Some people regard a hot shower as the greatest invention of mankind; for others, a soothing soak in the tub is “just what the doctor ordered.” But for many patients in hospitals or long-term care facilities, neither of these is possible. Cleanliness, however, is still the order of the day, and it is important to have a grip on the current protocols for bathing or helping patients, especially the elderly, bathe themselves.
There are health and social benefits to bathing, as well as providing patient comfort. Health benefits include skin cleansing, infection control, and stimulating tissue and muscles. It also provides an opportunity for the health care provider to inspect the patient’s skin. Socially, a bath controls body odor and enhances well-being. Last, but not least, bathing provides relaxation and positive sensory stimulation.
The body’s first line of defense against invading organisms is the intact skin (the largest organ in the body), which also serves to maintain homeostasis. Patients in all health care settings have a common need to maintain intact, healthy, moisturized skin, though many bathing routines and techniques can jeopardize the barrier function of the skin. Alteration in skin integrity is a practice issue across the continuum of care, particularly as patients age, when the epidermis gradually thins.1
The skin serves the functions of protection, sensation, metabolism, thermoregulation and communication, and provides protection against mech.anical injury. Several processes within the dermis and epidermis are vitally important for fluid and electrolyte balance. In the dermis, the sebaceous glands produce natural oils that lubricate the skin and provide a protective layer that minimizes fluid loss through the epidermis. It has been document.ed that moist skin is less prone to break down and heals faster than dry skin. Keeping a patient clean helps keep skin intact to fight infection and prevent injuries.
The aging process impacts the structure and function of skin. The ability of the skin to retain moisture decreases and results in less pliable tissue that is vulnerable to even minor trauma. Sebum production decreases with age, and this can be manifested as dried skin (xerosis). Dry skin affects as many as 59-85 percent of people over the age of 64. At least 70 percent of hospitalized patients are older than 65 years, and almost 90 percent of the residents in long-term care are older than 65 years of age. Therefore, a vast majority of the people who enter acute- and long-term care facilities have vulnerable skin and decreased resiliency.2
Using certain cleansing agents poses a threat to skin integrity. Many cleansing products not only remove dirt and debris from within the lipids of the skin, but remove the natural lipid layer, which in turn compromises the natural barrier function of the epidermis. Soap has poor rinsing qualities and can leave a residue of film on the skin. Soaps remove undesirable resident bacteria as well as desirable transient bacteria, decrease natural skin lubricants, inter.fere with water-holding capacity of the skin and alter the pH of human skin. The skin’s mild acidity is an effective antimicrobial barrier. Soap is alkaline, and the soap and water basin bath makes rinsing difficult. Soap often re.mains on the skin, and bar soap can become a haven for the growth of bacteria. Soap used in routine patient bathing should be liquid, non-antimicrobial, and neutral in pH, and must contain moisturizers.
It is customary in North America to bathe once a day. However, the threat of soap to the aging process of the skin, the patient’s preferences and time constraints on the nursing staff should be reason to re-evaluate this tradition. Though patients don’t, physiologically speaking, require bathing each day, one standard by which we have traditionally judged the quality of nursing care has been the bath.3
When a patient is unable to bathe herself, a basin bath is provided. One of the key disadvantages to this type of bath is the potential for bath water contamination and cross-contamination of the immediate environment and health care personnel.4 It is said that objects handled by the caregiver wearing gloves during the bath also can become contaminated, as well as the hands of the caregiver, due to ill-fitting or torn gloves. Also, when the water cools, it is uncomfortable and invariably chills the patient.
Many hospitals have gone to basinless baths with pre-moistened, disposable washcloths, which are warmed to a comfortable temperature that is maintained during the bath. In this technique, one cloth is used for each major body part, and the cleanser is not detrimental to the skin and contains moisturizers. The solution quickly evap.orates from the skin’s surface, making towel drying unnecessary. This method also avoids cross contamination and has been shown to lessen health care worker time.
When the skin is dry, there’s a potential for cracking, scaling and water loss. To avoid dry skin, the patient’s skin should be patted rather than rubbed, and harsh skin products should be avoided, such as bar soap. During bathing, the friction applied to the skin should be minimized. Low humidity and exposure to cold also can lead to dry skin. Moisturizers should be utilized whenever possible.
When bathing patients, it is better to assist them rather than do all the work for them. If they can still move their arms, they can wash their own face. This keeps patients from be.com.ing completely dependent and exercises their motor skills. If patients are confined to bed, always enlist the help of a co-worker. Work on the face and upper torso first, then each side of the body from the arm down to the leg. Use towels and cotton blankets to cover body parts until ready to wash them and again after being washed, in order to keep the patient warm and preserve patient dignity.
While the patient is undressed, check for skin rashes or sores in tummy folds, under breasts and in the crease of the groin and buttocks. If there are any red areas, the physician should be notified.
Christy Heckman, RN, who cares for geriatric patients at Somerset Medical Center in Somerville, NJ, offers the following advice: “When bathing, take special care to make sure the peri-anal area is clean. Older patients are susceptible to developing urinary tract infections.” If they have diabetes pay close attention to any cuts or sores on their feet, she added.
To help the bathing procedure go smoother, gather all supplies ahead of time. If the facility does not use basin-less baths, replace the water as necessary as it cools. Close the door to avoid drafts and to protect the patient’s modesty and privacy. Most individuals do not need a bath once a day, although the face, underarms and private areas should be cleaned daily. The frequency of skin cleansing should be individualized according to need and patient preference. After bathing, the bath basin should be disinfected and dried thoroughly to minimize the proliferation of organisms.
An elderly person may be embarrassed or feel vulnerable about being naked or having another person bathe them. It may be difficult for them to accept the loss of independence and self-esteem. Always be considerate and never argue or force a patient to bathe. The person’s dignity should be of utmost importance. Always maintain privacy by closing curtains, doors and blinds, while ensuring proper lighting. All this makes the patient more comfortable and relaxed, and may even boost her morale. Bathing should be done in a calm, unhurried manner.
Traditionally, many nurses have used bathing as time to spend with their patients, talking with them and assessing their condition. Since nurses are the health care workers most responsible for skin and wound management, they play a major role in helping to prevent skin problems in the elderly.