Infants

In infancy, the skin is thin and easily blistered or excoriated by friction, acid or alkaline substances. It is very sensitive to heat or cold, so it is vital that the temperature of bath water is tested before bathing; approximately 38°C is recommended as the newborn’s skin is prone to irritation (Gunn 2010). Mild, non-irritating soaps or soap-free solutions may be used on the skin and, as the infant has no bladder or bowel control, thorough cleansing of the genital and anal areas is necessary to prevent excoriation. After washing, the infant’s skin should be patted dry with a soft towel, paying particular attention to skin creases and folds. Cradle cap is a common form of dermatitis of infants which consists of thick, yellow waxy scales on the scalp, which may occur as a result of an accumulation of sebum. It can usually be prevented by regular gentle washing and drying of the scalp and hair (Barker 2009; Pantley 2003).

Adolescents

Adolescence is accompanied by many changes that are due to hormonal activity. Sweating from the axillae usually occurs at this stage and the adolescent may need education concerning the importance of having a regular shower or bath. Education can also include information about the function of deodorant and antiperspirant (Berman et al 2012). Acne is a common problem as sebaceous glands become more active in adolescence. Skin hygiene, together with a balanced diet, is important in preventing secondary skin infections.

The middle years

Middle age is often associated with further skin changes, particularly during the male climacteric (decreased levels of androgens) or the female menopause—because of a decrease in circulating ovarian hormone levels (primarily oestrogen and progesterone) the skin may become drier and the pubic and axillary hair may become sparse. Some women may experience thinning and dryness of the skin of the external genitalia, which may be accompanied by pruritus (Berman et al 2012). Lubricants are available to reduce any discomfort associated with such changes.

Older adults

Older age is associated with increasing change in the dermis, with the result that skin is thinner, less elastic and dry. The decreased production of sebum and associated dryness mean that the skin of older people is less able to tolerate soap. To help counteract the dryness, a mild soap or soap-free washing lotion can be used and a moisturising lotion applied after a bath or shower. To prevent skin irritation caused by dry skin some older people choose to change from a daily shower or bath to every second day or less frequently (Clinical Interest Box 21.1).

Cultural considerations

A client’s cultural beliefs and personal values may influence hygiene care. People from diverse cultural backgrounds follow different self-care practices. In many cultural groups in Australia, it is common to bathe or shower daily, whereas in some other cultural groups it is customary to bathe completely only once a week (Berman et al 2012).

Culture plays a role not only in hygiene practices and preferences but also in sensitivity to personal space; for example, some Chinese people may view tasks associated with closeness and touch as being offensive or impolite (Crisp & Taylor 2009). The nurse should ask the client what would make them feel most comfortable during a bath. Perhaps they would prefer only a partial bath from the nurse, with a family member assisting with the bathing of more private body parts. The client may also want to defer part of the hygiene. If, in the nurse’s judgment, hygiene is critical to prevent problems, such as skin breakdown, the nurse must try to understand the client’s concerns then help them understand the reason for accepting the nurse’s intervention. The nurse can play a very important role, particularly when caring for patients in rural settings, poor patients and older adults, in being able to screen for abnormalities such as dental decay and referring dental problems to a dental professional.

Hair care may also be important to people from other cultures. When caring for patients from different cultures, it is important to learn as much as possible from them or their family about preferred hair care practices. Cultural preferences may also affect how hair is combed and styled (Crisp & Taylor 2009).

Nursing observations of the skin

The skin should be observed for:

Abnormalities and changes should be reported and documented and appropriate nursing care implemented in response to nursing observations.

Care of the skin includes maintenance of cleanliness and protection from injury. The skin must be protected against injury by gentle handling and the use of appropriate bed linen and equipment. Cleansing involves the use of soaps and lotions that do not cause irritation or dryness and careful drying of the skin, particularly in folds or creases. If the client wishes, and it is not contraindicated, deodorants, powders and perfumes may be used to enhance the feeling of freshness and to improve morale. Cleansing of the skin may be achieved by several means and the method selected depends on the client’s level of mobility and independence. Some clients will be able to have a bath or shower, while more dependent clients may require a bed or trolley bath. Whichever method of cleansing is used the nurse must ensure the client’s privacy, comfort and safety. It is now sometimes a reality that male and female clients are accommodated in the same ward or unit area and some even share bathroom and toilet facilities. This can increase the client’s discomfort and concerns about privacy, especially during hygiene and toileting procedures. The nurse will need to be sensitive to the concerns of clients faced with this situation and reassure them that every effort will be made to maintain their personal privacy (Crisp and Taylor 2009; deWit 2009; Springhouse Staff 2007).

Nursing observations and assessment

If clients are able to attend to personal hygiene needs safely and independently, they may be left to bathe in private. It is the responsibility of the nurse to ensure that the bathroom has been prepared for use and that the client has all the necessary items. The nurse should ensure that the client knows where the call bell is located and that they know how to use it to call for a nurse.

