Vulnerable skin within the skin microclimate is caused by a multitude of factors that are often aggravated by one another. Urine and feces, for example, have a negative impact on the skin as a result of the microorganisms and enzymes they contain. These factors break down the skin barrier and...
Perspective of Nursing Care from Past to Future by Matron Marley
By Margaret Heale, RN, MSc, CWOCN
I was in the shower getting ready for my day volunteering at the nursing home and my mind bemoaned again how much I miss bathing. Relaxing in a deep hot bath, preferably with bubbles, background music and a cool drink...heavenly! Then I started thinking about how much the process of personal hygiene has changed since I was matron, way back when. As a child we bathed on Sundays which was great because the house was warmer on Sundays. I remember being really surprised when I went into nursing that we washed patients every day. By the time I was matron we had got rid of rubber draw sheets and had plastic ones. The rubber absorbed some of the odor from the urine, quite unpleasant. Linen changes were more frequent and we ran out of linen less frequently than earlier in my career. Most hospitals had their own laundry back then.
Methods of Bathing for Patient and Care Provider Safety
But today is now, so off we drove to Rose Cottage, the nursing home where my granddaughter works and I volunteer. One of the first things today is helping to shower a resident. Now in my day in England, we did not have showers, not even in the new hospitals. When I was matron we were trying to reduce back problems in staff and as the transfers in and out of the bath were so back breaking, we introduced hoists.
The nurses could do a single transfer to the bath chair/hoist from the bed, cover the patient with a blanket and troop off down the ward to the bathroom. The hoist would lower them into the water to get wet and washed. The water would be let out and the patient dried as well as possible. A foot pump was used to pump the hoist back up high to get them over the bath edge. We had large bathrooms so finding a dry area to have them stand safely to complete drying and dressing wasn't a problem. The 'baths' had always been a two nurse job but having the bath hoist made it twice as quick and much safer.
Helping with the shower today at the nursing home where my granddaughter works is quite alien to me. I am not sure what it is about the process but it just feels wrong, as wrong as 15 dunks at 10 minutes each. We have boots on and get very wet. The resident is cold (as am I) and the only good thing about the process is the warm blanket. Now this is something I wish I had discovered years ago. Warm blankets are the most amazingly comforting item in all the universe, whoever thought it up needs a medal.
The Importance of Hygienic Practice in Bathing Patients
I promised we would discuss bed bathing sometime and that time is now, because after helping in the shower, I went to help the same new nursing assistant I was volunteering with that day to conduct a client bed bath. As you may remember we use soap and water which did not occur to me was sub-optimal in any way. Well the new nurse was used to 'bag baths' and from the moment she filled a basin with wash cloths and water I just knew this might be interesting. As a matron in England, I expected the nurses to use two semi-disposable washcloths and two towels with a couple of changes of water to do a full bed bath. Only the towel used for the bottom was put in the laundry, the other towel would be used for that part the next day.
This woman had at least 15 washcloths and six towels. She threw a chux on the floor and proceeded to wash the patient. After doing the resident's face, she then soaped up a cloth and washed the woman's chest, both arms and armpits, threw the washcloths on the chux and rinsed with the next cloth. She left the patient uncovered for long periods, though when I was there I covered her promptly. The times I wasn't there to cover her was because I was picking up those cloths that missed the target of the chux.
As the nursing assistant whirled cloths up and down then onto the floor, she told me how at her last SNF the nursing assistants would make up bags of soapy washcloths and a bag of just wet washcloths and put them in the blanket warmer for the oncoming shift. Apparently it made the process much quicker. Better yet, she informed me you could now buy disposable impregnated cloths to wash residents with and she wanted us to use them. This new member of staff had convinced the DON that 'bag baths' are the way to go and a company rep was coming in to show us them. We were going to give them a trial.
