This is a quick and simple test that can identify problems, but it is not infallible.
It is a simple health screening tool that may reveal early indicators of disease that have not
yet caused symptoms in the patient.
Before testing a patient’s urine, the carer should gather together PPE30
, a clean bedpan or
bottle urinal to collect the urine, urine testing reagent strips and a way to time the passage of
60 seconds. The carer will also need the relevant documentation to record the results.
To conduct the test:
1. To get the sample to test, the carer should ask the patient to pass urine into a clean
bedpan or bottle urinal and explain why it is needed.
2. The urine sample should be observed, as well as tested. If the urine looks very dark,
cloudy or contains blood or other defects, this must be recorded.
3. Wearing appropriate PPE, the carer should remove a urine testing strip from the tub.
One end of the reagent strip will have several small faintly coloured squares on it.
This end should be dipped into the urine sample for a second, just time for the urine
to come into contact with the reagent strip.
4. Excess urine should be removed by tapping the urine testing strip against the side of
the receptacle.
29 The failure to show the symptoms of UTI is not uncommon among elderly patients.30 PPE - Personal Protective Equipment, depending upon the infection and risk, this might include gloves, apron,
facemask, overshoes, gown, goggles, etc.
57
5. The carer should wait for 60 seconds, then hold the reagent strip parallel to the
reagent strip tub and compare the colour of the urine testing strip against the scale on
the side of the tub.
6. The carer should dispose of the strip appropriately, remove their PPE and wash their
hands with soap and hot running water before documenting the result. When the
carer suspects that something abnormal has been detected, they must report the
matter to the responsible Registered Nurse or doctor and document this without
delay.
It is worth noting that some drugs affect urine test readings, giving false positive or negative
results. Examples include Vitamin C, L-dopa, Naladixic Acid, and Aspirin.
This test can provide a significant clue that a patient has a U.T.I. because bacteria are made
of protein. If there are bacteria in the urine, the reagent strip will indicate an abnormal protein
level. Protein can be present for many other reasons other than a UTI but it is a possible
indicator of a UTI.
Sometimes other urine samples are required. These are often sent to a pathology department
for further scrutiny. The pathology department reports the result of the tests to the relevant
doctor and the doctor arranges appropriate treatment or further investigations as required.
Commonly, the pathology department will ask for a Mid-Stream-Urine (MSU) specimen.
5.3.2 MSU – mid stream urine specimen
Ideally, this will be taken from the first urine passed by a patient in a day.
To collect this specimen, the carer will need a sterile urine collection kit often known as a
MSU kit. These kits may include a wipe for the patient to clean their genitalia before starting
to pass urine. Some institutions do not use the wipe, preferring the patient to use soap and
water instead. The carer will also need gloves and an apron to wear when transferring the
collected specimen and the Pathology department’s documentation.
The carer will also need a compliant, orientated and independent patient who understands
what is needed and has agreed to give the sample.
Collecting the sample
1. The patient is asked to clean their external genitalia with soap and water, washing all
soap away.
2. The patient should then pass the first part of their urine into the toilet (or bedpan or
urinal), the next part directly into the sterile cup supplied with the MSU kit, and the final
part into the toilet or receptacle. Urination should be continuous, without stopping and
starting, so the cup must be passed in and out of the stream of urine. In this way, the mid
(middle) of the stream of urine has been collected – giving a “mid stream” urine specimen.
3. The patient passes the sample cup to the carer who pours the urine from the cup into the
sterile specimen pot and seals it.
4. The patient washes their hands thoroughly.
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After transferring the specimen and sealing the sterile specimen pot, the carer should remove
their PPE and wash their hands before ensuring that the pathology department’s
documentation is complete before sending the specimen to them.
5.3.3 CSU specimens
The CSU acronym may be used to describe two types of specimen, Clean Specimen of Urine
and Catheter Specimen Urine (from which the acronym is derived).
Type 1 CSU collection – Clean Specimen of Urine
When a patient is unable to provide a mid-stream specimen of urine but can still use a
bedpan or a bottle urinal, a “clean catch” specimen can be obtained. As with an MSU
specimen, the specimen is ideally collected first thing in the morning.
To collect this specimen, the carer will need a sterile urine specimen pot, gloves and an apron
for use when transferring the collected sample into the specimen pot. They will also need a
clean bedpan or bottle urinal and the relevant Pathology department’s documentation.
The bedpan or bottle urinal should have been recently cleaned – it should not be one that has
been on the shelf for hours.
Collecting the sample
1. The patient is asked to clean their external genitalia (assisted as necessary) with
soap and water, washing all soap away.
2. The patient is given a clean bedpan / bottle urinal and asked to pass urine into it.
3. Taking care to avoid spillage, the carer pours a sample of the urine they have passed
into a sterile specimen container.
After transferring the specimen into the sterile pot the carer should remove their PPE and
wash their hands and ensure the relevant pathology department’s documentation is complete
before sending the specimen to them. The specimen should not be allowed to sit at room
temperature for any significant time because it may grow bacteria that were present in the
non sterile bedpan or bottle urinal and so give a misleading positive results.
CSU – type 2 collection – Catheter Specimen Urine
As the name suggests, this specimen is collected from the patient’s catheter bag. Specimens
should be taken from the first urine captured following catheterisation and when there is a
suspicion that the patient may have a U.T.I.
To collect this specimen, the carer will need:
1. PPE – gloves and an appropriate plastic apron.
2. A sterile urine specimen pot.
3. An alcohol swab.
4. A sterile 10ml syringe.
5. The relevant Pathology department’s documentation,completed before taking the
sample.
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Urinary catheters have a urine collection port built in. They might be a small coloured area or
a special port on the side of them. Because urinary catheters are designed to continually let
urine drain from the bladder into the urine drainage bag there is no accumulation of urine
anywhere except in the urine drainage bag. It is NEVER acceptable to collect a urine
specimen from a urine drainage bag. In order to encourage an accumulation of urine in the
catheter itself. it is necessary to apply a clean clamp to the outside of the urinary catheter, just
below the urine specimen collecting point, between this and the urine collecting bag.
Collecting a CSU specimen is a “no touch” process that is conducted as follows:
1. A clean clamp is attached to the catheter as described above.
2. When urine has accumulated, the collection port on the catheter bag should be cleaned
with an alcohol swab and allowed to dry. This is important because failure to let the area
dry means that any bacteria on the port may be introduced into the catheter (and the
patient) when the syringe is attached to the port.
3. Open the sterile syringe and push the syringe nozzle directly into the collection port of the
catheter.
4. Slowly withdraw the plunger of the syringe. Urine should be seen entering the syringe.
5. When at least two millilitres of urine have been collected, remove the syringe from the
catheter bag collection port and rub the collection port with the alcohol swab again.
6. Ensuring that the specimen bottle lid is removed and facing upwards (so that it does not
come in contact with any surfaces) gently squirt the urine into the sterile specimen pot.
After transferring the specimen, the carer should remove their PPE and wash their hands
before ensuring that the completed pathology department’s documentation is sent with the
specimen to them.
5.3.4 Urinary incontinence
Urinary incontinence is the involuntary passage of urine. This might involve passing a small
amount of urine “by accident” or the involuntary emptying of a full bladder – sometimes into a bed
that the patient is lying in or onto a chair where they are sitting. Whatever the amount, this has two
effects upon the patient – embarrassment and of them lying or sitting in urine.
Specific diseases or medications can increase the risk of this happening, to both men and women.
The carer should respond promptly to help the patient out of their wet clothes / bedclothes, to
ensure that the urine is washed off their skin and that clean dry linen is provided.
If further incontinence is anticipated it would be appropriate to apply a barrier cream to the
affected area – to prevent what is effectively a “nappy rash” developing. It may be appropriate for
the patient to wear a pad to absorb the urine. There are many pads on the market, and, depending
on the volume of urine involved, they can be very discreetly worn.
The practice of putting incontinent patients into large nappies or placing large incontinence pads
under the patient’s bottom is unacceptable and degrading. Any incontinence device applied should
be discreet and regularly changed with full skin care provided as necessary.
Discretion is the appropriate word to describe how all incontinence should be dealt with.
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Carers should avoid making comments like “it’s not a problem” and “don’t worry, I’m used to
it”. However well meant, this kind of statement can be interpreted as being patronising. The
carer might be accustomed to it, but the carer is not the priority in this equation of care. The
patient is.
Carers sometimes elect to catheterise (Section 5.3.5) an incontinent patient and this is often
an appropriate action. Catheterisation immediately reduces the risk of skin soreness caused
by urine burning the epidermis of the skin. It can provide a discreet solution for the patient
and dramatically increase their quality of life and independence. Catheterisation certainly has
advantages. but is not without risk. If the incontinence is a short term problem the
disadvantages (such as serious infection, loss of bladder tone, etc.) may outweigh the
advantages.
Urinary catheterisation should never be undertaken for the carer’s benefit only – it is not a
convenience tool designed to prevent staff having to deal with wet beds.
5.3.5 What is a urinary catheter and why are they used?
Sometimes patients have health problems that mean they can achieve better independence
and quality of life by having a sterile tube inserted into their bladder to drain the urine away.
This is known as a urinary catheter.
Occasionally a urinary catheter is inserted, the bladder drained and the urinary catheter then
removed completely. This is known as intermittent catheterisation.
There are two main types of Urinary Catheter, the “urethral” and the “supra pubic” catheter.
Both are sterile tubes designed to transmit urine from the patient’s bladder to a sterile urine
collection bag (often called a “Catheter bag”) outside of the patient. When a patient has a
urinary catheter inserted that is expected to be retained for several weeks or months, a
special design of long-term catheter should be used.
As the names imply, the “urethral” catheter tube is passed into the patient’s urethra and so
upwards into their bladder. The “supra pubic” catheter tube is inserted through the patient’s
abdominal wall, just above their pubic bone straight into the bladder. Both have a tip with
small holes in it that allow the urine to drain. Both have small balloon inflated after they have
been properly inserted. This balloon prevents the catheter “falling out”. The inflated balloon
usually lies at the trigone (bottom of the bladder). It is pressure on this area of the non
catheterised bladder that makes us feel we need to pass urine. A patient with the catheter
balloon pressing on this area of the bladder can make them feel that they need to pass urine
urgently, and this frequently occurs with recently catheterised patients. This is unpleasant but
usually resolves over a few hours as the body becomes accustomed to the presence of what
is a “foreign body”.
Sometimes, especially when a patient is not drinking much fluid, urine can deposit crystals on
the catheter tip (inside the bladder) resulting in a blockage that prevents drainage into the
catheter bag and makes the patient experience significant pain and discomfort.
Every type of urinary catheterisation carries a significant infection risk for the patient. If either
the urinary catheter or any of the equipment used to catheterise the patient is not sterile,
infection can easily track inside the patient and can ultimately be fatal. .
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Both urinary catheter insertion and the removal can be very distressing for patients – as can
the very fact that they have a catheter. Their embarrassment and potential loss of dignity are
very real. Both can be minimised by the way that the carer undertakes the maintenance of the
catheter and catheter bag.
Every patient who has a urinary catheter should be encouraged to drink plenty of fluids – this
reduces both the risk of infection and of crystal formation at the catheter tip.
The carers should avoiding taking unnecessary urine specimens because each access to the
catheter port to collect a specimen increases the risk of infection.
5.3.6 Care of the urinary catheter and catheter bag
The urinary catheter is usually attached to a catheter bag that will need to be emptied on a
regular basis. The emptying regime will vary according to the patient’s condition and intake of
fluids. Patients receiving intravenous fluids may need larger catheter bags than others.