It is the nurse’s responsibility to assess how much assistance a dependent client requires. Some clients may require help with transfers, while others will require the nurse to remain with them throughout the entire procedure. The nurse should remain with, and provide assistance for, any client who is weak, frail, unsteady or confused. Some clients may require a shower chair to sit on during the shower. For example, a chair would be helpful for a postoperative client who can walk to the shower but is at risk of becoming easily fatigued.

Devices used to assist when bathing and showering

There are several other devices designed to assist the nurse when providing hygiene care for clients. These include handrails, bath seats, mechanical hoists, mobile baths and shower trolleys.

Grab (hand) rails fixed to the wall at the side of the bath or shower can be used for support by clients who are able to stand. Bath benches or seats fit across the top of a bath and allow the client to shower using a hand-held shower hose.

Lifting devices such as hoists or standing machines may be used to safely transfer non-ambulatory clients onto a mobile shower chair so that they have the opportunity to shower or bathe. It is generally easier to remove the client’s clothing before the lift and transfer to the bathroom, but being moved around in a lifting device can feel extremely undignified and distressing. It is recommended in the policy of many institutions that hoists and standing machine transfers be used by two nurses to ensure maximum client safety. For further information regarding safe transfer of clients, refer to www.worksafe.vic.gov.au. The utmost care must be taken to ensure that the client’s privacy and dignity are maintained, in particular the client’s private body areas must be securely covered from view during transfer to the bathroom. Any client who requires the use of a mechanical lifting machine must never be left unattended in the device or in the bath. Clients who may require the use of a mechanical lifter include those who are heavy or extremely weak, frail or helpless.

When clients require aids in the home, structural alterations to the house may be necessary to facilitate their use. Government-funded care packages sometimes provide for this need. In some situations, nurses teach family members who are providing home-based care for dependent relatives how to use the hoist safely. (See the Australian Department of Health and Ageing at www.health.gov.au.)

Mobile baths are available in some healthcare facilities. A mobile bath can be moved to the client’s bedside. The client is transferred from the bed into the bath and transported to the bathroom. The bath is filled and the client bathed in the usual manner.

Shower trolleys are designed for use in the normal shower area. Using a hoist, the client is positioned onto the trolley and wheeled to the bathroom. The surrounding edge is inflated and converts the trolley into a shallow bath and the nurse washes the client using the shower hose.

A full explanation about the aid being used, reassurance about its safety and maintaining the client’s personal privacy and dignity during use are important components of reducing stress and embarrassment for the client. Examples of some aids that are available are illustrated in Figure 21.1.

Figure 21.1 Devices to assist bathing and showering. A: Mechanical lifting device. B: Shower chair. C: Handrails attached to the walls in the shower and toilet. D: Hand-held shower. E: Shower trolley

(A: Reproduced by permission of Haycomp Pty Ltd; B: © Lisa F. Young/Shutterstock; C: Copyright 2012 J.B.S.I—Custom Medical Stock Photo, All Rights Reserved; D: © B. Brown/Shutterstock; E: Image supplied by Hills Healthcare Equipment www.hillshealthcare.com.au)

Key aspects of assisting a client to bathe or shower are outlined in Procedural Guideline 21.1.

Clients requiring special consideration

Clients who are weak, frail, unsteady or confused will require the nurse’s assistance to bathe or shower. A client may feel faint and collapse in the bath or shower. If this occurs the nurse should immediately drain the bath or turn off the shower. Towels should be used to cover the client for warmth and dignity and extra towels should be placed under the client’s legs and feet to increase venous return. The nurse should summon immediate assistance and remain with the client, ensuring that the airway is clear. (See Ch 42 for full emergency care actions in situations in which a person has fainted.) Clinical Scenario Box 21.1 discusses the hygiene needs of a client following a stroke.

Some clients will require special consideration when bathing or showering; for example, special attention is needed for clients who have drainage or intravenous (IV) tubing, wound dressings, plaster casts or specific skin disorders. There may also be special needs associated with surgical or other interventions.

Bathing the client in bed

Clients who are confined to bed or whose condition does not enable them to have a bath or shower may be provided with equipment for washing in bed, or may be given a bed bath (also referred to as a sponge) by the nurse. If clients are able to wash unaided, they are provided with all necessary items, the upper bedclothes turned down and a towel placed over them for warmth and privacy. The nurse will need to help with washing and drying the back and any other parts of the body the client is unable to attend to independently. When the bath is completed and the client’s hair and teeth have been attended to, the nurse remakes the bed.

A complete bed bath involves washing the entire body of a client in bed. It is performed by the nurse when a client is unable to wash unaided. Clients who may require a bed bath include those who have a debilitating illness or are paralysed or unconscious. A bed bath is also frequently needed after surgery. Depending on the client’s level of mobility, either one or two nurses perform the procedure. Healthcare facilities commonly adopt their own specific guidelines concerning how to perform a bed bath. An alternative to the traditional sponge bowl method is the bag bath method (see Clinical Interest Box 21.2).