By this point we were ready to turn the resident to remove a soiled sheet, swooooosh splat, onto the floor went the sheet. Unable to leave the resident as she was rolled toward me I stood amazed at the brazen sloppiness of this woman (for she was not a new, young nurse, but a seasoned nursing assistant new to our facility). I had seen many residents washed whilst here and the young nurses did this well with care, dignity, compassion and some care regarding infection control. How does this happen, I thought. As we finished up and I helped give a drink to the resident, the colleague scooped up the linen with the chux in and stuffed the bundle into the laundry. I suddenly realized what the bits were that we would find at times in amongst the clean linen.
Products and Resources for Optimal Beside Bathing
The in-service regarding the bag baths was interesting. The rep had excellent chatter and some references to demonstrate that using impregnated wipes reduces skin tears in the nursing home environment. The one-step process of washing and moisturizing reduces nursing time and ensures the application of a moisturizer to improve the integrity of the skin. There were two different types of cloths: one for washing the body and the other for the perineal area. The peri-wipes have dimethicone in them, a silicone product that protects the skin from urine and stool; it is the ingredient of many protective creams (outlined last time I wrote).
When the rep described the way to bed-bathe a resident he described 'the perfect bed bath.' I just relaxed, all is not lost. Time for questions. I asked about drying the skin as our mantra here was, clean, dry, moisturize and protect (a Mikel Gray lesson). These particular wipes came with a warming cabinet and should just be blotted dry for comfort. More watery versions, from companies in direct competition, leave the skin wet and if not dried may cause moisture-associated skin damage. The DON asked him if there are any problems associated with flushing the wipes down the toilet. He made it clear they are not flushable. We have an ancient waste water system and the nursing director was concerned, as the peri-wipes will often be used in the toilet areas, flushing is bound to occur. She had heard of facilities having to spend thousands of dollars clearing up blockages and overflows. I shared her concern but he played this down rather.
I looked on YouTube later in the evening, as there are many instructional videos on bed bathing. Mostly, they are quite good, but worth critiquing with learners. I liked this one particular video for a partial bed bath, but found the perineal care clip that goes with it disappointing (she rolls the patient without the side rails up). The importance of nook and cranny care wasn't really emphasized, neither was proper drying. Click here to view the video.
Caregiving in the past had matrons such as myself looking, watching and waiting to catch transgressors of doctrine. I would only rarely catch people throwing linen on the floor and virtually never saw a patient with inadequate privacy maintained. With no matron to monitor practice, how do we know that what is taught is retained and then maintained in practice? At Rose Cottage we have a campaign to "always perform procedures as if you are a master of your craft, teaching a student." I plucked up the courage (yes, even as an ex-matron has to do this) to bring this to the attention of the nurse I had done the shower and bed bath with. She was embarrassed (a good start) and said she was in a hurry. I asked her if sloppiness saves time, is safe or professional. I hoped she would not ask, "where is the evidence", or for that matter offer to perform a multi-centered, double blinded controlled trial to prove it one way or the other! To exit from the discomfort I started talking to her about the patient bathroom that was installed last year, suggesting it is better than either showering or bed bathing our clients. The side of the bath lifts up allowing residents to stand pivot and sit. The side then locks into place. It fills quickly with water that is temperature controlled. The room is warm, comforting and has a warm cabinet for towels and bath blankets. Everybody loves it, residents and staff alike.
I wonder what we will have in the future, there is a robot giving a bed bath on YouTube! I prefer to think that there will be an approach more akin to a spa with exquisite foot care and massage available with relaxing music. They say what goes around comes around and indeed I hope this is so as it will be the return of matron (but with better people skills) and not the camera of 'Big Brother' that watches our every move.
Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233-41.
Groom M, Shannon RJ, Chakravarthy D, Fleck CA. An evaluation of costs and effects of a nutrient-based skin care program as a component of prevention of skin tears in an extended convalescent center. J Wound Ostomy Continence Nurs. 2010;37(1):46-51.
About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.