This article has been double-blind peer reviewed The underlying ... · Bed bathing a patient Bed...
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Copyright EMAP Publishing 2019 This article is not for distribution except for journal club use 45 Nursing Times [online] May 2019 / Vol 115 Issue 5 www.nursingtimes.net Keywords Hygiene/Bed bathing/ Infection prevention This article has been double-blind peer reviewed S upporting patients to maintain their hygiene needs while they are in hospital is a fundamental aspect of nursing care, yet there is very little evidence to support practice (Coyer et al, 2011). Personal hygiene includes care of the: l Hair; l Skin; l Nails; l Mouth, eyes, ears and nose; l Perineal areas (Dougherty and Lister, 2015); l Facial shaving (Ette and Gretton, 2019). Hygiene and skin care should be con- sidered as one entity, as both have a poten- tial impact on skin health and on patients’ comfort and wellbeing. Factors that have a negative effect on skin health include: l Excessive washing, particularly if harsh products are used; l Lack of hygiene, causing build-up of potential pathogens and increasing infection risk (Cowdell et al, 2014). Box 1 lists other factors. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dough- erty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin. Patients will have their own values and practices relating to hygiene, which nurses need to consider when planning care. For example, some patients may bathe in the evening as it helps them settle for the night, while others may prefer to shower in the morning. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015). As part of routine hygiene care, some patients may require urethral catheter care, mouth and denture care, footcare and eye care. These procedures are not cov- ered in depth in this article. Bed bathing a patient Bed bathing is not as effective as show- ering or bathing and should only be under- taken when there is no alternative (Dough- erty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity. Selecting appropriate equipment Plastic wash bowls were routinely used in hospitals for bed bathing but they can easily become contaminated with micro- organisms responsible for healthcare- acquired infections (Marchaim et al, 2012). As such, single-use disposable bowls are now commonly used. All patient should have their own toilet- ries or be supplied with single-patient use items until their own toiletries can be brought into hospital. Soap can alter skin pH, leading to dry- ness and skin breakdown, so it is suggested that skin-cleansing emollient creams should be used (Cowdell et al, 2014). These should be prescribed for individual patients, and a spoon or spatula should be used to decant the product into a dispos- able pot to prevent contamination; emol- lients in tubes or pump containers reduce this risk. New supplies should be pre- scribed following treatment for a skin infection (Lawton, 2016). Reusable washcloths should be avoided as they can harbour bacteria. This is par- ticularly important in patients who are immunocompromised or critically ill, or those whose skin integrity is compro- mised, for example, patients with burns (Dougherty and Lister, 2015). A relatively new development is pre- packaged cloths for bed bathing (com- monly known as the bag bath), which do not require water. A systematic review comparing bag baths with traditional bed baths concluded that ‘washing’ without water may be an alternative to the tradi- tional bed bath, although more research is required (Groven et al, 2017). Clinical Practice Practical procedures Essential care Author Sandra Lawton is nurse consultant dermatology, Rotherham Foundation Trust; Eileen Shepherd is clinical editor, Nursing Times. Abstract Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. This article outlines the procedure for bed bathing a patient. Citation Lawton S, Shepherd E (2019) The underlying principles and procedure for bed bathing patients. Nursing Times [online]; 115: 5, 45-47. The underlying principles and procedure for bed bathing patients Box 1. Factors that negatively affect skin health l Poor nutrition and hydration l Advancing age l Incontinence l Medical interventions, such as radiotherapy and chemotherapy l Concurrent or underlying skin conditions l Surgical interventions, wounds and drains l Poor mobility Source: Dougherty and Lister (2015)
Transcript of This article has been double-blind peer reviewed The underlying ... · Bed bathing a patient Bed...
Copyright EMAP Publishing 2019This article is not for distributionexcept for journal club use
45Nursing Times [online] May 2019 / Vol 115 Issue 5 www.nursingtimes.net
Keywords Hygiene/Bed bathing/Infection prevention This article has been double-blind peer reviewed
Supporting patients to maintain their hygiene needs while they are in hospital is a fundamental aspect of nursing care, yet there
is very little evidence to support practice (Coyer et al, 2011). Personal hygiene includes care of the: l Hair;l Skin;l Nails;l Mouth, eyes, ears and nose;l Perineal areas (Dougherty and Lister,
2015);l Facial shaving (Ette and Gretton, 2019).
Hygiene and skin care should be con-sidered as one entity, as both have a poten-tial impact on skin health and on patients’ comfort and wellbeing.
Factors that have a negative effect on skin health include: l Excessive washing, particularly if harsh
products are used;l Lack of hygiene, causing build-up of
potential pathogens and increasing infection risk (Cowdell et al, 2014). Box 1 lists other factors.Helping patients to wash and dress is
frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dough-erty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin.
Patients will have their own values and practices relating to hygiene, which nurses need to consider when planning care. For example, some patients may bathe in the evening as it helps them settle for the night, while others may prefer to shower in the morning. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015).
As part of routine hygiene care, some patients may require urethral catheter care, mouth and denture care, footcare
and eye care. These procedures are not cov-ered in depth in this article.