The following description of conducting a bed bath explains a more common approach. The basic equipment required for a bed bath is:

Key aspects related to performing a bed bath or sponge are:

The complete guidelines for performing a bed bath are provided in Procedural Guideline 21.2.

Bathing an infant

Bath time should be an enjoyable occasion for the infant and the bath should be completed as quickly and safely as possible because prolonged exposure may cause the loss of body heat (Berman et al 2012). Preparation for a bath includes:

The procedure for bathing the infant is as follows:

As the infant grows rapidly in the first 12 months, the procedure is adapted to suit the child’s developmental level and as the child grows, most of the actual washing is done in the bath, with the nurse supporting the infant as needed. Infants and young children must never be left unsupervised in a bath. Nurses have an important role in providing support and reassurance for new mothers, particularly when instructing them how to bathe their babies.

Nursing observations and assessment of the hair and scalp

As part of client assessment, the nurse should observe for and report any abnormalities such as excessive dryness, hair fragility or dandruff, alopecia (hair loss) or pediculosis capitis (head lice). The scalp should be observed for redness, heavy scaling, flaking or lesions. Some clients will be able to care for their hair independently, while others will require the nurse’s assistance. Clients may have their hair shampooed during a bath or a shower, or it may be done with the client sitting in front of a sink. If the client is confined to bed the hair may be washed with the client in bed or lying on a trolley.

Washing the client’s hair in bed

Certain devices are available to facilitate hair washing in bed, such as a shampoo tray (Fig 21.2A). If specially designed equipment is not available, a waterproof sheet can be placed under the client’s head and arranged so that the water can drain into a bucket at the side of the bed (Fig 21.2B). Clients who can be moved from the bed onto a trolley may be wheeled to a sink and positioned so that the neck is supported on a pillow and the head extended over the sink (Fig 21.2C).

Figure 21.2 Hair washing in bed. A: Using a shampoo tray. B: Hair wash in hospital. C: Client on a trolley for hair wash

The method of giving the client a shampoo is usually determined by the facilities available and the client’s condition. A suggested procedure for shampooing the hair of a client confined to bed is outlined in Procedural Guideline 21.3. The basic equipment for shampooing the hair consists of:

If a client is too ill or cannot tolerate a shampoo with water, a dry shampoo may be used. Several commercially prepared substances are available that are applied to the hair then brushed out.

Management of pediculosis (lice)

Pediculosis is a condition in which hair is infested with lice. Lice (or pediculi) are parasitic insects that suck blood from the skin and inject a toxin that causes itching, which may result in excoriation from scratching. The lice lay eggs (or nits) which attach themselves along the shaft of the hair with a cement-like substance that makes removal difficult. Pediculosis can occur wherever there is hair and the three varieties of lice infestation are pediculi capitis (head lice) pediculi corporis (body lice) and pediculi pubis (pubic lice). Signs and symptoms that pediculi have infested the hair include pruritus, excoriation of the skin from scratching and visible lice or nits. The body louse tends to adhere to clothing and may not be evident on the body (Parker 2012). Untreated pediculosis can result in secondary skin infection such as dermatitis. The lice also spread from person to person on clothing, bedding, combs and brushes. It is important to note that pediculosis is not necessarily a sign of poor personal hygiene, as the parasites survive equally well on clean hair. The nits and lice can be destroyed by the use of a prescribed lotion or shampoo. With the available preparations, one single application is often effective. Sometimes a second treatment is recommended about 1 week later, in case any remaining nits have hatched into lice. The bed linen, personal clothing, hair brush and comb belonging to the person infested with lice must also be treated to prevent reinfestation. To avoid transmitting the parasites to others, the nurse should wear gloves and perform thorough handwashing after the treatment.

Shaving

Many men shave every day; if so, this should be continued during illness. Shaving promotes client comfort by removing whiskers that may itch and irritate the skin. A facial shave can be performed using an electric or blade razor. Because the skin can be cut or nicked with a blade razor, an electric one is preferable. If a client is unable to shave independently the nurse will need to assist or perform the procedure for the client. Electric razors should be checked for function and cleanliness before use and brushed free of whiskers after use. If the razor head is adjustable the appropriate setting will need to be selected. The nurse proceeds as follows:

Some females develop a growth of facial hair, and this is usually removed by depilatory creams, tweezers or wax. Shaving should be avoided because the blunt angle of the cut hairs makes the regrowth look heavier.

Assessment and care of the eyes

The eyes are the organs of sight through which visual information about the environment is transmitted to the brain for interpretation. If the eyes are not cleansed adequately, secretions may accumulate. The conjunctiva of the eyes should be observed for inflammation or pallor, and the sclera observed for signs of jaundice. Any discharge, discomfort or pain and the presence of contact lenses, prostheses or spectacles should be noted. Under normal circumstances the eyes are kept clean by face washing and showering. If the eyes become irritated or infected, some clients may require extra care, which consists of cleansing, usually with sterile, soft gauze swabs, to remove secretions from the eyelids and to reduce discomfort. As eye bathing is sometimes required as part of the client’s hygiene needs, guidelines for the procedure are outlined in Procedural Guideline 21.4.

