Presentation on theme: "NUR 111 SKILL 17-1 BATHING A PATIENT. ASSESSMENT 1. Assess environment for safety (e.g., check room for spills, make sure that equipment is working."— Presentation transcript:
ASSESSMENT 1. Assess environment for safety (e.g., check room for spills, make sure that equipment is working properly and that bed is in locked, low position). 2. Assess patient’s fall risk status (if partial bathing out of bed or self-bath is to be performed), tolerance for bathing and activity, comfort level, cognitive ability, musculoskeletal function, and presence of shortness of breath. 3. Assess patient’s visual status, ability to sit without support, hand grasp, ROM of extremities. 4. Assess for presence and position of external medical device/equipment (e.g., IV line or oxygen tubing). 5. Assess patient’s bathing preferences, including frequency, time of day, and type of hygiene products used.
ASSESSMENT – CONT’D 6. Ask if patient has noticed any problems related to condition of skin and genitalia. 7. Before or during bath, assess condition of patient’s skin. Note the presence of dryness, indicated by flaking, redness, scaling, and cracking or excessive moisture, inflammation, or pressure ulcers. 8. Identify risks for skin impairment. Option: Use a pressure ulcer assessment tool. A. Immobilization (e.g., patients with paralysis, immobilized extremities, traction; weakened or disabled patients). B. Reduced Sensation (e.g., patients with paralysis, immobilized extremities, traction; weakened or disabled patients)
ASSESSMENT – CONT’D C. Nutritional and hydration alterations. D. Excessive moisture on the skin, particularly on skin surfaces that rub against one another (e.g., under breasts, perineal area). E. Vascular insufficiencies F. External devices applied to or around skin (e.g., casts, braces, restraints, dressings, catheters, tubes). G. Older-adults H. Shear or friction (sliding down in bed). I. Incontinence (bowel or bladder).
ASSESSMENT – CONT’D 9. Assess patient’s comfort on a 0 to 10 pain scale. 10. Assess patient’s knowledge of skin hygiene in terms of its importance, preventive measures to take, and common problems encountered. 11. Review orders for specific precautions concerning patient’s movement or positioning.
PLANNING 1. Expected outcomes following completion of the procedure: Skin is free of excretions, drainage, or odor. Skin shows decreased redness, cracking, flaking, and scaling. Joint ROM remains same or improves from previous measurement. Patient expresses sense of comfort and relaxation. Patient tolerates bath without fatigue or chilling Patient describes benefits and techniques of proper hygiene and skin care.
PLANNING – CONT’D 2. Gather equipment and supplies. 3. Adjust room temperature and ventilation. 4. Explain procedure and ask patient for suggestions on how to prepare supplies. If partial bath, ask how much of bath patient wishes to complete – Promotes patient’s cooperation and participation and promotion of self-care as appropriate. 5. If it is necessary to leave the room, be sure that call light is within reach of the patient. – Provides for patient’s safety. Clinical Decision Point : Never leave the bedside without ensuring that at least two but not more than three side rails are raised and the bed is in the locked, low position. The number of side rails depends on the patient’s fall risk assessment; however, having all side rails raised is considered a restraint. Check agency policy.
IMPLEMENTATION 1. Close room doors and windows and draw room divider curtain. 2. Offer patient bedpan or urinal. Provide towel and moist washcloth. – Patient will feel more comfortable after voiding. 3. Perform hand hygiene. Apply clean gloves. 4. Place supplies on bedside table, including a washbasin two- thirds full with warm water. Check water temperature and have the patient place their fingers in the water to test the temperature tolerance. Place plastic container of bath lotion in bath water to warm if desired. 5. Raise bed to a comfortable working height. Lower side rail closest to you and help patient assume comfortable supine position, maintaining body alignment. Bring patient toward side closest to you.
IMPLEMENTATION 6. Place bath blanket over patient. Have patient hold top of bath blanket and remove top sheet from under bath blanket without exposing patient. Place soiled linen in laundry bag. 7. Remove patient’s gown or pajamas – Provides full exposure of body parts during bathing. A. Whether or not patient has an IV line, simply unsnap sleeves and remove gown. B. If an extremity is injured or has reduced mobility, begin removal from unaffected side first.