Whatever the size of bag, if any catheter bag is allowed to fill completely the weight of urine it
contains can tug on the bladder causing pain and may even cause long term damage. A full
catheter bag is also more bulky and more visible, adding an unnecessary potential for patient
distress. Carers must ensure that catheter bags are never left un-emptied for so long that
they become full.
Some patients will require catheterisation after surgery and their treatment may include the
infusion of fluids intravenously. When this occurs, it can be necessary to accurately identify
their urine output on a regular basis because their subsequent treatment will be influenced by
their urine output.
When a urinary catheter is to be maintained for several days or weeks there is not usually a
need for the patient to be given intravenous fluids. Without intravenous input, the amount of
urine the patient produces will be much less and smaller catheter bags (known as “day” or
“leg” bags) can be used during the day. These smaller bags have straps that are used to
secure the catheter to the patient’s leg which often allows them to be concealed under the
patient’s clothing and so be more discreet.
To reduce the risk of infection, the patient will need information and encouragement to care
for their catheter. When a patient cannot provide this care, the carer must do it for the patient.
Catheter care involves:
Washing the urethral meatus (where the catheter exits the body) at least once a day and
more frequently if needed, for example if the patient is faecally incontinent. The urinary
catheter tube should be routinely cleaned as part of each episode of relevant personal
care. Using a gloved hand and a warm soapy piece of gauze, the carer should wipe the
tube in an action moving away from the patient and towards the urinary catheter bag.
Ensuring that the patient drinks fluids frequently – to dictate a specific amount here would
be dangerous because many elderly patients have concurrent health problems (for
example heart failure) that could be made much worse by the patient drinking too much
fluid.
Every urinary catheter bag should be hung in a way that ensures drainage by gravity. It
should be hung either from the bed frame, on a special stand or on the patient’s leg. A
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catheter bag must never be placed on the bed surface beside the patient. Wherever the
urinary catheter bag is hung, it must never be allowed to touch the floor.
Emptying the catheter bag at least twice daily and every time that the catheter bag is
approximately half full. This reduces the risk of the weight of urine pulling on the neck of
the patient’s bladder.
5.3.7 Emptying / changing the urinary catheter bag
Every time that a urinary catheter bag is emptied, the closed urine drainage circuit is broken
and there is a risk of infection being introduced. An infection can track into the patient causing
a urinary tract infection, renal damage or even septicaemia which can be fatal. This means
that emptying a catheter bag requires care and the application of infection control procedures.
The carer should gather together the following in preparation for emptying a urinary catheter
bag:
PPE – usually gloves and a plastic apron – there may be a specific colour of apron
required locally
A clean jug or other receptacle to empty the urine into.
Cover for the urine collection receptacle,
Either an alcohol swab to clean the ‘tap’ on the urinary catheter drainage bag or a
new sterile urinary catheter bag.
Screens or curtains or other means to ensure patient privacy.
Relevant documentation to record the event.
The carer should follow this process:
1. The carer must ask the patient’s permission to empty the bag discreetly – this has
nothing to do with anyone else. If the patient is unconscious or unresponsive, the
carer must still explain what they are going to do.
2. The carer should wash their hands thoroughly, reducing the risk of introducing
infection, then apply non sterile gloves and an appropriately coloured plastic apron.
3. If the urinary catheter bag has a drainage tap at its base, wipe the tap with an alcohol
wipe and allow it to dry. The drying destroys bacteria. If the catheter bag cannot be
drained or is to be replaced, the old urine collection bag will need to be detached.
Before detaching the old bag ensure the new bag is opened and the attachment to be
inserted into the catheter has had the cap removed but that it is still sterile. Detach the
bag and place it into the collection receptacle while simultaneously attaching the
sterile urine collection bag. When the catheter bag can be drained rather than
changed, hold the clean urine collection receptacle underneath the bag without letting
the drainage tap touch the receptacle. Wipe the drainage tap with an alcohol swab,
allow it to dry before sliding the tap open.
4. Slide or twist open the tap and allow the urine to flow into the receptacle.
5. When the bag is empty, close the tap, then wipe the tap again with an alcohol swab.
6. Ensure that the urinary drainage bag is appropriately positioned to ensure drainage
and that the patient is comfortable.
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7. Measure the volume of urine being taken away, then cover the receptacle and take it
to empty in the appropriate area.
After cleaning or disposing of the urine, bag and collection receptacle in appropriate places,
the carer should remove their PPE and wash their hands before completing the
documentation required.
The carer should change all urinary catheter bags (with emptying taps) after they have been
used for seven days (or earlier) and record the fact that the bag has been changed both on
the bag and in the patient’s care record. The bag should also be changed if it has been
compromised – for example, if the drainage tap has been resting on the floor.
If a patient has a leg bag, when possible the carer should attach a secondary urinary
drainage bag to the end of the leg bag for over-night use. When this is done, there is no need
to disconnect the leg bag from the catheter overnight.
5.3.8 Urinary catheter removal
To avoid risk of infection, the removal of urinary catheters must be conducted using an
aseptic or “no touch” technique.
Before removing a urinary catheter, the carer will need to collect together the necessary PPE,
(usually gloves and an appropriate plastic apron), a receptacle in which to place the catheter
and urinary catheter bag and a sterile 10ml syringe, still in its sterile packaging.
The carer should follow this process:
1. The carer must ask the patient’s permission to remove the catheter discreetly – this
has nothing to do with anyone else. If the patient is unconscious or unresponsive, the
carer must still explain discreetly what they are going to do..
2. The carer should wash their hands thoroughly, reducing the risk of introducing
infection, then apply non sterile gloves and an appropriately coloured plastic apron.
3. Then place the clean receptacle for the urine bag and catheter in an easily accessible
position.
4. The patient should ideally be lying on a bed.
5. Taking care not to touch the syringe nozzle, the carer should open its packaging and
apply it directly to the inflation point of the urinary catheter. Then let the plunger of the
syringe move back by itself so that it fills with fluid – this is the sterile water that was
inflating the balloon inside the patient’s bladder. It is vital to ensure that no more fluid
can be withdrawn. Leave the syringe attached to the inflation point. Never try to
withdraw the sterile water by pulling the plunger back, let this happen by itself. If the
carer actively withdraws the plunger of the syringe it causes wrinking of the deflated
catheter balloon and possible damage to the patient as the catheter is being gently
removed.
6. When a patient is responsive, ask the patient to take a deep breath. As they do so,
gently withdraw the whole catheter. The deep breath does not assist in extracting the
urinary catheter, it is an effective distraction technique. NEVER tug the catheter out. If
it does not slide out, it is likely that some fluid is left in the balloon inside the patient.
The carer should try to withdraw more fluid. (If the syringe had been removed from
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the inflation point it would no longer be sterile.) If the catheter still will not slide out, the
carer must refer the problem to a Registered Nurse Practitioner or doctor
immediately.
7. After the catheter has been fully removed, place it into the receptacle brought for it.
8. Ensure that the patient is comfortable – in whatever position they wish
9. Take the receptacle with the catheter and catheter bag to the sluice / bathroom as
appropriate.
10. Examine the catheter – visually inspect it to ensure it is all there. After this has been
confirmed it can be disposed of.
11. If there is any suspicion that part of the catheter has broken off and been retained
inside the patient, the carer must inform either the Registered Nurse Practitioner or
doctor urgently (retaining the catheter to show them).
After cleaning or disposing of the catheter and collection receptacle in appropriate places, the
carer should remove their PPE and wash their hands before recording the removal in the
patient’s notes. If the patient’s records require information about the volume of urine being
excreted the carer must record the volume of fluid in the urinary drainage bag.
After a urinary catheter has been removed, the patient’s bladder may take a few days to
develop its tone again. It is vital that the carer record if and when the patient passes urine
following a urinary catheter removal. This is because sometimes the patient’s bladder no
longer feels full when it is full of urine, and they cannot pass urine when they try to. This is
known as urinary retention. Conversely sometimes the patient feels they need to pass urine
urgently when they only have a small amount of urine in the bladder, almost as though their
bladder had “shrunk”.
Any problems must of course, must be recorded in the patient’s notes and reported to the
Registered Nurse Practitioner or doctor as appropriate.
5.4 Bowel care
Having bowels open is a basic bodily function, but one that can cause the patient immense
distress if they are constipated or too embarrassed to “go”’.
There is no ”normal” frequency of bowel movements – each individual is different. The carer
should aim to maintain what is both normal and comfortable for the patient.
There are two main deviations from normal with regarding to bowel actions, diarrhoea and
constipation. Either condition can be a symptom of disease or caused by poor fluid or
nutritional intake, lack of activity, infection or a side effect of drugs delivered to treat pre-
existing conditions.
Diarrhoea can occur either due to infection within the gut, as a side effect of medication or
(surprisingly) as a result of constipation when the constipated faecal plug blocks the bowel
(causing constipation) but the liquid faecal content drains around it.
The patient with diarrhoea may feel weak, nauseated, unwilling to do much and totally
humiliated if incontinent.
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Appropriate treatment will depend on the symptoms – and may involve the carer having to
collect a stool in a stool specimen pot. Sometimes specimens are required from more than
one sample. When it is necessary to look for occult (hidden) blood, for example, three
samples from three separate bowel movements must be collected on individual cards.
Diarrhoea samples are often sent for culture (growing) in a Pathology department. This can
help to identify the nature of any infection. Many infections resolve themselves but some
require specific medication.
Constipation occurs when there is delayed movement of intestinal content through the bowel
but what constitutes “delay” is patient specific. Some patients may not defecate for three days
but pass motions without pain at regular three day intervals. Others who miss a day may be in
discomfort.
The patient with constipation might feel distended, bloated, unwell, weak, lethargic, have a
headache, not like moving and prefer not to drink. They might well be confused if at the same
time as feeling constipated they have any diarrhoeal symptoms. Failure to move and drink
can aggravate their constipation so the carer should encourage both whenever possible.
Constipation requires clearing the faecal blockage and then preventing its recurrence by the
use of stool softeners, stimulant laxatives or osmotic agents.
The use of suppositories or enemas as a means of clearing a blockage in the bowel is
common. Provided that there is no ileus (where the bowel stops moving as it digests food),
gynaecological or colonic obstruction, the use of suppositories or enemas should not cause a
physical problem. Sometimes the blockage can be so hard or bulky that it could tear the
anus, causing bleeding and pain, so the rectum should be prepared with adequate lubricant
gel.
5.4.1 Risks associated with faecal incontinence
The patient with diarrhoea will be losing fluid and so at risk of becoming dehydrated.
The faecally incontinent patient is at significant risk of developing excoriation, (soreness). If
faeces is not immediately removed from the peri-anal area, the bacteria within the faeces can
either track inside the urethra causing a urinary tract infection, or mix with any urine in the
same area and break down the outer protective area of the skin, causing soreness. The
stronger the patient’s urine the greater the risk. The mixing of both faeces and urine together
significantly increases this risk.
When the outer layer of skin has broken and become sore, the patient is at increased risk of
developing pressure sores (sometimes known as pressure ulcers).
Incontinence sheets were used but they had a tendency to break up or become packed into
lumps that actually caused areas of pressure. This is why they are no longer routinely used.
Clean, wrinkle free, cotton sheets do not have this problem.
A main risk is to the patient’s self image and morale (dignity). When a patient is incontinent,
the use of large, bulky highly visible nappies must be avoided. If incontinence pads or
nappies must be used, they must be of minimal bulk and should be discreet enough to allow
the patient to receive visitors without embarrassment.