When bathing the eyes the nurse uses an aseptic technique to reduce the risk of introducing microorganisms. (See Ch 20 for information concerning aseptic technique and the prevention and control of infection.) The eyes are always cleansed from the inner to the outer canthus. The procedure must be carefully performed to prevent any injury to the eyes (Fig 21.3).

Figure 21.3 Swabbing the eyes

Clients who may require special eye care include those whose corneal reflex is impaired, due to altered consciousness or facial paralysis and those whose eyes are irritated or infected. Clients with conjunctivitis, a common condition caused by infection, allergies or irritating substances such as dust or smoke, may also require special eye care. Swabbing or bathing the eyes is sometimes referred to as an ‘eye toilet’ and the basic equipment consists of:

Procedural Guideline 21.4 provide the guidelines for performing an eye toilet but it should be noted that, provided that the principles of asepsis are maintained, it may not always be necessary to use a sterile dressing pack each time an eye toilet is performed. It is best to consult the policy and procedure/safe operating procedure manuals of individual institutions for appropriate guidelines.

Assessment and care of the ears

Lack of aural hygiene can lead to an accumulation of dirt and wax, which may result in discomfort and temporary hearing loss. The ears are cleaned as part of normal hygiene practices, for example, during a shower. They should be assessed for any discharge or complaints of tinnitus, discomfort or pain, and the use of a hearing aid should be noted. (See Ch 32 for relevant information about hearing aids.)

Clients who are dependent on others for their hygiene needs should have their ears cleansed with the face washer during the shower or bath. If there is an accumulation of debris or wax in the orifice, this should be documented and reported. The nurse should not insert any object, including cotton-tipped applicators, into a client’s ear canal as part of routine hygiene. Applicators may compact the cerumen, making the ear more difficult to clean (deWit 2009). Excessive cerumen or dry wax necessitates ear irrigation. This is undertaken only after examination and authorisation by a medical officer and should only be performed by someone who is experienced in this procedure (Linton & Lach 2007).

Assessment and care of the nose

Secretions from the mucous membrane that lines the nose may accumulate, causing discomfort and providing a medium for the growth of microorganisms. The nose should be assessed for the presence of any discharge other than the normal mucus secretion, for bleeding, swelling of the mucosa or any obstruction.

Blowing the nose is the most effective way of removing secretions from the nostrils. If clients are unable to perform this function, as a result of being unconscious or due to presence of an intranasal tube, the nurse may be required to clean the nostrils. This is commonly achieved using small cotton-wool-tipped applicators moistened with a solution such as water or normal saline. An applicator is inserted gently into the nostril, rotated and withdrawn, and the technique is repeated until the nostrils are clean. Sometimes a water soluble cream is applied around the nostrils to prevent soreness. If a client has an endotracheal, nasogastric or feeding tube inserted through the nose, any tapes anchoring the tube should be changed at least daily (Crisp & Taylor 2009).

Oral hygiene

Oral hygiene involves measures to keep the mouth and teeth clean and in healthy condition. Care of the mouth includes brushing the teeth, mouth rinses and regular visits to the dentist. The measures necessary to maintain the mouth and teeth in a healthy condition include:

If oral hygiene is neglected, complications may occur, including:

At-risk clients

Clients with reduced flow of saliva or those who experience difficulty with normal chewing or whose swallowing actions are impaired are particularly prone to developing an unhealthy condition of the mouth. Examples include clients who:

Clients who have had chemotherapy or radiotherapy are at risk of developing oral thrush and mucositis. It is, therefore, recommended to clean the mouth using saline or water after every meal (Engelking et al 2008).

Assisting the client with oral hygiene

Many clients are able to attend to their oral hygiene but others may require encouragement and some assistance. The nurse should offer clients the opportunity to brush their teeth after meals and in the evening. The nurse should ensure that each client has a toothbrush and toothpaste and should assist them to the bathroom if necessary.

Some clients with cognitive or memory impairment may need repeated prompting to enable them to complete the task of cleaning their teeth. Clients may not clean effectively or may refuse to clean their teeth at all; clients with Alzheimer’s or dementia may not understand what it is they are being asked to do. They may get frustrated, irritated, agitated and even aggressive as a result. Sometimes the problem may be resolved by temporarily distracting the client with another activity and returning later to cleaning the teeth. It may be helpful to follow the routine for cleaning the teeth conducted previously, for example the same time of the day, after breakfast or after getting dressed. It may even help to have a familiar mirror, towel or other object from home. It should be remembered that the client is not being deliberately difficult; a calm, quiet approach and gentle encouragement is often the key to managing challenging responses. Nurses need to find the key to gaining trust from each person.