IMPLEMENTATION – CONT’D C. If patient has an IV line and gown with no snaps, remove gown from arm without IV line first. Then remove gown from arm with IV line. Pause IV fluid infusion by pressing appropriate sensor on IV pump. Remove IV tubing from pumps, then use regulator to slow IV infusion. Remove IV container from pole and slide IV container and tubing through arm of patient’s gown. Rehang IV container, reconnect tubing to pump, open regulator clamp, and restart IV fluid infusion by pressing appropriate sensor on IV pump. If IV fluids are infusing by gravity, check IV flow rate and regulate if necessary. Do not disconnect IV tubing to remove gown.
IMPLEMENTATION – CONT’D 8. Remove pillow if allowed. Raise head of bed 30 to 45 degrees. Place bath towel under patient’s head. Place second bath towel over patient’s chest. 9. Wash face. A. Inquire if patient is wearing contact lenses. B. Form a mitt with a washcloth. Immerse in water and wring thoroughly. C. Wash patient’s eyes with plain warm water, using a clean area of cloth for each eye and bathing from inner to outer canthus. Soak any crusts on eyelid for 2 to 3 minutes with a warm, damp cloth before attempting removal. Dry around eyes gently and thoroughly. D. Ask if patient prefers to use soap on face. Wash, rinse, and dry forehead, cheeks, nose, neck, and ears without using soap. Ask men if they want to be shaved.
IMPLEMENTATION – CONT’D E. Provide eye care for unconscious patient: 1. Instill eye drops or ointment per health care provider’s order. 2. In the absence of blink reflexes, keep eyelids closed. Close eyes gently, using back of your fingertip, before placing eye patch or shield. Place tape over patch, or shield. Do not tape eyelid.
IMPLEMENTATION – CONT’D 10. Wash upper extremities and trunk. A. Remove bath blanket from patient’s arm that is closest to you. Place bath towel lengthwise under arm. Bathe with water and minimal soap using long, firm strokes from distal to proximal (fingers to axilla). B. Raise and support arm above head (if possible) to wash axilla, rinse, and dry thoroughly. Apply deodorant to underarms as needed or desired. C. Move to other side of bed and repeat steps with other arm. D. Cover patient’s chest with bath towel and fold bath blanket down to umbilicus. Bathe chest using long, firm strokes. Take special care with skin under female patient’s breasts, lifting breast upward, if necessary with back of hand. Rinse and dry well.
IMPLEMENTATION – CONT’D 11. Wash hands and nails. A. Fold bath towel in half and lay it on bed bedside patient. Place basin on towel. Immerse patient’s hand in water. Allow hand to soak for 3 to 5 minutes (if necessary) before cleaning fingernails. Remove basin and dry hand well. Repeat for other hand. 12. Check temperature of bath water and change water if necessary; otherwise continue. 13. Wash abdomen: A. Place bath towel lengthwise over chest and abdomen. (You may need two towels). Fold bath blanket down to just above pubic region. Bathe, rinse, and dry abdomen with special attention to umbilicus and skinfolds of abdomen and groin. Keep abdomen covered between washing and rinsing. Dry well. B. Apply clean gown or pajama top by dressing affected side first. Option: You may omit this step until completion of bath.
IMPLEMENTATION – CONT’D 14. Wash lower extremities A. Cover chest and abdomen with top of bath blanket. Expose near leg by folding blanket toward midline. Be sure that other leg and perineum remain draped. Place bath towel under leg. B. Wash leg using long, firm strokes from ankle to knee and knee to thigh. Assess for signs of redness, swelling, or pain along leg – this promotes circulation and venous return. Assessment is a key to identifying signs and symptoms of venous thrombosis.
IMPLEMENTATION – CONT’D 14. Wash lower extremities C. Clean foot, making sure to bathe between toes. Clean and file nails as needed (check agency policy). Dry toes and feet completely. Soaking feet in warm water for 10 minutes can help maintain cleanliness of the nails and feet; however, do not soak feet of patients with diabetes mellitus. D. Raise side rail; remove towel; move to opposite side of bed, lower side rail, place dry towel under second leg, and repeat Steps 14b and c for other leg and foot. Apply light layer of moisturizing lotion to both feet. When finished, remove used towel. E. Cover patient with bath blanket, raise side rail, and change bath water.