Bed bathing a patientBed bathing is not as effective as show-ering or bathing and should only be under-taken when there is no alternative (Dough-erty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity.
Selecting appropriate equipmentPlastic wash bowls were routinely used in hospitals for bed bathing but they can easily become contaminated with micro-organisms responsible for healthcare-acquired infections (Marchaim et al, 2012). As such, single-use disposable bowls are now commonly used.
All patient should have their own toilet-ries or be supplied with single-patient use items until their own toiletries can be brought into hospital.
Soap can alter skin pH, leading to dry-ness and skin breakdown, so it is suggested that skin-cleansing emollient creams should be used (Cowdell et al, 2014). These should be prescribed for individual patients, and a spoon or spatula should be used to decant the product into a dispos-able pot to prevent contamination; emol-lients in tubes or pump containers reduce this risk. New supplies should be pre-scribed following treatment for a skin infection (Lawton, 2016).
Reusable washcloths should be avoided as they can harbour bacteria. This is par-ticularly important in patients who are immunocompromised or critically ill, or those whose skin integrity is compro-mised, for example, patients with burns (Dougherty and Lister, 2015).
A relatively new development is pre-packaged cloths for bed bathing (com-monly known as the bag bath), which do not require water. A systematic review comparing bag baths with traditional bed baths concluded that ‘washing’ without water may be an alternative to the tradi-tional bed bath, although more research is required (Groven et al, 2017).
Clinical PracticePractical procedures Essential care
Author Sandra Lawton is nurse consultant dermatology, Rotherham Foundation Trust; Eileen Shepherd is clinical editor, Nursing Times.
Abstract Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. This article outlines the procedure for bed bathing a patient.
Citation Lawton S, Shepherd E (2019) The underlying principles and procedure for bed bathing patients. Nursing Times [online]; 115: 5, 45-47.
The underlying principles and procedure for bed bathing patients
Box 1. Factors that negatively affect skin health
lPoor nutrition and hydrationlAdvancing agelIncontinencelMedical interventions, such as
radiotherapy and chemotherapylConcurrent or underlying skin
conditions lSurgical interventions, wounds and
drainslPoor mobility
Source: Dougherty and Lister (2015)
Copyright EMAP Publishing 2019This article is not for distributionexcept for journal club use
46Nursing Times [online] May 2019 / Vol 115 Issue 5 www.nursingtimes.net
Only expose the part of the body that is being washed.
14. Starting with the arm farthest away,wash and dry the upper body, includingthe arms, hands, axilla and torso. Movingacross the body in this way ensures thepatient is clean and dry by the end of theprocedure (Dougherty and Lister, 2015)(Fig 1b). Always wash down the body, forexample from axilla to hands.
15. Ask the patient if they would like tosoak their hands in water (Fig 1c).
16. Remove clothing from the lower body,then wash and dry the legs and feet,starting with the leg farthest away andworking from the top of the leg to the foot. Check feet for any problems such as cal-luses and dry skin.
17. Change the water and wash cloth and, if required, apply non-sterile gloves beforewashing the patient’s genitalia.
18. If appropriate, ask the patient if they wish to wash their own genitalia, orgain consent to continue with the proce-dure. Female patients should be washedfrom front to back to reduce the risk of urinary tract infection (Fig 1d). The fore-skin in uncircumcised men should bedrawn back and the skin underneathshould be washed.
19. Dispose of water – and gloves if used.
20. Decontaminate your hands and fill adisposable bowl with warm water,checking the temperature again with thepatient.
21. With help from a colleague (who hasdecontaminated their hands and put on an apron), roll the patient onto one side using appropriate equipment. Assess if glovesare required for washing the sacrum.Using a clean wash cloth and towel, washand dry the back then the sacral area,moving from top to bottom (Fig 1e).
22. Roll the patient back and both you andyour colleague decontaminate your hands.
23. Change the lower sheet according tolocal procedures.
24. Help the patient to get dressed.
25. Check the patient’s fingernails and toe-nails, and offer nail care if it is required.
l Comb/brush;l Equipment for oral and denture care;l Disposable wash bowls;l Linen skip;l Non-sterile gloves if personal
protective equipment is required or for intimate care.
The procedure1. Review the patient’s care plan forhygiene needs. Ensure that someone will be available to help you during the procedure.
2. Decontaminate your hands.
3. Discuss the procedure with the patient,ask about their usual hygiene routine andgain informed consent for a bed bath.
4. Check whether the patient has any pain. Administer analgesia if necessary andensure it has taken effect before startingthe bed bath. This will help to relieve anypain associated with moving the patientduring the procedure.
5. Ensure the patient’s privacy and checkthe environment is warm and draught free.
6. Check whether the patient wishes toempty their bowel or bladder beforestarting the bathing procedure.
7. Assemble your equipment and ensure everything is to hand to minimise theamount of time the patient is exposed.Ensure the bed is at the correct workingheight.