For clients confined to bed, the nurse should provide teeth-cleaning equipment consisting of a toothbrush, toothpaste, a mug of water, a container for used water and a towel. Clients who are accustomed to using dental floss as part of their normal hygiene should be encouraged to continue the practice. Flossing involves inserting waxed or unwaxed dental floss between the teeth. The motion used to pull floss between teeth removes plaque and tartar from tooth enamel. To prevent bleeding, patients who are receiving chemotherapy or radiation or are on anticoagulant therapy should use unwaxed floss and avoid flossing near the line of the gum. To aid in cavity prevention, apply toothpaste before flossing, thus allowing fluoride to come in direct contact with tooth surfaces. Flossing once a day is sufficient. Floss holders are available for patients who have difficulty managing the floss (Crisp & Taylor 2009).

Clients who are unable to brush their teeth will require the nurse’s assistance with this procedure. Clients are taken to the bathroom, or teeth-cleaning equipment is brought to the bedside. The client should be assisted into a comfortable sitting position and the clothing protected by a towel. The nurse should apply toothpaste to a dampened toothbrush and gently but thoroughly brush the client’s teeth using an up-and-down movement. Water is provided for the client to rinse the mouth, and a container is positioned to receive the used rinsing water. The mouth is then rinsed, but leaving some paste helps protect the teeth. Finally the lips are wiped dry, the toothbrush and toothpaste put away and the mug and container removed for cleaning.

Some clients wear partial or full dentures, which, like natural teeth, require effective care to remove deposits and to prevent mouth odour. Care of dentures involves removing, brushing and rinsing them after meals. If it is the client’s usual practice, dentures may be soaked in a commercial denture cleaner before brushing. All dentures should be removed at night, so the nurse should ensure that they are put in a container labelled with the client’s name and placed in a safe position. Many clients are very reluctant to be seen without their dentures, so it is important to pull curtains and close doors to provide privacy when necessary. If clients are not able to care for their dentures independently it is the nurse’s responsibility to attend to this.

To remove a partial denture the nurse, wearing disposable gloves, exerts equal pressure on the clips each side of the plate ensuring that pressure is not placed on the borders, because they may easily bend or break. A full upper denture may be removed by breaking the seal of the denture from the palate. This can be achieved by taking hold of the denture at the front or side with the thumb and index finger. A lower denture is removed by holding it in the centre, and turning it slightly before lifting it out of the mouth. A gauze square may be used to provide a firm grip on the dentures. Dentures should be gently placed in a denture container and taken to the bathroom for cleaning and rinsing. When handling dentures care must be taken to avoid damage.

Before the dentures are replaced, the client’s mouth is rinsed and the gums brushed to remove any debris. When clients are unable to insert their own dentures the nurse should assist. Moistening the dentures facilitates easier insertion and aids correct positioning into the mouth to keep them firmly in place. Clients should be encouraged to wear their dentures to facilitate eating and speaking and to prevent changes in the gum line that may affect denture fit.

If normal oral hygiene practices are not possible, the mouth and teeth must be cleaned by other means. Special mouth care is often required if the client:

In these instances, the client’s mouth is cleansed either by the use of alcohol free mouth rinses or by carefully swabbing all areas. The latter procedure is often referred to as a ‘mouth toilet’. A variety of substances may be used to clean and refresh the mouth. The nurse should refer to the healthcare facility’s policy and procedure/safe operating procedure manual for information on the equipment, substances and method to be used.

A suggested procedure for performing special mouth care (swabbing) is outlined in Procedural Guideline 21.5. The basic equipment consists of:

Routine nail care

Nails should be kept clean and trimmed according to the policy of the healthcare agency and the client’s personal preference. As part of the policy of many healthcare facilities, a podiatrist is required to perform nail care for clients. Nails can be kept clean by removing any visible dirt with a blunt instrument such as an orangewood stick. A metal nail file is not used because it can make the nails rough and trap dirt. Some clients will have their own hand-care products and they should be encouraged to use them after a shower or bath. Nails that are particularly dirty or thickened are easier to attend to if the client’s hands or feet are soaked in warm soapy water for 5–10 minutes before the care begins. Whenever nails are being trimmed, extreme care must be taken to prevent any damage to the nail beds and surrounding tissue

At-risk clients

Clients who have diabetes or any circulatory disorder that affects the lower limbs are at high risk of infection, which can start easily in a damaged nail bed. It is therefore often the policy of the institution that such clients have foot and nail care undertaken only by a podiatrist. The podiatrist is also often required to care for the feet of older people whose nails have become thickened and distorted with age or for those with conditions such as corns, calluses or in-growing toenails. Nail clippers are used in preference to scissors for trimming nails. Toenails should be cut straight across. Nails not trimmed in this way tend to grow inwards, creating a risk for pain and infection in the surrounding soft tissue.