IMPLEMENTATION – CONT’D 15. While patient is supine, provide perineal care (see procedural guideline 17-1). 16. Wash back: A. Apply clean gloves. Lower side rail. Help patient assume prone or side-lying position (as applicable). Place towel lengthwise along patient’s side. B. If fecal material is present, enclose in fold of under-pad or toilet tissue and remove with disposable wipes. C. Keep patient draped by sliding bath blanket over shoulders and thighs during bathing. Wash, rinse, and dry back from neck to buttocks using long, firm strokes. Pay special attention to folds of buttocks and anus. D. Clean buttocks and anus, washing front to back. Clean, rinse, and dry area thoroughly. If needed, place clean absorbent pad under patient’s buttocks.
IMPLEMENTATION – CONT’D 17. Remove gloves and massage back if patient desires. 18. Apply body lotion to skin and topical moisturizing agents to dry, flaky, reddened, or scaling areas. Clinical Decision Point: Massage is contraindicated in the presence of acute inflammation and where there is the possibility of damaged blood vessels or fragile skin. Massage of the legs is also contraindicated because of the possible presence of a blood clot, which could become dislodged.) 19. Place clean gown on patient and adjust any external lines and equipment.
IMPLEMENTATION – CONT’D 20. Assist patient with grooming, oral hygiene, shaving, hair care, and application of makeup (if desired). 21. Make patient’s bed (see Procedural Guidelines 17-5 and 17-6). 22. Check function and position of external devices (e.g., indwelling catheters, nasogastric tubes, IV tubes, braces). 23. Remove soiled linen and place in dirty laundry bag. Do not allow linen to contact uniform. Clean and replace bathing equipment. Replace call light and personal possessions. Place bed in low, locked position with at least two but no more than three side rails raised. Make sure that patient is as comfortable as possible. 24. Perform hand hygiene and leave the room.
EVALUATION 1. Observe skin; pay particular attention to areas that were previously soiled, reddened, flaking, scaling, or cracking or that showed signs of breakdown. Inspect areas normally exposed to pressure. 2. Observe ROM during bathing. 3. Ask patient to rate level of comfort (on a scale of 0 to 10). 4. Ask if patient feels tired – this determines patient’s tolerance of bathing activities.
UNEXPECTED OUTCOMES 1. Areas of excessive dryness, rashes, irritation, or pressure ulcer appear on skin. Review agency skin-care policy regarding special cleansing and moisturizing products. Complete pressure ulcer assessment Institute turning and positioning measures to keep patient off pressure ulcer. Obtain special bed surface if patient is at risk for skin breakdown. 2. Patient becomes excessively tired and unable to cooperate or participate in bathing. Reschedule bathing to a time when patient is more rested. Patients with cardiopulmonary conditions and breathing difficulties require pillow or elevated head of bed during bathing. 3. Patient seems unusually restless or complains of discomfort. Use a less stressful method of bathing such as a disposable bath-in-a-bag product. Consider analgesia before bathing Schedule rest periods before bathing.
RECORDING & REPORTING Record procedure, including the amount of patient participation and how the patient tolerated the procedure. Record condition of skin and any significant findings (e.g., reddened areas, bruises, nevi, joint or muscle pain) in nurses’ notes and electronic health record (EHR). Report evidence of alterations in skin integrity, break in suture line, or increased wound secretions to nurse in charge or health care provider.