There is never an alternative to the patient having access to toileting facilities.
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5.4.2 Administering an enema or suppository
The administration of enemas or suppositories to remove a constipation blockage has the
potential for the patient to feel humiliated and embarrassed. The process itself may be
distressing and the aftermath must be managed to minimise distress to the patient.
When caring for a patient who has received either an enema or suppositories, the carer must
ensure that the patient has privacy, call bell, access to a toilet, commode or bedpan, and
should be on hand if the patient needs help. When a patient has not had this treatment
before, the carer may need to be particularly supportive.
5.4.3 Administering suppositories
The basic equipment required when administering suppositories is:
PPE – usually non sterile gloves and an appropriate plastic apron.
The prescribed suppositories.
A small amount of lubricant gel on a gauze (examples KY jelly or aqualgel) or when
glycerine suppositories are to be used, a small bowl of warm water to place them into.
Sheet or towel to place under the patient’s buttocks.
Immediate patient access to a toilet, commode or bedpan and toilet paper.
Immediate patient access to a call bell to summon assistance.
Hand-washing facilities for the patient.
To administer suppositories, the carer should put on their PPE and follow this process:
1. Prepare your equipment required and ensure that the patient has privacy.
2. Discreetly explain to the patient what is necessary and why, asking for their
agreement. If the patient is unconscious or unresponsive, the carer should still explain
what is happening, and why.
3. Ask the patient to lie on their left side and help them to achieve this when necessary.
Position the patient so that their buttocks are facing the side of the bed
4. Lower the patient’s underclothes (or remove them as the patient prefers), then place a
towel or special sheet under their buttocks.
5. Keep all parts of the patient’s body that do not require immediate access covered up.
6. Apply gloves.
7. Prepare each suppository, lubricating it with gel or softening it in warm water.
8. Using a gloved index finger gently insert each suppository into the rectum as far as
possible.
9. When the suppositories are in place, the carer should remove their gloves and
dispose of them appropriately before helping the patient to get into a more
comfortable position.
10. Ensure that the patient has immediate access to toilet or commode and to their call
bell. The carer should ask to be told when they have finished or are ready to wash
their hands.
11. Generally, the longer the suppositories can be retained, the more effective they are.
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After leaving the patient, the carer must ensure that all the equipment used has been
cleaned, dried and disposed of, as appropriate .
5.4.4 Administering an enema
The basic equipment required when administering an enema is:
PPE – usually non sterile gloves and an appropriate plastic apron.
A small amount of lubricant gel on a gauze (examples KY jelly or aqualgel).
The prescribed enema which may be a small “micro” enema or larger sachet.
If the enema is an “oil” type, a small bowl of warm water in which to place the oil
enema before insertion is required.
Sheet or towel to place under the patient’s buttocks.
Immediate patient access to a toilet, commode or bedpan and toilet paper.
Immediate patient access to a call bell to summon assistance.
Hand-washing facilities for the patient.
To administer an enema, the carer should put on their PPE and follow this process:
1. Prepare the equipment required and ensure that the patient has privacy.
2. Discreetly explain to the patient what is necessary and why, asking for their
agreement. If the patient is unconscious or unresponsive, the carer should still
explain what is happening, and why.
3. Ask the patient to lie on their left side (helping them to achieve this when
necessary. Position the patient so that their buttocks are facing the side of the
bed.
4. Lower the patient’s underclothes (or remove them as the patient prefers), then
place a towel or special sheet under their buttocks.
5. Keep all parts of the patient’s body that do not require immediate access covered
up.
6. Apply gloves.
7. Ensure that the nozzle of the enema has been opened and has been well
lubricated with gel.
8. Using a gloved index finger gently insert the nozzle into the rectum as far as
possible, then squeeze the enema until it is empty.
9. When the patient is responsive, ask the patient to clench their buttocks as the
enema nozzle is removed. This can help reduce the risk of enema fluid following
the nozzle out of the patient.
10. After the enema has been administered and the empty container removed from
the patient’s buttocks the carer should remove their gloves and dispose of them
appropriately before helping the patient to get into a more comfortable position.
11. Ensure that the patient has immediate access to toilet or commode and to their
call bell. The carer should ask to be told when they have finished or are ready to
wash their hands.
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Both suppositories and enema are most effective when they are retained for as long as
possible before the patient goes to the toilet. In practice this is very difficult and often worries
the patient who is concerned that they may be incontinent.
5.4.5 Colostomy / ileostomy
Sometimes when a patient has a diseased or injured bowel or section of their gut it no longer
functions properly. This can mean that the affected section of the bowel or gut has to be
removed or provided with a period of “rest”. A colostomy / ileostomy allows this and may have
been undertaken as part of a planned procedure or as an emergency operation. It involves a
surgeon forming an artificial opening by making a piece of bowel open directly out of the
patient’s abdomen. The surgeon might then remove the diseased portion of bowel and
sometimes after a period of allowing the gut to “rest” the operation is later reversed. This
artificial opening from the bowel to the patient’s abdomen is known as a stoma. The stoma
allows the expulsion of the contents of the colon or small intestine into a special type of bag.
Depending on what part of the bowel has been accessed, the procedure is known as either a
colostomy (when the colon was accessed) or an ileostomy (when the small bowel was
accessed).
The patient with a colostomy or ileostomy not only has to cope with a diagnosis that might
well distress, the presence of this colostomy or ileostomy bag will mean a serious lifestyle
change that will undoubtedly require significant carer support.
When they are first in place both colostomies and ileostomies frequently involve the
production of gas. This gas can dislodge the colostomy or ileostomy bags from the patient’s
abdomen with catastrophic effects. Thankfully this gas does reduce but initially the carer
should presume a problem and take a proactive approach to check for gas and avoid such
accidents.
The carer should empty the bag before it is full and always before meals. It should be
emptied into a toilet when possible. Always avoid adding to a patient’s discomfort or
embarrassment. If the smell is bad, consider placing an aromatic device in the room.
I cannot overemphasise the importance of the carer’s reaction to both the sight of the stoma
and the contents of the bag. A burst or dislodged bag can have a catastrophic effect on both
the patient’s morale and confidence.
5.4.6 Cleaning a colostomy or ileostomy bag
There are many types of colostomy and ileostomy bags. Some attach directly to the patient’s
skin around the stoma, other have a special flange attached to the skin around the stoma .
The flange is kept in place for as long as possible, the bag is attached onto the flange, and
changed as required.
Some types of colostomy bags have a clip at the bottom that allows the bag to be emptied
and re-clipped.
The basic equipment required for changing a colostomy / ileostomy bag is:
PPE – usually non sterile gloves and an appropriate plastic apron.
Bowl of warm water and gauze / cotton wool or non perfumed wet wipes.
Small clean hand towel, kept for this purpose.
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Clean replacement bag.
Plastic bag to hold used cotton wool etc., and the used stoma bag
To change a colostomy / ileostomy bag, the carer should gather the necessary equipment,
put on their PPE and follow this process:
1. Discreetly explain to the patient what is necessary and why, asking for their
agreement. If the patient is unconscious or unresponsive, the carer should still explain
what is happening, and why.
2. Undertake the change of bag in a toilet area when possible. Arrange the patient so
that they are comfortable while allowing access to the stoma area and bag.
3. Ensuring the patient’s privacy, expose the area where the bag is attached. When the
bag is attached directly to the skin it can be hard to release the sticky area wearing
gloves. If necessary, loosen the corners of the sticky area before applying gloves.
4. Peel off the plastic from the skin. This will remove the bag and contents at the same
time. Place the bag into a waste bag immediately. Close the waste bag to reduce the
release of unpleasant odour.
5. If the patient has a flange, remove the bag and contents from the flange and place the
bag into the waste bag immediately. Close the waste bag to reduce the release of
unpleasant odour.
6. Use warm water and cotton wool, gauze or non perfumed wet wipes to clean the area
around the stoma.
7. Dry the area using the towel retained for this purpose.
8. Apply a new adhesive bag or flange bag as appropriate.
9. Remove PPE (disposing of it appropriately) then provide any help necessary to make
the patient comfortable, ensuring that their bag is discreetly concealed.
After leaving the patient, the carer must ensure that all the equipment used has been
cleaned, dried and disposed of, as appropriate.
5.4.7 Emptying a “clipped” colostomy or ileostomy bag
When the patient has a “clipped” bag it is usually because they have had a colostomy for a
long time and it has become “predictable”. This sometimes means that it fills at predictable
times and often contains a well formed stool.
The basic equipment required for changing a colostomy / ileostomy bag is:
PPE – usually non sterile gloves and an appropriate plastic apron.
Unsterile jug of tepid tap water.
Tissue / gauze for wiping the outside of the bag.
A few drops of deodorizing fluid, as prescribed.
To empty a “clipped” colostomy or ileostomy bag, the carer should gather the necessary
equipment, and follow this process:
1. Discreetly explain to the patient what is necessary and why, asking for their
agreement. If the patient is unconscious or unresponsive, the carer should still
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explain what is happening, and why. When it is possible, the carer should
encourage the patient to move to the toilet area where it is easier to contain
unavoidable odour and so preserve the patient’s dignity and privacy.
2. When the patient is compliant and able, ask whether they want to empty the bag
themselves. If so, the carer should ask whether they should remain in case of
difficulty.
3. When a patient does not want to empty the bag themselves or wants the carer to
remain, the carer should put on their PPE.
4. To empty the bag, the clamp at the base of the bag is released and the bag is
emptied directly into the toilet (or a suitable receptacle).
5. The tepid water is poured into the bag, rinsing it, and the water emptied into the
toilet (or the suitable receptacle).
6. When the interior of the bag is clean, the outside is wiped with gauze / toilet roll /
tissue and the clamp replaced.
7. The carer should remove their PPE (disposing of it appropriately) then provide
any help necessary to make the patient comfortable, ensuring that their bag is
discreetly concealed.
8. When a patient has emptied their bag themselves, the carer must encourage the
patient to wash their hands with soap and water.
9. Before moving to the next patient, the carer must wash their own hands
thoroughly with soap and water.
After leaving the patient, the carer must ensure that all the equipment used has been
cleaned, dried and disposed of, as appropriate.
5.4.8 Problems with colostomies and ileostomies
Apart from the psychological / emotional problem of coping with a bag of faecal matter lying
on their stomach, the patient may also suffer uncontrollable wind evacuation that is
embarrassing and distressing. The fitting of a colostomy / ileostomy will often have coincided
with a serious diagnosis that the carer should expect to have been deeply unsettling, turning
the patient’s world “upside down”.
Associated physical problems include the fact that all new colostomies and ileostomies collect
very loose stools in the colostomy bag. The contents become firmer as the body adapts to its
presence. Any development of diarrhoea will require vigilance over the bag changing regime
and especially diligent skin care around the stoma.
When a patient with a colostomy or ileostomy becomes constipated, a suppository can be
administered via the stoma. Whenever possible, the carer should seek to prevent
constipation
The skin around the stoma is at risk of becoming sore or inflamed. Scrupulous cleaning and
drying reduces the risk but when soreness has been identified the carer must apply a barrier
cream (designed for the purpose) and / or change of type of colostomy / ileostomy bag.
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The barrier cream must have been designed for the job and not be greasy, because greasy
creams will stop the bag sticking. The correct barrier creams have a paste like consistency
and must be allowed to dry before the bag is attached. Specialised barrier creams should be
available via an appropriate Specialist Nurse, Registered Practitioner or G.P.