Nursing observations and assessment

While undertaking nail care the nurse observes for:

Pallor or cyanosis of the nails may indicate heart disease, while brittleness and/or a spoon-like shape may indicate the presence of an iron-deficiency anaemia. Any change or abnormality should be reported and documented. During nail care, the nurse can take the opportunity to educate clients, or those who care for them at home, on how best to provide nail care. Education can also include how to inspect the hands and feet for lesions, dryness or signs of inflammation or infection, and the importance of reporting any change or abnormality promptly to the registered nurse or medical officer.

Clothing and comfort

A person’s comfort is enhanced if they are able to wear clothes of their own choice. Many people feel uncomfortable and undignified if they are required to wear clothing such as a hospital gown provided by the healthcare facility. For this reason, clients returning from surgery or other procedures are changed into their personal attire as soon as their condition allows. Some residents living in aged-care facilities or special accommodation do not have adequate clothing of their own. In this case the nurse should ensure that the clothes supplied by the agency are appropriately selected to meet the residents’ individual needs. For example, for an older person living in an aged-care facility the choice of clothes should be appropriate in terms of age, gender, temperature and other environmental conditions. They should be clean, fit well and, in the case of clients who are very frail or confused, be easy for them to manage, for example, velcro fastenings for ease of dressing and toileting.

Comfort and the environment

A suitable physical environment is one in which there is adequate lighting, fresh air, ventilation, warmth and cleanliness. Depending on the patient’s age and physical condition, the room temperature should be maintained between 20°C and 23°C. The acutely ill, infants and older adults may need a warmer room. However, some ill clients benefit from cooler room temperatures to lower the body’s metabolic demands (Crisp & Taylor 2009). Ideally the environment should be free from excessive noise and unpleasant sights and smells. In addition, there should be sufficient space for the client’s personal belongings, and facilities available for visitors. In the case of residents in long-term accommodation the environment should be as home-like as possible, have attractive views to the outside world and an outdoor area that is safe and accessible. Ideally, residents will have a single room. If not, the facility should provide a room where residents can spend private time with visitors if they wish. The environment should also provide a relaxed happy atmosphere and opportunities to enjoy activities that enhance quality of life, such as outings, concerts and games. For those who are able, the environment should provide the chance for residents to participate in simple everyday activities such as watching television, gardening, crafts or cooking. Comfort can be enhanced by promoting a psychological climate in which the client is encouraged to communicate any fears or anxieties. A physical environment that reduces the client’s privacy and independence is unsuitable and can be a source of stress and discomfort.

Equipment to promote comfort

Provision of a comfortable bed

A comfortable position is, to a significant extent, dependent on the client’s bed. The prime objective of bed making is the promotion of comfort, as a bed that is made incorrectly may disrupt rest and sleep and may be a contributing factor to the development of complications such as decubitus ulcers (Berman et al 2012). Beds may be made up in a variety of ways to meet the client’s needs and each healthcare facility commonly adopts its own method of bed making. Although the techniques may vary slightly, the principles of bed making remain the same.

Various types of bed are available, most of which can be adjusted manually, mechanically or electronically. Most beds can be raised or lowered horizontally and most can also be adjusted to alter the position of the head, foot or centre. Beds are fitted with wheels, which enables them to be moved easily when necessary, and a brake device that prevents inadvertent movement. The nurse should check that the brakes are applied at all times when the bed is stationary. There are several special types of beds, frames and mattresses that are used for particular circumstances.

Frames are available that may be either fitted to the bed or used in place of a more conventional bed. The Balkan frame, for example, is made from wood or metal, extends lengthwise above the bed, and may be used in conjunction with traction apparatus. The Bradford frame consists of a metal frame across which canvas slings are stretched, and may be used to nurse a person who has a fracture or disease of the hip or spine. The Stryker frame consists of two canvas-covered frames attached to a metal frame and may be used to facilitate changing the position of a person with a spinal cord injury or paralysis. Figure 21.4 illustrates the Balkan and Stryker bed frames.

Figure 21.4 Bed frames and special beds. A: Balkan frame. B: Stryker frame. The client is turned to the prone or supine position. Body alignment is not changed during repositioning

Foam mattresses are commonly covered with a waterproof fabric, which facilitates cleaning and therefore helps to prevent cross-infection. Clients with specific needs, such as those who are more vulnerable to the development of decubitus ulcers, may be nursed on special mattresses. The most commonly used pressure relieving devices are alternating air mattresses. These devices work by over- and underinflating in sequence as the client moves around in the bed (Fig 21.5A). Other, less commonly used devices include the gel mattress (Fig 21.5B) and the foam overlay (egg-crate style) mattress (Fig 21.5C). The type of mattress selected must meet the client’s needs, provide comfort and support and should help prevent development of complications.

Figure 21.5 Special mattresses. A: Air mattress. B: Gel mattress. C: An egg-crate mattress

(A: © Brian Bell/Science Photo Library/Getty Images; B: Blue Chip Medical Products, Inc.; C: © kanusommer/Shutterstock)

Pillows are available in a variety of materials, most of which are enclosed in a protective waterproof covering over which a pillow slip is placed. The number of pillows used depends on the needs of the client, and should be sufficient to provide maximum comfort and support.