END OF SKILL This is the end of the skill. While everything may look “smooth” on paper, you still need to go into the skills lab and practice this skill, or you won’t pass it. Your book has provided a video for you and the link is below: http://bookstie.Elsevier.com/Perry- Potter/ClinicalSkills/video19.php. http://bookstie.Elsevier.com/Perry- Potter/ClinicalSkills/video19.php Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques. 8e-17.1 Bathing and Personal Hygiene. I have decided to include the following procedural guideline in this power point presentation: Procedural Guideline 17-1: Perineal Care
NUR 111: PROCEDURAL GUIDELINE 17-1: PERINEAL CARE
PERINEAL CARE - INTRODUCTION Perineal care involves through cleansing of the patient’s external genitalia and surrounding skin. A patient routinely receives perineal care during a complete bed bath. However, patients who have fecal or urinary incontinence, and indwelling Foley catheter, or rectal or genital surgery many need more frequent perineal care. Wear gloves during perineal care because of the risk of contacting infectious organisms present in fecal, urinary, or vaginal secretions. To avoid embarrassment, always act in a professional and sensitive manner and provide privacy at all times.
PROCEDURAL STEPS 1. Assess environment for safety (e.g., check the room for spills, make sure that equipment is working properly and that the bed is in a locked, low position. 2. Provide privacy and explain procedure and importance in preventing infection. 3. Perform hand hygiene. Apply clean gloves.
PERINEAL CARE FOR A FEMALE A. If patient is able to maneuver and handle washcloth, allow to clean perineum on own. B. Help patient assume dorsal recumbent position. Note restrictions or a limitation in patient’s positioning. Position waterproof pad under patient’s buttocks. C. Drape patient with bath blanket placed in shape of a diamond. Lift lower edge of bath blanket to expose perineum. D. Fold lower corner of bath blanket up between patient’s legs onto abdomen and under hip. Wash and dry patient’s upper thighs.
PERINAEL CARE FOR A FEMALE – CONT’D E. Wash labia majora. Use non-dominant hand to gently retract labia from thigh. Use dominant hand to wash carefully in skinfolds. Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth. Rinse and dry area thoroughly. F. Gently separate labia with non-dominant hand to expose urethral meatus and vaginal orifice. With dominant hand wash downward from pubic are toward rectum in one smooth stroke. Use separate section of cloth for each stroke. Clean thoroughly over labia minora, clitoris, and vaginal orifice. Avoid tension on indwelling catheter if present and clean area around it thoroughly.
PERINEAL CARE FOR A FEMALE – CONT’D G. Rinse and dry area thoroughly, using front-to-back method. H. If patient uses a bedpan, pour warm water over perineal area and dry thoroughly. I. Fold lower corner of bath blanket back between patient’s legs and over perineum. Ask patient to lower legs and assume comfortable position.
PERINEAL CARE FOR A MALE PATIENT A. If patient is able to maneuver and handle washcloth, allow him to clean perineum on his own. B. Help patient to a supine position. Note restriction in mobility. C. Fold lower half of bath blanket up to expose upper thighs. Wash and dry thighs. D. Cover thighs with bath towels. Raise bath blanket to expose genitalia. Gently raise penis and place bath towel underneath. Gently grasp shaft of penis. If patient is uncircumcised, retract foreskin. If patient has an erection, defer procedure until later.
PERINEAL CARE FOR A MALE PATIENT – CONT’D E. Wash tip of penis at urethral meatus first. Using circular motion, clean from meatus outward. Discard washcloth and repeat with clean cloth until penis is clean. Rinse and dry gently and thoroughly. F. Return foreskin to its natural position. G. Gently clean shaft of penis and scrotum by having patient abduct legs. Pay special attention to underlying surface of penis. Lift scrotum carefully and wash underlying skinfolds. Rinse and dry thoroughly. H. Fold bath blanket back over patient’s perineum and help him to a comfortable position. Clinical Decision Point: After administering male perineal care for uncircumcised males, make sure that foreskin is in its natural position. This is extremely important in patients with decreased sensation in their lower extremities. Tightening foreskin around the shaft of the penis causes local edema; discomfort; and, if not corrected, permanent urethral damage.
PERINEAL CARE FOR A MALE PATIENT – CONT’D 6. Observe perineal area for any irritation, redness or drainage that persists after perineal hygiene. 7. Dispose of glove in receptacle area and perform hand hygiene. END OF SKILL
END OF SKILL This is the end of your skill. Your book has not provided a video for this skill and while I have looked on you-tube for one, there is not a video that exactly matches the details of this skill. In order to pass this skill, you need to go into the skills lab and PRACTICE!