Everyone finds that some foods “disagree” with them, whether or not they have a colostomy
or ileostomy. When a patient reports a problems with specific foods or medication affecting
their digestion, the carer must record this and ensure that the problem is avoided whenever
possible.
5.4.9 Post-toileting needs
Whenever a patient has used a toilet, bedpan, commode or bottle urinal, the carer must
ensure that they are given the opportunity to clean their hands. Whenever possible, this
should involved washing with soap and water. When it involves using a handwipe, a disposal
bag must be easily accessible and emptied regularly.
Bedpans, commode liners and bottle urinals can be multi-use or disposable. Most are multi-
use and must be sterilised between uses. The receptacle should be emptied in the
appropriate place before being put through a sterilisation process.
In the patient’s own home, the toilet receptacle is usually emptied and rinsed in the toilet
bowl. A mild solution of bleach can be used to sterilise the item when required. This is
achieved by filling the receptacle with a mild bleach solution and leaving for 20 minutes or
longer, then empty down the toilet and rinse with clean water.
Within institutions, all surfaces of a commode should be wiped after each use with wipes,
taking the commode apart to do so. In patient’s homes, the commode surfaces should be
cleaned regularly with appropriate disinfecting wipes or warm soapy water, taking the
commode apart so that all surfaces are cleaned. Wherever the commode is, a more rigorous
cleaning regime should be followed when the user has a clostridium infection.
5.4.10 Pressure ulcers
A pressure ulcer is sometimes known as a “bed sore”. The definition of a pressure ulcer31 is
“an area of localised damage to the skin and underlying tissue caused by pressure or shear
and / or a combination of both”. It is an ulcer caused by an unrelieved pressure on an area of
the skin which restricts the blood supply. When blood flow is reduced, insufficient oxygen is
delivered to the tissue in the area and, as a result, some of that tissue dies – tissue necrosis.
The reduced blood supply also diminishes the removal of tissue “waste products” that a full
blood flow would carry away. As a result, the waste products accumulate to the level where
they become toxic to the living tissue and the epidermis of the skin in the area breaks down.
When that protective epidermal layer has been compromised, the underlying tissues become
very vulnerable to the further tissue necrosis that is known as “ulceration”.
Unless immediate action is taken to reduce the pressure, the ulcer will get deeper and deeper
until it reaches the bone.
31 NICE guidelines, Sept 2005.
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Pressure ulcers can also be caused by friction or shearing forces that damage the epidermal
layer of the skin. This may occur when a patient is moved using poor manual handling
techniques such as dragging.
Pressure ulcers form more readily in areas that have reduced subcutaneous tissue – areas
where the bone is near the surface such as elbows and heels. Patients who have little
adipose (fat) tissue over bony prominences or with an inefficient circulation of their blood are
also at increased risk of developing pressure ulcers.
Pressure ulcers are graded into four classifications of “stages”:
Grade 1: Non blanchable erythema (redness)
Grade 2: Partial thickness
Grade 3: Superficial ulcer
Grade 4: Deep ulcer.
Category 1, Stage 1: Non-blanchable erythema
This is characterised by an area of intact skin with non-blanchable32 redness in a localized
area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler
than adjacent tissue. Category 1 can be difficult to detect in individuals with dark skin tones
that do not show signs of visible blanching when healthy. In these instances, the colour of the
erythema may differ from the surrounding area. Those with darker skin may be classed as
being at greater risk of suffering a Stage 1 pressure ulcer than pale skinned individuals.
Category 2, Stage 2: Partial thickness
This is characterised by the thickness of the skin being reduced, presenting as a shallow
open ulcer with a red pink wound bed, without slough or bruising33. It may also present as an
intact or open/ruptured serum-filled blister. This category should not be used to describe skin
tears, tape burns, incontinence associated dermatitis or maceration .
Category 3, Stage 3: Full thickness skin loss
This is characterised a full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle is not exposed. Slough (darker tissue) may be present. It may include
undermining and tunnelling but bone or tendon is not visible or directly palpable (feelable).
The depth of a Category 3 pressure ulcer will vary according to its location. The bridge of the
nose, ear, occiput and malleolus do not have (adipose) tissue and Category 3 ulcers in these
areas can be shallow. In contrast, areas of significant adiposity (fat) can develop extremely
deep Category 3 pressure ulcers, which can be very painful.
Category 4, Stage 4: Full thickness tissue loss
This is characterised by full thickness tissue loss with exposed bone, tendon or muscle and
often includes undermining and tunnelling. Slough may be present. The depth of a Category
4 pressure ulcer will vary according to its anatomical location. The bridge of the nose, ear,
occiput (back of head) and malleolus (ankle) do not have adipose tissue and Category 4
32 Skin is “blanchable” when it temporarily turns a lighter colour after being pressed for a few seconds.33 Bruising would indicate a deep tissue injury.
Slough is made up of white blood cells, bacteria and debris, as well as dead tissue, and is easily confused with pus
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ulcers in these areas can be shallow. Category 4 ulcers can extend into muscle and/or
supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to
occur. Exposed bone/muscle is visible or directly palpable. This is a very painful ulcer and
often has a quite pungent smell.
When a pressure ulcer has developed, they are very slow and difficult to heal. This is
because they must heal by granulating from the bottom upwards and from the sides inwards,
never simply by healing across the top. They require very specific care and dressings. In a
hospital environment, a Specialist Nurse known as a Tissue Viability Nurse can generally
advise on appropriate dressings. When no such expertise is available, it will be the
responsibility of the medical doctor to prescribe appropriate dressings.
Pressure ulcers should never happen. They take many months to heal, or may never heal.
They are very painful and frequently become infected and smelly. They are costly to treat
and, more importantly, they cause patients and their relatives unnecessary anguish and pain.
The pain and the smell frequently leave the sufferers demoralised and anguished.
Let’s be clear, a pressure ulcer is ALWAYS caused by poor standards of care. In
many cases a pressure ulcer is the direct result of neglect.
Any patient who has limited or no movement of their body inevitably has large parts of their
body staying in the same position for long periods of time.
Certain factors significantly influence the risk of an immobile patient developing a pressure
ulcer. These risks have allowed specialists to devise assessment tools34 designed to identify
those patients at increased risk. By predicting those at high risk, the carer can act proactively
to prevent pressure ulcers happening. Whatever assessment tool is used, the assessment
must be repeated every three days (or sooner if there is a change in the patient’s condition)
and the care adjusted as necessary.
5.4.11 How to prevent pressure ulcers developing
The simple way to prevent pressure ulcers forming is for the carer to prevent areas of the skin
being subjected to compression (and so a restriction of the blood supply) for long periods.
The carer should identify those areas of the body that are at risk and ensure that the patient
moves or is moved appropriately at regular intervals.
The areas at risk will depend on the patient’s position. The main risk areas of the patient who
is immobile in a sitting or prone position are:
Back of the head (especially if the patient has thinning hair)
Shoulders and elbows
Spinal column
sacrum
Heels and toes.
The main risks areas for the patient lying on their side are:
Ears
Shoulders
34 One assessment tool is a waterlow chart: there are others in use throughout the U.K.
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Elbows
Hips
Knees
Ankles.
Other factors that increase the risk include:
Patient’s weight, (very thin patients have little subcutaneous fat);
Grossly overweight patients, (layers of tissue can press onto each other);
Dehydrated or poorly nourished patients;
Patients taking chemotherapy drugs;
Patients taking large doses of steroids;
Patients on whom steroid cream has been applied to any of the pressure ulcer “risk
areas”;
Incontinent35 patients;
Unconscious patients;
Aged patients (because poor circulation often increases with age);
The dying patient (their gradual “shutting down” reduces the blood pressure
maintaining their circulation).
Whenever a patient has an increased risk, a proactive approach is required. This can include
providing increased nutrition and fluids, and frequent movement. Timely cleaning of areas of
skin affected by incontinence will also help to reduce the risk.
The simplest way to lower the risk of a pressure ulcer developing is to “turn” the patient,
changing their position so that no area has compression for more than four hours at most.
Patients identified as being at very high risk should be turned every two hours. Unfortunately,
this is not always as simple as it seems because patients have preferred positions for comfort
and sleeping. Obliging a reluctant patient to move into an uncomfortable, painful or
distressing position is unacceptable. All regular movements should accommodate the
patient’s preferences whenever possible. This might require analgesia (pain killers) in
preparation for the movement.
Because pressure ulcer development involves restricting the circulating of blood to and in the
area, another approach is to stimulate blood flow in the area. An effective (if old fashioned)
method is to wash the area in warm soapy water. The warmth stimulates the circulation, the
soap reduces skin flora, and it has the added bonus of making the patient feel refreshed! If it
is done, the skin must be thoroughly dried to prevent soreness. This must be done by patting
the area gently with a soft towel, never by rubbing – because rubbing may destroy some of
the protective epidermis. Soap can also dry the skin, increasing the risk of skin damage.
Unfortunately, the time it takes to collect the required resources and undertake this every few
hours may make it impossible for carers who have many responsibilities. Those caring for a
patient at home may have time to use this approach. It can certainly be effective in the
prevention of pressure ulcers with some patients.
35 Incontinence does not cause a pressure ulcer but the protective epidermis of the skin can be destroyed by being in
contact with urine or faces for any length of time, so significantly increasing the risk of a pressure ulcer developing.
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Other old fashioned treatments were less effective. For years, it was accepted practice to rub
either talcum powder or cream into the area at risk. This was not a good idea because the
talcum powder damaged the epidermis and boggy creams encouraged bacterial growth and
possible skin damage.
The risk of developing pressure ulcers can be reduced by using specialised equipment36 that
is designed to reduce pressure by keeping the weight off the limbs. While effective, these can
leave the patient feeling cold unless a blanket or fleece is put between the equipment and
their skin. There are also many special mattresses designed to prevent areas of pressure
developing. These include various types of electric profiling, airbeds and water beds. In an
institution, the carer should get advice about the appropriate type of equipment and its
availability from the Registered Practitioner, Physiotherapist or Tissue Viability Nurse. Home
Carers should seek advice from the patient’s G.P. or Community Nurse.
Finally one of the simplest things that can reduce the risk of pressure ulcers developing is for
the carer to always ensure the patient is not resting on creased sheets. Creased sheets
increase the risk of developing skin damage and pressure ulcers, and can generally be
corrected by smoothing the sheet and tucking it in securely.
When a carer finds areas of redness or broken skin on a patient, they must record and report
this to those responsible for the patient’s medical treatment urgently.
It is every carers responsibility to reduce the risk of pressure ulcers by:
1. ensuring that the patient is moved appropriately at the frequency instructed,
2. ensuring that the patient’s skin is kept clean (remembering that creams do not prevent
pressure ulcers but can form a barrier to prevent epidermal damage of the skin);
3. ensuring that that any special mattresses are used in accordance with their
instructions;
4. ensuring that bed linen is soft and wrinkle free.
SSKIN Bundle
The SSKIN bundle is an example of a simple tool designed to remind the carer about best
practice in the prevention of pressure ulcers.
SSKIN =
S surface Consider the type of mattress/cushion. If an air mattress is it inflated,
and working?
S skin integrity Check for signs of pressure ulcers two hourly if the patient is
considered to be at high risk
K keep moving Keep repositioning the patient. Turn the patient. When possible,
stand them up, lift their legs or sit them out on a chair.
I incontinence Ensure that any incontinence, urinary or faecal, is dealt with rapidly
and the patient left clean and dry.
36 Such as a leg trough or bed cradle.
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N nutrition Consider the type of diet that the patient is receiving and whether they
would benefit from the receipt of supplements including extra fluids.