Sheets are commonly available in two styles: the long sheet is similar to a conventional single-bed sheet; the draw sheet is a narrow sheet that may be placed across the bottom sheet. Because of their design, draw sheets are easy to replace under a client without disturbing the other bedclothes. A waterproof sheet may be placed under the draw sheet to protect the bottom sheet against moisture, for example, if a client is incontinent or is required to use toilet utensils in bed. In some care settings, special reusable incontinence bed protectors with tuck-in flaps are available and may be used instead of a draw sheet. These maintain a client’s comfort because they are double or multi-layered and very absorbent. They have an integral waterproof barrier, which means that the side on which the client lies remains dry. They are commonly referred to as ‘Kylie sheets’. Disposable liners are more commonly used these days. Care needs to be taken if an air mattress is in place that sheets are not tucked in, as this interferes with the inflation/deflation.

The frequency with which bed linen is changed depends on the healthcare facility’s policy, but any bed clothing that becomes wet, soiled or excessively wrinkled should be replaced promptly to maintain the client’s comfort. Blankets, quilts and bedspreads are available in loosely woven cotton that is easily laundered. Some healthcare facilities may use continental-style quilts in place of blankets and a bedspread.

The use of supplementary items is also an important aspect of nursing care in maintaining comfort.

Supplementary equipment

A variety of supplementary equipment is available that may be used to enhance comfort, provide added support or promote safety.

Bed cradle. A bed cradle is a frame designed to keep the upper bedclothes off all or part of a client. The cradle may be large enough to extend from one side of the bed to the other, or small enough to place over one leg. The cradle is positioned directly above the area of the client’s body which is to be free of the bedclothes and the top sheet and blankets are brought up over the cradle. A bed cradle may be used for a client with a burn, an uncovered or painful wound or a plaster cast. The cradle protects the area by elevating the bedclothes, and facilitates observation of the area by the nurse or medical officer (Fig 21.6A).

Figure 21.6 Supplementary equipment used in bed making. A: Bed cradle. B: Sheepskin board. C: Bed rails. D: Overhead trapeze

Heel or elbow protectors. Made from sheepskin, foam rubber or inflatable plastic material, these protectors are designed to fit the shape of the heel or elbow (Fig 21.6B). Polyurethane foam dressings may also be used. They are commonly used to prevent the development of decubitus ulcers on these areas, as they reduce friction between the skin and the bed linen.

Bed rails. Many beds are fitted with built-in side rails that can be raised (Fig 21.6C). Historically, side rails have been used to prevent clients, such as those at risk of seizures or who are restless or confused, from falling from the bed. However, bed rails are a form of restraint and whenever possible, the use of bed rails is replaced by less restrictive, safe alternatives such as the use of very low beds. This change is in line with a policy of careful risk assessment and the use of the minimal restraint possible for any client in any situation. (See Ch 13 for issues concerning restraint and safety.)

Trapeze. An overhead trapeze, monkey bar or hand grip is a swinging bar suspended from an overhead pole, which may be used by a client to facilitate movement in bed (Fig 21.6D). They should not be used for clients with upper body or shoulder injuries.

Rope. A length of rope or similar material may be attached to the foot of the bed and positioned on top of the quilt. By holding on to the end of the rope, the client is able to pull themself up into a sitting position.

Sandbag. A sandbag is commonly a waterproof bag filled with sand, used to maintain part of the body in alignment; for example, sandbags may be used to immobilise a fractured leg before splinting or surgery.

Wedge-shaped pillow. A wedge-shaped pillow is placed between the legs to maintain abduction, for example, after total hip replacement.

The nurse must ensure that any supplementary equipment is positioned and used correctly to promote the client’s comfort and safety.

Making an unoccupied bed

An unoccupied bed is the term used to describe a bed that is either temporarily vacated by the client, for example, during a shower, or a bed that is being made up after a client’s discharge from the healthcare facility. The unoccupied bed can be made up as a ‘closed’ or an ‘open’ bed. To make a closed bed, the upper bedding is tucked in at the bottom and sides. To make an open bed, the upper bedding is folded up at the bottom and sides. The advantage of the open style is that the upper bedding can be quickly folded lengthwise, or into a pack to facilitate ease of transferring a client from a trolley into the bed. (See Procedural Guideline 21.6.)

Key principles related to bed making

Figure 21.7 Mitred corners

A suggested procedure for making an unoccupied bed is outlined in Procedural Guideline 21.6.

Making an operation bed

An operation bed (Fig 21.8) is a version of an open unoccupied bed and is made up to receive a client after surgery or anaesthesia. An operation or surgical bed is also sometimes referred to as a surgical or post-anaesthetic bed. The upper bedding is arranged into a pack, which can be easily removed to facilitate efficient transfer of the client from a trolley into the bed. Once the client is in the bed, the upper bedding pack is unfolded and carefully placed over the client. The suggested procedure for making an operation bed is provided in Procedural Guideline 21.7. (See Ch 44 for information concerning other preparation required for receiving postoperative clients back in their room.)

