Providing for a patient's hygiene is probably the most basic of all nursing care activities, but it is undoubtedly one of the most important. Not only is it a provision for the patient's physical needs; it also contributes immeasurably to the patient's feeling of emotional well-being. Learning Outcomes: After completing this lesson, you will be able to: Determine purposes for giving a patient a bath. Identify conditions, which encourage skin breakdown. Identify interventions, which can prevent skin breakdown. Identify patient needs and observations to make during the bathing procedures. PURPOSE OF THE PATIENT'S DAILY BATH • Removal of bacteria from the skin. o Confinement in bed increases perspiration, and bacterial growth is stimulated by moisture. o Skin irritation from hospital bed linens may result in skin breakdown and subsequent infection. • Relaxation effect on the patient. • Stimulation of blood circulation to the skin, respirations, and elimination. • Maintenance of joint mobility. • Improvement of the patient's self-image and emotional and mental well-being. • Providing the nurse with an opportunity for health teaching and assessment. • Providing the nurse with an opportunity to give the patient psychological support. o The process of building rapport may begin during the initial bath. o The bath aids in the development of the therapeutic nurse-patient relationship as the patient has the nurse's undivided attention. PHYSICAL CONDITIONS WHICH ENCOURAGE SKIN BREAKDOWN IN A PATIENT WHO IS CONFINED TO BED Immobility. Continuous pressure over any body part impairs circulation to that part and can cause breakdown and eventual ulcerations. Incontinence. If the patient is unable to control the bladder or bowel functions, skin breakdown is likely to occur due to the presence of moisture and bacteria on the skin. Emaciation. An emaciated patient may be prone to skin breakdown over bony prominence (heels, elbows, and coccyx). Obesity. An obese patient may have many skin folds where perspiration and bacteria may contribute to skin breakdown. Age-Related Skin Changes. An older person's skin is very thin and inelastic. The sweat and oil glands are less active. Thin, dry skin is more susceptible to pressure areas and skin breakdown. Any Disease or Condition that Affects Circulation. Any disease or condition that affects circulation can encourage skin breakdown in a patient who is confined to bed. NURSING INTERVENTION TO PREVENT SKIN BREAKDOWN a) The time of the patient's bath or back massage is the most logical time to thoroughly observe the patient's skin for pressure areas. b) At the first sign of redness, the area should be washed with soap and water and rubbed with lotion; measures should then be taken to keep the patient off the reddened area. c) Report any signs of pressure to the charge nurse. d) Keep sheets under the patient clean, smooth, and tight to help eliminate skin irritation. e) Ensure adequate nutrition and fluid intake, according to physician's orders. f) Every effort should be made to keep urine and feces off the patient's skin, washing the skin with soap and water and keeping the buttocks and genital area dry (lotion or powder may be used depending upon the patient's skin type) when the patient is incontinent. g) Obese patients may need assistance washing and drying areas under skin folds (groin, buttocks, under breasts, and so forth.) h) For the patient with very dry skin, various bath oils may be added to the bath water. • Soap may be omitted because of its drying effect. • Lotions and oils may be used after the bath. TIMING OF PATIENT HYGIENE PROCEDURES A patient's bath may be given at any time, according to the patient's needs, but certain routines are generally followed on a ward. a. Morning Care. (a) The procedure followed in the morning affects the patient's comfort throughout the day. (b) Each morning before breakfast, the patient should be assisted to the bathroom, or a bedpan or urinal should be provided, according to the patient's activity level. (c) The patient is then given the opportunity to wash his/her hands and face and brush his/her teeth. The bed linen is straightened, and the overbed table is cleaned in preparation for the breakfast tray. (d) After breakfast, the patient has a complete bath (type is dependent upon the patient's condition and mobility), mouth care, a change of clothing, and a back massage. (e) Bed linens are changed; and the unit is cleaned and straightened to provide a comfortable and safe environment for the patient. b. Evening Care. 1) The care the patient receives at the end of the day greatly influences the patient's level of relaxation and ability to sleep. 2) An opportunity is provided for elimination; the patient's hands and face are washed; the teeth are brushed; a back rub is given. 3) Bed linens are straightened; the patient's unit is straightened to ensure comfort and safety. It is important that there are no items, which the patient could slip on, or fall over, such as chairs or linens, on the floor. PROVIDING FOR SELECTED PATIENT NEEDS WHILE BATHING A PATIENT a. Safety. (1) The bed may be in the high position during the patient's bed bath, but should be placed in the low position upon completion. (2) The side rails should be up after the patient's bath for the patient who is confined to the bed. (a) Side rails help to prevent falls for the elderly patient or the patient who is confused or has a decreased level of consciousness. (b) The legal aspect requires diligence on the part of nursing personnel. (3) The patient's call light should be within easy reach to prevent the need to reach for it and risk falling out of bed and to provide easy access in case of pain or distress. (4) Fire safety in the patient care area calls for the following rules: (a) No smoking in bed. (b) No smoking if oxygen is in use. (5) Always wash your hands before entering and upon leaving the patient's room. b. Privacy. (1) Respect for the patient's privacy decreases the patient's emotional discomfort during personal care. (2) Keep the door to the patient's room closed. (3) Pull the curtains around the unit and drape the patient's body during care. (4) Allow the patient to complete as much personal care as possible; self-care is appropriate and provides additional privacy. c. Comfort. (1) Ensure a comfortable temperature in the patient's room. (2) Close any windows and the door to the patient's room to prevent drafts and chilling. (3) Drape the patient appropriately during the bath. (4) For a bedside bath, maintain bath water between 110° F and 115° F; change the water as it cools and/or gets soapy. SIGNIFICANT NURSING OBSERVATIONS DURING THE BATHING PROCEDURE a. Physical Observations. (1) Observe the skin under good, natural light. (2) Any abnormal skin condition should be described as to its location, color, and size and how it feels to the patient. (3) The following skin observations should be checked upon admission and daily thereafter: (a) Cleanliness. (b) Odor. May be caused by sweat secreted by the sweat glands; by abnormal conditions, such as infection or kidney disease; or by bodily discharges (urine, feces) that need to be cleaned. (c) Texture. Smooth and elastic or dry and rough; nutritional deficiencies can influence skin texture. (d) Color. Reddened areas that could indicate pressure, cyanosis (bluish tinge) or jaundice (yellowish tinge). (e) Temperature. Hot skin could mean fever; cold skin could mean poor circulation. (f) Sensitivity. Pain, tenderness, itching, or burning. (g) Swelling (edema). Stretched or tight appearing; usually begins in the ankles or legs or any other dependent part; may be associated with injury. (h) Skin lesions. Rashes, growths, or breaks in the skin. (4) Observations may begin at the head (scalp) and proceed to the feet in a systematic manner. b. Psychosocial Observations. (1) Problems in this area may be related to the patient's present problems. (2) The time of the patient's bath may be a good time to find out more about the patient's psychosocial needs. (3) Remember that the patient's nonverbal communication may tell you much about the way he/she is feeling.