5.5 Managing pain relief
No patient should be in pain. It is a subjective experience and is as severe as the patient
reports it to be – so when a patient reports pain, the carer must act to alleviate it.
The carer must recognise the presence of pain before it can be relieved. The patient’s report
is enough, but is not the only indicator of pain. The quietest patient is often the one in
constant pain and feeling too ill to move or too stoic to complain.
If pain may be an issue, the carer should ask themselves:
Is the patient’s skin pale, grey or waxy?
Has the patient got rapid respirations?
Has the patient got a rapid pulse?
Does the patient’s skin feel clammy to the touch?
Is the patient’s body stance or movement awkward or reduced? Do they appear to be
in pain when they move – or are moved?
Are they crying or showing signs of distress?
All are indicators of pain and should prompt the carer to ask the patient searching questions.
If the patient can communicate and is lucid, it is relatively easy to identify and rectify any pain
they are suffering. Identifying and rectifying pain in the confused or disorientated patient
requires a little more carer ingenuity and the carer could start by considering the clues
suggested above. These clues are only suggestions and certainly not an exhaustive list of the
possible symptoms of a patient being in pain.
When a patient is in pain, the carer must record that fact and ensure that it is immediately
brought to the attention of the person responsible for their medical treatment. There are many
pain killers available, many of which have a targeted efficiency that is astonishing, so there is
usually no need for any patient to be in prolonged pain. An exception may occur when a
patient is already receiving medication that may be incompatible with the pain killers.
Sometimes a patient has a medical history that results in “normal” pain killers being
ineffective. These patients may need different or stronger drugs.
To assist in its treatment, the carer should encourage the patient to describe the pain and its
location as clearly as possible. Pain is often difficult to describe so it can help to suggest
words and phrases that the patient may find appropriate. Some useful descriptors are:
Constant pain; comes and goes; I feel it every time I (do something)
Sharp pain; dull ache; throbbing pain; feels bruised; deep pain; surface pain;
Makes me feel sick; cannot be ignored; fades but returns suddenly.
Many institutions have pain assessment score sheets that are used to record the patient’s
expressed level of pain. A simple score of 1-10 added to one of the descriptors suggested
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can provide a useful description of the patient’s pain level. Because the patient estimates the
score, any change in pain should show up reliably when the question is asked again.
Pain is sometimes less bearable because of a patient’s concurrent worries such as personal
problems or anxieties. Addressing these may reduce anxiety and reduce the pain being
experienced. The patient may appreciate the opportunity to talk about these things, both as a
distraction from the pain and a path towards its reduction.
Generally, a degree of pain is inevitable following surgery and, paradoxically, movement is
often the quickest way to achieve pain reduction by promoting healing. In such situations,
gentle movements taken in conjunction with analgesia (pain killers) can be entirely positive
even if uncomfortable, provided that the movement does not exacerbate any other problems
the patient may have.
Pain may be a short term or long term problem. Short term pain management is usually
easier to achieve because the patient is recovering from the cause of the pain. Longer term
management is more difficult because the cause may be increasing for months or possibly
years. When a patient has a deteriorating condition, the type, dose and frequency of pain
killers required will inevitably change as their condition deteriorates. Within an institution, the
medical staff or an appropriate Specialist Nurse should adjust the prescriptions to reflect the
changed need. Within the patient’s own home, appropriate analgesics (pain killers) should be
prescribed by the patient’s G.P. or an appropriate Specialist Nurse, adjusting the medication,
its dose and delivery as appropriate.
When a patient has a long term debilitating and deteriorating terminal disease, effective pain
management is critical. A Hospice is the institution with the experience to be best able to
manage the patient’s pain appropriately. A Hospice can also can also provide respite for the
home carer and for the patient. Hospices are not just somewhere for a patient to go to die.
They are a refuge and sanctuary for many with a terminal prognosis – and a terminal
prognosis does not necessarily mean that death is imminent.
5.5.1 Delivering varied pain killers (analgesia)
I will refer to these drugs as “pain killers” because that is what the patient knows them as.
Pain killing drugs can be given in a variety of ways, as described below.
1. Tablet or liquid painkillers are often very easy for the patient to take orally. When a
patient has difficulty opening their mouth, the pain killers can be given in liquid form
using a special oral syringe (which is purple in colour).
2. Pain killing drugs given rectally, usually by suppository, are very effective and are
usually effective for several hours..
3. Pain killing drugs are often given via an injection, usually intravenous (IV), when the
pain is excruciating and immediate relief is required. This injection should always be
administered by a doctor of an appropriately trained Registered Practitioner. Pain
killers given intravenously will have an almost immediate effect and last for quite a
long time.
4. Pain killing drugs can be given by injection intramuscularly (IM). The injection should
always be administered by a doctor or an appropriately trained Registered
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Practitioner. These will take slightly longer to take effect but usually last for several
hours.
5. Pain killing drugs can be given via an IV infusion that the patient themselves can
control. This involves the patient having a special infusion attached to their vein and a
device with a control button. Whenever they press a button on the device, a small
amount of strong pain killer is delivered into their veins. The device restricts the total
amount they can have in a given amount of time because too much of this drug can
be dangerous. It records the button having been pressed even when no drug is
delivered. This type of delivery is known as a PCA (patient controlled analgesia)
pump. Staff caring for a patient using this type of PCA pump should be assessing and
recording how many times the patient has pressed the button to receive pain relief. If
they see that the patient has pressed the button often but that the machine restricted
the amount of pain killer they were given, the care staff should record this and inform
the Registered Nurse Practitioner or doctor responsible for the patient. The strength
of pain killer in the device should be changed to a more effective strength so that the
patient does not need to request pain relief as often.
6. Pain killing drugs can also be delivered by a special patch that is impregnated with
the pain killing drug and when attached to the skin slowly releases the drug, often
over 72 hours.
7. Pain killers can also be delivered by a continuous injection into the subcutaneous
(S/C) tissues.
Both of the final two methods (6 and 7 above ) have the advantage that they continually
deliver a small amount of pain relief that gradually builds up. When it has built up, this can
give the patient a constant and effective dose of pain killer that uses less of the drug than is
required using other methods. Pain killing drugs can have side effects, so using less of them
whenever possible without distressing the patient makes sense. The delivery devices must be
regularly maintained or changed in order to ensure a continuous dose. If the dose is allowed
to stop, the pain killing effect will be reduced and it will take time to build up to an effective
dose again – so the carer must be diligent about maintaining the means of pain killer delivery
appropriately.
5.5.2 Common side-effects of pain killers
A major side-effect of many types of pain killer is constipation so all patients regularly taking
pain killers of any type should be monitored for signs of constipation by discreetly identifying
and recording their bowel movements. If their bowel movements provide cause for concern,
the carer must record the fact and ensure that the responsible Registered Nurse Practitioner
or doctor takes appropriate corrective action.
When pain killers are given intravenously, there is also the risk of the strong pain killer
affecting the patient’s brain, causing it to “forget” to tell the patient to breathe. This condition
is known as “respiratory depression”. When a carer is looking after a patient who is receiving
these IV painkillers, it is part of their legal responsibility to be aware of both the signs of
respiratory depression and the appropriate resuscitation procedures and equipment required
to rectify the problem if it occurs.
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5.6 Making clinical observations
Clinical observation starts with observing how the patient appears. This may seem rather
obvious, but with the plethora of medical gadgets currently available, staff are often forgetting
to simply “look” at their patient.
Any machine that is used to provide a reading is only providing part of the information used to
assess a patient. It is only a machine, and a machine that is generally tuned to a broad set of
parameters intended to reflect what is “normal” or “healthy”. The machine’s scale is generic
but each patient is unique. It follows that the mechanical assessment should be examined in
the context of what is normal for each specific patient.
For example, a patient might usually have a pulse of 72 beats per minute (as recorded in their
notes) and then their pulse is found to be 96 beats per minute – which will be an indicator of a
significant change from the “norm” for that patient. Significantly, both of these beat rates fall
within the “normal” range set in pulse reading devices, so the device will not indicate a
deviation from the norm and a carer who relied solely on the device would miss an early
indicator of a problem.
Every machine is only a tool in the “toolkit” of clinical assessment. It does not replace the
intelligent and patient specific assessment that should be regularly conducted by the carer.
5.6.1 Observation of the patient
The carer should always approach the patient with an assessment of how they look. When
the patient is known, this assessment will be a comparison with previous assessments. Is the
patient awake and looking happy; communicative; withdrawn, tense; confused; less than fully
conscious; showing indicators of discomfort or pain; flushed or pale, etc. When a patient’s
pallor is of concern, the carer should examine where the colour is, cheeks, lips, neck etc.,
looking for a localised explanation and asking for the patient’s input whenever they are
responsive.
When a carer knows a patient well, their observations can be a very reliable indicator of a
change in the patient’s condition. Even when the carer does not know the patient well, the
observations provide earlier indicators that should be followed up on the patient’s behalf.
5.6.2 Responsive to communication
The patient’s level of responsiveness is often hugely relevant to their wellbeing. If their level
of responsiveness varies, there will be a reason (positive or negative). When approaching a
patient who is not known, the carer must ensure that the patient can see and hear them and
that the conditions for communication are in place. See Section 4.1 above.
When there is anything unusual about their response there will be a reason and it is the
carer’s responsibility to find it out. Start by assessing the patient’s temperature, pulse and rate
of respiration (T.P.R.). These basic parameters provide an important initial assessment of the
patient’s current condition. Compare it with the patient’s record because any change may
indicate physical deterioration that requires further investigation or treatment. Alternatively, a
change could indicate that the patient is uncomfortable and may require assistance to move.
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5.6.3 Temperature, Pulse and Respiration (T.P.R.)
Assessing a patient’s TPR is a core skill that every carer should have.
Before starting this assessment, the carer must explain their intentions to the patient and gain
their consent whenever possible. Within institutions it is also appropriate to confirm the
patient’s identity because actions and clinical decisions will be taken on the results of these
clinical observations and the patient’s record must be available.
5.6.4 Temperature
A person’s temperature usually fluctuates in accordance with their circadian rhythms, often
being between 0.5 – 1.5°C higher in the evening than in the morning. It also rises during
ovulation or following eating and drinking. It can also rise in response to bodily infections or
as an immune response to specific triggers. In the elderly it does not always rise in response
to bodily infections.
An unusually low temperature (more common in the young or elderly) is known as
hypothermia and can be life threatening. A temperature below 35°C is known as clinical
hypothermia.
Sudden temperature rises usually indicate infection, but not always. A high temperature is
known as pyrexia or hyperthermia. There are several grades of hyperthermia:
Low grade: a temperature rise from the patient’s normal up to 38°C. This is
common in mild infection, trauma or post surgery.
Moderate to High grade: a temperature between 38 and 40°C. This is often
infections in the respiratory system, wounds, or urinary infections.
Hyperpyrexia: a temperature of 40°C or above. This is usually caused by
serious illness, environmental factors or damage to the brain.
But a rise in temperature can also be caused by problems other than infection. Other
common causes include: alcohol withdrawal; stroke; response to prescribed or self-
administered drugs (which may be an allergic reaction); some types of overdose; gout; an
immune response (to a blood transfusion, for example), etc.
It is worth noting that as people age they do not develop a temperature in response to an
infection as reliably as they did when they were young.
The patient’s temperature is usually taken using a thermometer. The temperature can be
measured in the patient’s mouth, armpit, ear or rectum.