8. Decontaminate your hands and put on an apron.
9. Fill a disposable bowl with warm waterand ask the patient to check the tempera-ture is comfortable.
10. If the patient is wearing a watch,hearing aid or glasses, remove them.
11. Place a towel under the patient’s chinand cleanse the patients eyes according tolocal policy. Wash the face, neck and ears,checking whether the patient likes soap on their face (Fig 1a).
12. Clean hearing aids and glasses if worn,and return them to the patient to facilitate communication during the procedure.
13. Help the patient to remove their upperclothes and use a sheet to cover the patient.
Glove useThe World Health Organization (2009) stated that non-sterile gloves are not required routinely for washing and dressing patients. Nurses need to assess individual patients for risk of exposure to blood and body fluids (Royal College of Nursing, 2018) and be aware of local poli-cies for glove use.
Evidence suggests that patients may prefer nurses to wear gloves to provide intimate care (Loveday et al, 2014a), for example, washing genitalia. When gloves are required they must be single-use and be disposed of in accordance with local policy (Loveday et al, 2014b).
Undertaking a bed bathBox 2 outlines the general principles of bed bathing.
Equipment neededl Disposable apron;l Clean bed linen and clothes;l Two bath towels;l Wash cloths;l Patient toiletries;
Clinical PracticePractical procedures
Box 2. General principles of bed bathinglKeep the patient warm at all timeslPosition a linen skip near the patient
and dispose of used linenimmediately to reduce dispersal ofmicroorganisms and dead skin cellsinto the environment
lOnly expose the area of the bodybeing washed (Fig 1)
lChange water if it becomes dirty orcold and always after washing thegenitalia and sacrum
lChange wash cloths if they becomesoiled and after washing the genitaliaand sacral area
lCheck skin for pressure damagelAvoid contaminating dressings and
drains with waterlPat the skin dry to reduce the risk of
friction damagelSeparate skin folds, and wash and
pat them drylUse the correct manual handling
procedures and equipment to avoidinjury to yourself and the patient
lIf the patient is unconscious,remember to talk them through whatyou are doing; nurses should not talkover the patient
Source: Ersser et al (2005); Dougherty and Lister (2015)
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Copyright EMAP Publishing 2019This article is not for distributionexcept for journal club use
47Nursing Times [online] May 2019 / Vol 115 Issue 5 www.nursingtimes.net
Clinical PracticePractical procedures
Professional responsibilitiesThis procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
26. Help the patient to clean their teeth and/or dentures, or assist them with mouth care following local procedures.
27. Comb or brush the patient’s hair. Offer to help male patients with shaving if this is part of their normal routine.
28. Finish making the bed and ensure the patient is warm and comfortable with a call bell and a drink (if allowed). Ensure that their belongings are within reach.
29. Remove and dispose of aprons and decontaminate your hands.
30. Record the care that has been under-taken, along with any abnormal finding(s), and ensure you update the patient’s care plan. Contact the tissue viability specialist if you have any concerns about the patient’s skin. NT
ReferencesBurns S, Day T (2012) A return to the basics: interventional patient hygiene (a call for papers). Intensive and Critical Care Nursing; 28: 4, 193-196.Cowdell F et al (2014) Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings (Protocol). Cochrane Database of Systematic Reviews; Issue 12: CD011377. Coyer FM et al (2011) The provision of patient personal hygiene in the intensive care unit: a descriptive exploratory study of bed-bathing practice. Australian Critical Care; 24: 3, 198-209.Dougherty L, Lister S (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell.Ersser SJ et al (2005) A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies; 42: 7, 823-835.Ette L, Gretton M (2019) The significance of facial shaving as fundamental nursing care. Nursing Times; 115: 1, 40-42.Groven FM et al (2017) How does washing without water perform compared to the traditional bed bath: a systematic review. BMC Geriatrics; 17: 31.Lawton S (2016) Emollients and ageing skin: optimising effectiveness and safety. British Journal of Nursing; 25: 11, 596-598.
Loveday H et al (2014a) Clinical glove use: healthcare workers’ actions and perceptions. Journal of Hospital Infection; 86: 2, 110-116.Loveday HP et al (2014b) epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 86: S1, S1-70.Marchaim D et al (2012) Hospital bath basins are frequently contaminated with multidrug-resistant human pathogens. American Journal of Infection Control; 40: 6, 562-564.Rassool GH (2015) Cultural competence in nursing Muslim patients. Nursing Times; 111: 14, 12-15.Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Contact Dermatitis. Bit.ly/RCNGlovesWorld Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care. Bit.ly/WHOHands2009
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Fig 1. The procedure: bed bathing a patient
Clitoris
Urethral opening
Labia majora
Vagina
Labia minora
Perineum
Anus
1a. Place a towel under the patient’s chin. Wash their eyes, face, neck and ears, check whether they like soap on their face
1b. Starting with the arm farthest away, wash and dry the top half of the body. Only expose the part of the body being washed
1c. Patients may enjoy soaking their hands and feet in a bowl of water placed on the bed
1d. Wash the genital area of female patients from front to back to reduce the risk of urinary tract infection
1e. Wash the patient’s back and sacrum, moving from top to bottom