Figure 21.8 Operation bed

(Potter & Perry 2013)

Making an occupied bed

The term ‘occupied’ is used to describe a bed that is being made while the client is sitting or lying in it. When making an occupied bed the nurse must be aware of any restrictions in the client’s movement or position, such as a painful wound or a urinary catheter. The nurse should ensure that the client’s safety and comfort are maintained throughout the procedure. In addition to following the key principles relating to making a bed, before starting to make an occupied bed the nurse should:

Figure 21.9 The log-roll method of moving a client A: Positioning for log-rolling B: Log-rolling the client

(From Swartz MH: Textbook of physical diagnosis, ed 6, Philadelphia, 2009, Saunders)

The technique used to make an occupied bed should be one that causes minimal disturbance to the client. Commonly, the bed is remade after attention to the client’s daily hygiene needs. It may be necessary to make an occupied bed more frequently, for example, if the bedclothes become wet, soiled or disarranged. When possible, two nurses should work together to make the bed, for the promotion of client comfort and safety. At times it may be necessary for more than two nurses to make an occupied bed, for example, to help when a client has multiple injuries. The use of a slide sheet is helpful when moving clients in and around the bed. It reduces the risk of injury to nurses and to clients.

Making an occupied bed provides the nurse with an ideal opportunity for communicating with and observing the client. During the procedure the nurse is able to assess certain aspects of the client’s condition, such as emotional state, skin colour, the presence of pain, the ability to move or distress associated with exertion. Observations should be documented and any deviations from normal should be reported immediately to the nurse in charge. When the condition of clients permits, they may be able to move themselves during bed making, by using an overhead hand grip.

Making a divided bed

A divided bed is sometimes referred to as a split or traction bed. Making a divided bed involves arranging the upper bedding into two sections. This style of bed is commonly used for a client who has traction equipment applied to a lower limb. A divided bed allows the leg in traction to be free from the weight of the upper bedding, while the rest of the client’s body is covered. Because the upper bedding is arranged in two sections, the client’s torso and unaffected leg may be kept covered without interference to the traction apparatus. A lightweight cover may be placed over the leg in traction to ensure adequate warmth.

The foot of the bed is elevated to counterbalance the traction and a fracture board is commonly placed under the mattress to provide a firm and supportive surface. A trapeze or overhead bar should be provided to facilitate the client’s movement. When changing or straightening the bottom sheet, it is sometimes easier and less disruptive for the client in traction if nurses work from the top to the bottom of the bed, rather than from side to side.

Certain adverse effects may be associated with prolonged bed rest and immobility; it is therefore important that the nurse implements preventive measures to reduce such effects.

Key aspects related to positioning

To minimise the risk of back strain, nurses are advised to observe the principles of body mechanics and the no-lift policy when assisting clients to move (see Ch 26).

The client should be provided with information about the importance of correct positioning and the reasons why a specific position may be indicated. To provide some exercise and to promote independence the client should be encouraged to participate in regular changes of position unless active movement is contraindicated.

All parts of the client’s body should be maintained in proper alignment, with equal weight distribution and the joints in a functional or neutral position. Muscle tension and strain are prevented when the joints are maintained in a slightly flexed position.

Adequate support should be provided to maintain the natural curves of the client’s vertebral column.

To promote safety and comfort, adequate assistance should be obtained to move a heavy, very frail or dependent client. The client’s body should be handled gently to prevent pain or injury. Appropriate lifting devices are used when necessary to assist clients into position.

Supplementary equipment should be used when needed (e.g. slide sheets, pillows).

To prevent prolonged pressure on any area of the body, the client’s position should be changed at least every 2 hours. Each time a client’s position is changed, the nurse should observe the status of the client’s skin to detect any signs of the consequences of prolonged pressure.

The client should be encouraged to participate in some form of exercise unless this is contraindicated. Exercise helps to promote circulation and muscle tone; if the client is unable to move independently, all joints should be put through the full range of motion.

There are various positions that an individual may assume, or be required to assume.

Sitting positions

There are three variations of a sitting position:

Figure 21.10 Sitting positions. A: Semi-upright, or semi-Fowler’s, position. B: Upright, or high Fowler’s, position may also be adapted to the orthopnoeic position if the client leans onto an over-bed table

A particular one of these sitting positions may be indicated:

The disadvantages of a sitting position include:

Positions for specific situations

There are a variety of other positions suitable for a range of different circumstances. These include:

Figure 21.11 illustrates this range of positions.

Figure 21.11 Various positions. A: Supine. B: Prone. C: Lateral. D: Sims’. E: Coma. F: Dorsal/Lithotomy. G: Genupectoral (knee–chest)