1. A correctly used oral (mouth) thermometer should report the patient’s oral
temperature accurately. This is not necessarily the same as their core body
temperature but usually provides the baseline for a patient’s “norm”.
2. Any rectal reading provides a reading that is approximately 1°C higher than oral
temperature.
3. Any (armpit) axillary reading will usually report a temperature 0.5 to 1°C lower than
the oral temperature.
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4. A correctly used tympanic (ear) thermometer will record a temperature that is
approximately 1°C higher than the patient’s oral temperature.
Within specialist care areas such as the Intensive Care unit (ITU) or in operating theatres,
additional methods of measuring temperature may be used.
While institutions generally have preferred equipment, many types of thermometer are
available to the home carer. It is important to read the instructions and not allow differences
between devices and / or the place where the temperature is measured to be misleading.
5.6.5 Measuring temperature orally
Commonly, disposable paper temperature assessment strips are used to measure a patient’s
temperature by placing them under the base of the patient’s tongue and leaving them there
for 60 seconds. These are often used for patients being nursed in isolation from other
patients. When these are not used correctly, the recorded temperature can be as much as
1.5°C out. Keeping them still under the base of the tongue for 60 seconds can be
uncomfortable for patients, especially when a patient is breathless or has a cold. While some
argue that the 60 second delay is time consuming, I counter this by saying that the time can
be well spent by making an accurate visual, pulse and respiratory assessment - and by
talking to the patient, but they cannot respond until the 60 seconds is up!
Alternatively a mercury (glass) thermometer is used by placing the thermometer bulb under
the patient’s tongue and leaving it there for several minutes. The mercury thermometer is no
longer used in many institutions because mercury is poisonous and it is possible for a patient
to bite the thermometer and release the mercury. A mercury thermometer should never be
used with children or patients who are not reliably responsive and compliant. Mercury
thermometers have largely been superseded by aural (tympanic, in the ear) thermometers.
5.6.6 Measuring temperature rectally
Taking a patient’s temperature rectally requires the use of a rectal thermometer or disposable
probe. The equipment varies and the maker’s instructions should be followed. Formerly,
rectal thermometers were often used to take the temperature of infants and children, but they
have now been largely superseded by the use of tympanic thermometers. This method is
rarely used for adults unless they are severely hypothermic (extremely cold). A rectal reading
is not reliable when the patient has a full rectum.
5.6.7 Measuring temperature axially (under the arm)
The digital axial thermometer is a small hand-held device with a "window" showing the
temperature in numbers. The equipment varies and the maker’s instructions should be
followed. Formerly favoured for use with patients who were considered at risk of injury or non
compliance with the use of an oral thermometer, these are now rarely used. The probe or a
disposable paper thermometer would be placed under the axilla and left for several minutes.
While the risk to a non compliant patient was reduced, they were often unable / unwilling to sit
still for several minutes with their arm against their chest while the thermometer ”cooked”.
Axial thermometers have been largely superseded by use of the aural thermometer.
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5.6.8 Measuring temperature aurally (in the ear)
Tympanic Aural thermometers are commonly used in many institutions. The equipment varies
and the maker’s instructions should be followed. Aural thermometers are electronic battery
operated devices and measure temperature via a probe inserted into the patient’s ear. The
probe has a disposable cover that is discarded after use. Aural thermometers provide a fast
temperature reading, taking only a few seconds but the probe must be inserted properly for
the reading to be accurate. Inaccurate readings can also result when the patient’s ear is full of
wax.
5.6.9 Measuring a pulse
Changes in pulse rate can be an early indicator of the patient’s condition deteriorating, so it is
often taken regularly and recorded for comparison. Recording the patient’s pulse before any
intervention can provide a “base line” against which to measure change, so should be done
whenever possible.
A pulse can be felt where a patient’s artery is close to the skin surface and passes over a firm
area, such as ligament or bone. The more fatty layers there are above an artery, the more
difficult it can be to detect the flow through it.
It can usually be felt in nine areas of the patient’s body, but the commonest arteries used are
the radial (felt in the wrist), brachial (felt on the inside of the upper arm), carotid (felt in the
neck) or femoral (felt in the groin).
Three things are assessed when taking a patient’s pulse properly, the rate, the rhythm and
what we call the “amplitude”, which means the force and volume of the pulse.
5.6.10 The pulse rate
The “normal” pulse rate of each patient will vary according to factors including, age, co-
existing morbidity (illness), posture, movement, electrolytes (blood salts), body temperature,
emotion, infection, medications taken, activity and any cardiac problems.
The average pulse of a six year old is 100 beats per minute (often known as BPM) and a
general average for an adult is around 80BPM. These are crude averages. Each patient is
unique and so, whenever possible, the patient’s pulse should be recorded before any
treatment or surgical inventions are made. The patient’s “normal” pulse provides their “base
line” pulse rate.
A “tachycardia” is an abnormally fast pulse rate, generally one of more than 100 BPM.
However, this might not be abnormal if a patient has just physically exerted themselves, such
as by hurrying up a flight of stairs. The pulse rate should be viewed in context. If there is
doubt, this can often be resolved by taking the pulse again after 15 minutes. When a patient
does develop a tachycardia, it might be a significant symptom of bleeding or infection.
An abnormally slow pulse is known as a” bradycardia”. Usually if a patient has a pulse of 50
BPM or fewer, they will be referred to as being bradycardic. Such slow rhythms can be
caused by drugs, a cardiac problem or as a sign of raised intracranial pressure (pressure
within the brain). It can also be an indication of a patient who is very physically fit. Once
again, the significance of the pulse rate is patient dependent.
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5.6.11 The rhythm
Each contraction of the heart produces a pulse. The two atria in the heart contract together
squeezing blood into the ventricles of the heart. Then the ventricles contract, squeezing blood
out into the rest of the body. The action of the two ventricles can be felt in the pulse as the
“lub dub”. After the “lub dub”, the heart has a brief ‘resting’ period before the next “lub dub” is
felt. The pulse should have a regular rhythm.
If any part of the heart or its electrical conducting system is not working as well as it might,
the pulse can be “irregular”. When the irregularity has pattern it is referred to as being
“regularly irregular”. When the irregularity seems random, it is referred to being “irregularly
irregular”’.
When the two atria contract more rapidly than the two ventricles, this known as “atrial
fibrillation”. When this happens, not every contraction of the atria can be felt so the pulse
feels irregular and can seem to stop for periods. This occurs when weaker beats do not reach
the radial artery, so cannot be felt.
Variations in the rhythm of the patient’s pulse can be an indicator or serious problems and
must be recorded in the patient’s notes, and the carer should ensure that the responsible
Registered Nurse Practitioner or doctor is informed.
5.6.12 Amplitude
The term “amplitude refers to the apparent volume of blood in each beat, or the strength of
the pulse. The arterial walls of most younger people are less hard than the elderly and the
artery expands and contracts more readily, so making the pulse feel different. With
experience, the carer can learn to distinguish between a thready (weak) or a bounding
(forceful) pulse. Both can have important clinical implications and should be recorded.
5.6.13 Taking a patient’s pulse
The carer should discreetly explain to the patient what they are doing and why, asking for
their agreement. If the patient is unconscious or unresponsive, the carer should still explain
what is happening, and why.
The pulse is usually taken by feeling the radial pulse (at the wrist). However there are two
important and significant exceptions.
1. When a patient has the cardiac condition known as atrial fibrillation, it is usual for one
carer to listen with a stethoscope placed over the patient’s heart area and the other to feel
the radial pulse at the same time. Both listen to the number of beats per minute, then
document these. The two will not be the same and the difference can be very important
when determining the patient’s medication needs.
2. When a patient is clinically shocked and very unwell, taking the radial pulse can be totally
unreliable. This is because when a patient is extremely unwell, or dying, their body
automatically “prioritises” where the oxygen in their blood is taken. It does not prioritise
their fingers or toes. It prioritises their heart, lungs, liver, kidneys and brain. So the
amount of blood being delivered to the radial pulse at the wrist will be reduced and can be
very difficult to detect. When taking the pulse of any patient who is very sick or clinically
compromised, the carer must take the pulse “centrally”, meaning in the groin or neck.
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5.6.14 Assessing the radial pulse
With the patient’s consent whenever possible, the carer should place one of the patient’s
arms across their chest with the palm of their hand facing downwards. The carer then places
the second and third fingers of their own hand onto the patient’s wrist immediately below the
thumb. Some small adjustment may be necessary because the patient’s radial pulse might be
found in a slightly different spot. When found, the pulse will usually be obvious to feel under
the carer’s fingertips.
Using a watch or clock with a second hand, the carer must count the number of beats (lub
dubs) that can be felt for either 30 seconds or a minute. When only feeling for 30 seconds,
the result should be doubled to give the beats per minute (BPM). When taking pulses is a
new skill, or the result causes concern, it should be taken for a full 60 seconds.
When the pulse has been taken, the non registered carer must record the result accurately
and report any concerns to the Registered Nurse Practitioner
5.6.15 Respirations
A patient’s respirations refers to the intake and outlet of breath while they breathe. It involves
counting the number of times their chest rises to take in oxygen every minute, but much more
than just that. Assessing a patient’s respiration has a history of being the least acquired skills
amongst many carers, including Registered Nurse Practitioners and medical staff.
Most cells within the patient’s body requires regular oxygen to function. This is usually
obtained by respiration (breathing in), while expiration (breathing out) removes waste
products from these cells.
The brain controls all aspects of respiration automatically and unconsciously but the patient
can also alter the rate or depth of respiration consciously.
When a patient’s physical condition begins to deteriorate significantly, the body automatically
tries to take in extra oxygen, increasing the respiratory rate so that the patient breathes faster
and deeper whenever possible.
In many clinically deteriorating patients who are becoming compromised and in danger of
significant further deterioration, the first clinical sign is an increase in their respiratory rate.
The patient’s pulse will then rise to accommodate this need. If these early signs are not
detected and appropriate treatment given, there is often an increased risk of patient mortality.
A common early symptom of insufficient oxygen (hypoxia) is sudden agitation in a previously
relaxed patient. Confusion and pallor can be later indicators, as can a greyish blue tinge
around the lips. The carer should never think that a patient who has not got a blue tinge to
face and lips is getting enough oxygen. By the time they are looking “blue” they are seriously
compromised and areas of the body are not getting enough oxygen. Insufficient oxygen can
cause tissue to die and must be addressed urgently. If it is not, insufficient oxygen will
ultimately cause death. The golden rule is never to wait for a patient to look ”blue” before you
think he or she is not getting enough oxygen.
Before starting to count the number or respirations per minute, the carer should ask
themselves the following questions:
Is the patient sighing, coughing, gasping, wheezing or croaking?
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are both sides of their chest moving when they breathe?
are they using accessory muscles to breathe – raising their shoulders, holding their
head up, do they have nostrils flaring open as they inhale?
Do they appear to be breathing in for longer than they are breathing out?
Are their breaths deep or shallow?
Does the patient appear paler than usual?
Do they have any cyanosis – blue tinges to their lips, nose or fingers?
Having answered those questions, the carer should count the number of respirations that the
patient makes over 60 seconds. Very rapid but shallow breathing is known as
“hyperventilation”.
A rapid respiration rate of breathing at a normal depth is known as “Tachypnoea” and is
commonly a response to in infections. On average, the respiratory rate increases by seven a
minute for each 1°C rise in the infected patient’s temperature.
A very slow respiration rate is known as “hypoventilation”.
A decrease in the rate or depth of respiration in a patient with a head injury can be a sign of
serious deterioration that requires urgent medical intervention.
5.6.16 Assessing the patient’s respirations
Recording the patient’s respirations before any intervention can provide a “base line” against
which to measure change, so should be done whenever possible.
Without moving their hands, when the carer has finished taking the patient’s radial pulse they
can record the patient’s respiratory rate. This is done by keeping their hand in the same
position on the patient’s wrist over their chest and feeling how frequently the patient’s chest
rises and falls within 30 seconds. When only feeling for 30 seconds, the result should be
doubled to give the respiration rate per minute. When counting respirations is a new skill or
the result causes concern, they should be counted for a full 60 seconds.
5.6.17 Blood pressure (B/P)
BloodPressure can be assessed either manually (using a stethoscope and
sphygmomanometer) by those with the appropriate skill or by using an electronic device that
undertakes the reading automatically.
Two measurements are taken to record a patient’s blood pressure – the systolic and the
diastolic measurements. When the B/P is recorded, the systolic reading comes first, and the
diastolic second, so 100/60 means that the patient has a systolic pressure of 100 and a
diastolic pressure of 60.
When listening for the patient’s blood pressure using a stethoscope, the systolic blood
pressure is the first sound that is heard as the sphygmomanometer is slowly deflating. It is the
noise made by the contraction of the ventricle as it forces blood out of the heart and is
measured in mm Hg. The diastolic is identifiable when the pulse gets much quieter or the
sudden absence of sound. What you are hearing is the minimum pressure against the wall of
the blood vessel wall , an indication of blood vessel resistance.
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There is no “normal” blood pressure – situations vary and readings of the same patient’s B/P.
can vary considerably when taken only a few minutes apart. This is why no patient should be
diagnosed as having a high B/P (hypertension) on the strength of a single B/P. reading. The
diagnosis should be made after three recordings taken with the patient at rest over several
days. It may also be assessed by using a 24 hour Blood Pressure Monitor (there are many on
the market) to record regular blood pressure recordings while the patient is engaged in their
normal activities37.
As a rule of thumb, anything between 100/60 and 140/90 can be considered a “normal” B.P.
Common factors that can lead to a high B/P reading include:
Sodium or fluid retention. The patient’s blood ‘salts’ are not as they should be.
Tachycardia, rapid pulse.
Obesity.
Increased blood volume, the patient has too much blood.
Vasoconstriction, the patient’s blood vessels have constricted for some reason.
Hormones.
Stress.
Exercise.
These do not always mean that the patient is hypertensive.
Common factors that can lead to a low B.P. reading (hypotension) include:
Haemorrhage, bleeding.
Alcohol.
Bradycardia. When the patient has a very slow pulse, usually lower than 60 BPM
Decreased blood volume. The patient does not have enough blood.
Dehydration. The patient is drying out because of raised salt levels or insufficient fluid
intake.
The risks of persistent hypertension are well known and include heart disease and strokes.
The risk of hypotension as a sudden event can also be catastrophic.
Blood is circulated throughout the body taking oxygen to all the tissues and removing ‘waste
products’. If the blood is not being circulated properly the tissues don’t get enough oxygen,
the patient becomes hypoxic and tissues die. The symptoms of this happening will vary
according to the areas affected.
In an acutely ill situation a drop in B./P.does not usually occur immediately. The body
“compensates” for the problem and the respiration rate increases and gets deeper. The pulse
rises and the patient may look pale as blood is diverted by hormonal action so that it is
concentrated in the vital organs. During all this, the patient’s B/P often appears to remain
more or less unchanged.
37 NICE guidelines on diagnosing hypertension 2013.
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Notice that the base line respirations and pulse do change. It is the carer’s job to recognise
these changes and record and report them as a matter of urgency BEFORE the patient’s
blood pressure drops.
5.6.18 Recording a patient’s blood pressure
There are electrical and manual ways to take a record of a patient’s blood pressure. Both
have to be used by the carer with skill and concentration.
The manual way is called ausculatory (“listening”) and usually involves measuring the blood
pressure in the brachial artery in the arm. It involves using a manual sphygmomanometer.
The electronic B/P reader (often referred to by the trade name, Dynamap) is also usually
conducted using the brachial artery in the upper arm.
Both manual and electronic methods involve applying an inflatable cuff attached to a length of
tubing between the cuff and the machine.
The electronic devices do not require any skill other than the application of the appropriate
size of cuff (which is a size approximately 2/3 of the patient’s upper arm width) and pressing a
button on the machine to start it operating.
The electronic devices are exceptionally easy to use, requiring no more than the press of a
button but they can be unreliable / inappropriate because they do not assess weak
heartbeats, do not identify irregular heartbeats and are known to give unreliable results when
a patient is hypotensive (has a low blood pressure).
The ausculatory (manual) method is more reliable, but requires greater skill to use properly.
The manual assessment requires use of a stethoscope, the bell of it which should be cleaned
with an alcohol wipe between each patient, and the ear pieces similarly cleaned between staff
using them.
Whichever method is used, the B/P cuff should be cleaned with disinfectant or an antiseptic
wipe between patients. When the patient is known to have an infection, the machine itself
should be wiped with an appropriate disinfecting wipe and the actual cuff washed in warm
soapy water and allowed to dry completely before using again.
5.6.19 Recording a patient’s blood pressure using a manual
sphygmomanometer
The carer should discreetly explain to the patient what they are doing and why, asking for
their agreement. If the patient is unconscious or unresponsive, the carer should still explain
what is happening, and why.
1. If the patient is compliant and mobile, the carer should generally ask them to sit, then
wait several minutes before taking the recording. When two separate readings must
be taken, one lying down and one upright, the lying down blood pressure should be
recorded first. Unless the patient was already lying down, the carer should wait three
minutes between their movement and taking the reading.
2. The patient’s arm should not have an intravenous infusion running in that limb. A B/P
reading should not be taken on a lymphoedematous area, in the vicinity of shunts or
on the side of a mastectomy. Having selected the arm from which to record the B/P,
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the carer should ask the patient to remove any restrictive clothing that will be in the
way, helping if necessary.
3. The carer should ensure that the patient’s arm is supported on a pillow because
holding an unsupported arm out for this procedure would require muscle contraction
that can affect the reading.
4. The carer must ensure that they have the correct size of inflatable cuff, then wrap the
cuff around the patient’s upper arm, ensuring that the centre of the cuff bladder is
placed over the brachial artery. There should be at least 2.5 cm (more than an inch)
between the bottom of the cuff and the anticubital fossa – where the elbow bends and
the arm is creased. Pushing the stethoscope bell underneath the blood pressure cuff
is not the correct method of taking a reading.
5. If it has not already been done, the carer should wipe the stethoscope bell with an
alcohol wipe between each patient. When the stethoscope is used by others, its ear
pieces should be treated similarly.
6. The carer should already have examined previous readings so that they know what to
expect. Generally, the higher the blood pressure the more highly inflated the cuff will
have to be. This can be uncomfortable for the patient so the high pressure should not
be held for longer than necessary. The carer should expect to inflate the cuff to 30
mm HG higher than previous recording systolic readings.
An alternative that can be useful when a patient’s previous readings are not known is
for the carer to inflate the cuff very slowly simultaneously feeling the patient’s radial
pulse. When the radial pulse cannot be felt, the pressure shown in the cuff gives an
approximate systolic B/P. This allows the carer to know what approximate pressure
will be needed. They should deflate the cuff and wait 30 seconds before inflating the
cuff again, increasing the pressure to 30 mm HG higher than the estimated systolic
reading that they had just obtained.
7. Then place the diaphragm (bell) of the stethoscope over the pulse point of the
brachial artery – in the anti-cubital fossa (crease of the elbow) and inflate the cuff to
the anticipated level.
8. Deflate the cuff gradually in 2 mm HG stages, listening for the start of the pulse. The
sound of the “lub dub” of the pulse will suddenly be heard. This is the systolic blood
pressure reading.
9. Keep slowly deflating the cuff while listening for the “lub dub ” of the pulse to either
suddenly stop or suddenly become much quieter. Some patient’s blood pressure goes
quieter, in others it appears to suddenly stop. This is the diastolic blood pressure
reading.
The result must be recorded in the patient’s records and any concerns or deviations from the
patient’s previously recorded B/P should be reported to the Registered Nurse Practitioner or
medical staff. After finishing the B/P reading the carer should ensure that the patient is
comfortable, and clean the stethoscope bell (and ear-pieces when appropriate) before
replacing the equipment in its designated place.
Common reasons for recording incorrect blood pressure readings include:
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Carer error;
Worn connections or tubing;
Incorrect size cuff;
Wrongly positioned cuff (usually the cuff is too low and covers the pulse area);
Patient not resting / sitting as suggested prior to the recording being made.
5.6.20 Recording a patient’s blood pressure electronically
Electronic cuff devices can be especially useful when a patient has a well-padded anticubital
fossa (inside of elbow) and the pulse is difficult to hear through the stethoscope.
Taking a patient’s B/P with an electronic B/P reading device is as simple as attaching the cuff
appropriately. This will vary by device, so the user should follow the manufacturer’s
instructions. But the use of electronic cuff devices to take a patient’s B/P can have several
important disadvantages.
Disadvantages of electronic cuff devices:
The available cuff is often a single size and may not fit the patient well.
The cuff may be unclean.
The machine always inflates to a pre-set range – and this can be very uncomfortable
or bruising for patient.
The machine does not record weak beats that are not strong enough to reach the
brachial artery.
These machines are unreliable when recording low blood pressures (hypotension).
The machine will not detect a weak or irregular pulse.
The machines cannot assess other indicators, such as the patient’s skin colour,
whether the patient’s skin is clammy or hot and dry, or how the patient feels, or their
tone of voice;
The machine reduces contact with the patient.
So beware, taking a B/P using an electronic method may be simple, but it can cause
problems and does not replace the carer / patient contact that is an essential part of a full
assessment.
Whenever an electronic B.P device gives a result indicating hypotension, the
reading must be taken again using a manual method.
5.6.21 Oxygen saturation levels – known as “Sats”
Oxygen saturation levels (often known as “sats”) in a patient’s blood can be measured using
a detector that attaches to a soft clip on a patient’s finger, toe or ear. The normal oxygen
saturation range is between 95 and 98%. This is slightly lower in patients with COPD38 ,
patients with COPD should have SATS of between 88 and 92%. A reduced ”Sats” reading
can indicate that the patient is clinically deteriorating and is not getting sufficient oxygen to
38 Chronic Obstructive [Pulmonary Disease, such as chronic bronchitis, emphysema
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their vital organs and peripheral circulation. Or alternatively a reduced reading could mean
that:
The patient’s fingers or toes are cold;
The patient is anaemic;
The patient is hypotensive; they have a very low blood pressure
The patient is wearing nail varnish.
If any of these situations applies, the clip should be attached to the patient’s earlobe for an
alternative reading.
After use, the probe and the machine should be wiped with an antiseptic wipe and allowed to
dry between patients.
Sats devices are increasingly used in the community as well as hospitals, often for patients
with chronic lung conditions as a method of assessing their lung function at that moment in
time. But they should be used with the same caveat as with all devices. They are useful and
can prove an excellent indicator of the patient’s condition, but they are only one tool in the
“toolbox” of patient assessment.
5.7 Care of the unconscious and / or dying patient
To begin with, it is necessary to define “‘dying”? In broard terms, we are all getting closer to
death, so slowly dying. The newly diagnosed patient with a terminal prognosis might
reasonably interpret that as “dying” although their death may not be imminent. A patient with
such a prognosis will require support from their carers, and that support can often be given by
simply listening to them.
In general within medical institutions the term “dying” is only used when death is imminent.
The term might be used to describe a sudden deterioration in the patient or to describe a
longer protracted death. For some people in some circumstances, patients, relatives and their
carers, the imminent death will be partly perceived as a welcome release from anguish.
People react to terminal diagnosis and death in individual ways and many medical institutions
do not have the facilities and support networks that they need. This is not a criticism but an
acceptance of the competing demands on their resources. If the hospice sets the gold
standard for providing support to the dying and their relatives, then all carers should aspire to
that standard within the context where they are working. There is much that carers can do,
and many achieve a great deal without much more than common sense and good will.
When a carer feels that there may be something further that could be done for the patient or
their relatives, they should record this in the patient’s records and verbally report this,
ensuring that those in a position to respond receive their report.
5.7.1 The anticipated (expected) death
After a patient has been ill or suffering for a long time the relatives may feel that the death will
be a release, and then feel guilty because they are almost wishing their loved one away.
When a relative need to express this, the carer should be there for them, listening and never
judging.
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The patient might want to talk to the carer about their impending death and the carer should
welcome this trust. It can be hard to know what to say, but just holding their hand can provide
comfort. The patient will often want to spend protracted time with their relatives and loved
ones and this must be accommodated whenever possible. Carers should remember that
relatives will need sustenance and they should be offered it whenever possible. In some
institutions, financial assistance for food and parking may be available, and the carer should
ensure that they know about any special arrangements that may be available. There may be
nothing the carer can do about the big issue they are facing, but the carer should smooth
away the small issues whenever possible.
Relatives have the right to be present while their relative dies, provided that their presence is
not detrimental to the welfare of other patients or staff. They should be allowed to be there at
all hours (not just visiting hours) unless their behaviour is impossibly disruptive. Any carer
who denied this would be ignoring the fundamental principles of care, behaving unreasonably
and possibly breaching the legal rights of the patient and their relatives.
As death approaches, the dignity of the dying is paramount. Basic nursing care must be
maintained throughout their decline and the carer should address any Religious or Cultural
needs of both the patient and their relatives. Each institution should provide “Religious and
Cultural” resources to guide the carer when the relatives cannot.
There are special nursing instructions such as the “care of the dying pathway”39 (the Liverpool
Pathway that used to be followed should have been superceded by alternative guidance) that
provides advice on everything from discussing the situation with the patient to preventing the
patient from suffering with pain, nausea or bronchial secretions in the last days of life.
Generally, this pathway is only started when the patient is expected to die within the next few
days. Provided that it does not conflict with any religious or cultural factors the Liverpool Care
of the dying pathway for the terminal / dying patient, or a similar pathway, should be followed
whenever a patient’s death is imminent.
Within hospitals and many institutions specific palliative care advice is available. When the
patient is dying in their own home, there any several types of support designed to help the
patient and the relatives or carers within the family. Their involvement is not imposed, but
negotiated. Sometimes family carers want to retain overall control and when this is the case,
it should be accommodated. When the family would rather not cope alone, the help and
advice can include taking control when that is what the relatives or family carers want.
Unpaid carers can access advice and support via their (or the patient’s) G.P. even when they
have previously been managing independently. The emotional effects of imminently “losing” a
relative or friend often renders the family carer exceptionally vulnerable and they should be
expected to need more support than they may have previously.
After the patient has just died, the relatives may well like some time alone with them. The
carer should respect this. When there are large numbers of relatives, the carer may need to
ask their managers how best to accommodate them while they wait to “pay their last
respects”.
39 http://www.endoflifecare.nhs.uk/care-pathway/step-5-care-in-the-last-days-of-life/liverpool-care-pathway.aspx
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5.7.2 Communicating with the dying patient
The carer should always remember that it is widely believed that the unconscious patient can
very often hear what is said around them. The carer should encourage relatives to talk to
(and touch) their loved one if they appear to want to. There are often many things that need
to be said.
The carer should always tell the unconscious dying patient what they are doing and why.
Every aspect of the six principles of care covered in this book should be addressed and
followed as appropriate for the patient throughout. Dignity and privacy must be maintained
throughout every aspect of the basic nursing care delivered.
5.7.3 Sudden death
When a patient dies, this may result in the care staff attempting full resuscitation (this is most
common in a hospital but it could happen anywhere). This can be especially hard for any non-
medical staff present. Relatives and visitors may react in strange ways, and say some
unexpected things. Sometimes relatives can be very angry or aggressive or equally can
appear totally calm or shocked. There is no right or wrong response.
When a patient dies suddenly this can also be a shock to other patients within the area who
are often distressed by the “speed of events” and might show this in different ways. The
situation will affect everyone, including the carers – and especially those carers who had
direct dealings with the patient. Affected carers should take time to discuss a sudden death
with their colleagues.
No-one ever said being a nurse was not going to hurt. And the day that a
carer does not care is the day they should find another job.
If a carer ever feels particularly distressed over any death, they should discuss it with their
senior colleagues and, if necessary, seek professional support. Support can help to alleviate
shock and grief and should not only be available to patients and their direct relatives but to
carers as well.
When a carer is looking after a relative or loved one at home and they suddenly die, this can
leave the carer bereft in more ways than one. They have lost the relative and also the caring
that has often become a purpose in their life. Family, friends, G.P. and support services
should rally around and ensure that the carer is supported until the change can be accepted.
Following any episode of CPR40 in response to the sudden death of a patient, it is important
to clear away as much of the CPR equipment as possible before bringing the relatives in to
see the deceased. Certain equipment may have to be retained in the deceased patient (such
as tubes) but these can often either be covered or cut back so they are less visible.
5.7.4 Washing the deceased patient in hospital
The carer should not forget to refer to the Religious or Cultural requirements of the deceased
patient and / or their relatives and try to accommodate those needs at all times.
40CPR, cardiopulmonary resuscitation often involving chest compressions in an effort to ‘restart’ the patients heart. This is
not the same as resuscitation – resuscitation is a much broader remit and can include several clinical interventions
including drug and fluid administration, surgery etc. , plus of course CPR.
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When death has been confirmed, unless otherwise requested, the deceased patient should
be laid flat and their eyes closed (if not already). This can be achieved by gently closing the
eyelids and then applying wet cotton wool balls or wet gauze on the eyelids.
If the deceased wore dentures, they should be replaced if not already. Wet them with water to
ease insertion.
If the deceased’s mouth is gaping open, place a rolled towel under their chin to hold it closed
until rigor mortis (stiffening of the body) occurs.
When the death was a sudden, unexpected event, any cannula (often referred to as needles
but in fact they are usually fine plastic type tubes in the vein) , or catheters should not usually
be removed until after a post mortem. When the death was expected, a post mortem is
unlikely to be required so it is possible for it to be acceptable for all tubes, cannula, etc., to be
removed from the body and dressings applied to the sites when appropriate. The carer
should check the relevant policy at the institution where they work when they are uncertain
about which ‘tubes’ should be removed at this time.
The issue of jewellery should be considered. Usually this only involves ensuring that the
deceased’s wedding ring is in place but there may have been other requests that the patient
made while alive and these must be respected.
Ideally the patient should be left for an hour. Any relatives who were not present might wish to
come in say “goodbye” at this point. It is vital that they see the arrangements of the deceased
demonstrate a caring attitude that is in accord with their expressed Religious or Cultural
requirements. The carer should always check that the cotton wool on the eyes and the towel
under the chin are removed before they allow the relatives to see the deceased.
After any relatives have visited, it is usual practice in hospitals for the body to be washed and
prepared to be taken to the mortuary. Outside of hospital this is often done by the undertaker
who collects the body. The family will decide which undertaker to use.
The carer will need all of the equipment necessary to give a full body wash (see Section
5.1.4) plus a disposable shroud, clean sheet, three identification labels and adhesive tape.
The patient or their relatives might require the patient to be dressed in specific clothing.
Within some cultures or religions they would prefer the carer not to touch or wash the
deceased and will undertake this themselves. For this reason it is vital that the carer is
conversant with the patient’s religious or cultural requirements following their death.
When undertaking the final body wash for the deceased, the carer must wash and dress the
deceased as they would have done when the patient was alive. Many carers find themselves
talking to the deceased as they do this, which is respectful and human.
It is not necessary to plug any orifice (body openings) unless the deceased is leaking fluid
copiously. It is normal for there to be slight incontinence but this is usually self limiting and
when the cavity is empty, there is no further leakage. A body leaking continuously should be
placed in a special body bag as an infection control measure. When used, the bag should be
closed with the zip running from the deceased’s toes to their head. This requirement would be
unusual out of hospital setting. The undertaker should be able to advise carers in other
environments when this is a requirement.
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In hospital while preparing the body, the carer should ensure that there is an ID41 band
around the deceased’s wrist and attach three identification labels with the deceased’s name,
date of birth and ward recorded on them. One ID label is taped to their chest on top of the
shroud. The second is attached to a bandage that is gently attached to both big toes, so
keeping the feet together in an upright position. When the deceased has been dressed, the
sheet underneath the body is folded over the and taped together, so enclosing the face. The
third label is taped to this sheet over the deceased’s chest. This should mean that the body
has four methods of identification attached when it is taken from a hospital ward.
Many nurses / carers like to cross the patient’s hands on their chest with a flower placed
under their wrists. This is acceptable – as long as it does not conflict with any of the
deceased’s religious requirements or those of their relatives.
5.7.5 Death in other institutions or at home
After the patient has died, their death will require confirmation, usually by the deceased’s
G.P. who, unless they are a locum doctor, might know their medical history.
An undertaker is contacted and they will collect the deceased’s body. Whether the body is
washed and dressed before collection is a personal decision, made by the family. The
undertaker is then the main person who can advise the next of kin about any post mortem
requirements and the funeral arrangements. The undertaker will arrange for any identification
labels required.
Some institutions, especially those within the Hospice movement, maintain contact with the
deceased’s family for much longer and support them within their initial grieving period.
Unfortunately very few hospitals in Britain routinely undertake this. Support does not have to
be institutionalised. I worked with one Accident & Emergency sister who always contacted the
next of kin of every person who had either died within the department or been brought into
the department while having CPR that proved ultimately unsuccessful. She brought comfort to
many although these actions were never acknowledged at a senior level. For a real carer like
her, that did not really matter.
The real carer supports the needs of the patient and their relatives without
expecting any special recognition.
41 Identification label – with written details of the patient’s full name, date of birth, hospital registration number and ward
area.
95
6 Useful reference material for the new carer
The book I most recommend is: Royal Marsden Hospital Manual of Clinical Nursing
Procedures (Professional Edition), Lisa Dougherty; Wiley-Blackwell, 2015. ISBN-10:
144433509X: ISBN- 978-1-118-74592-2 9th Edition (I advise buying the latest edition).
There is also a student nurse edition. These are designed to provide more extensive
information than can be provided in this book.
There is an enormous amount of potentially useful information available via the internet, but I
respectfully remind the reader that not everything on the internet is correct or up-to-date.
The National Institute for Health and Clinical Excellence (NICE) www.niceguidelines.co.uk. At
the website, enter the name of the disease you are dealing with and the screen will show any
links to disease specific NICE guidelines, support groups and information sites that are
available.
Alternatively, use a search engine to type in the name of the patient’s illness and the words
‘support groups’ or ‘care forum’. For example, for advice or support when helping a patient
suffering with any type of dementia, you could either type ‘dementia care forum’ or the
‘specific type’ of dementia care forum in the search engine.