BRUSHING TEETH

Thorough brushing of teeth, ideally 4 times a day (after meals and at bedtime), is basic to an effective oral hygiene program. A toothbrush should have a straight handle and a brush small enough to reach all areas of the mouth. An even, rounded brushing surface with soft, multi-tufted nylon bristles is best. Rounded soft bristles stimulate the gums without causing abrasion and bleeding. Older adult patients with reduced dexterity and grip may require an enlarged handle with an easier grip or an electric toothbrush. Simple ways to devise an enlarged brush handle are to pierce a soft rubber ball and push the brush handle through, or glue a short piece of plastic tubing around the handle. Patients should be advised to obtain a new toothbrush every 3 months or following a cold or streptococcal infection of the throat to minimise growth of microorganisms on the brush surfaces and subsequent reinfection.

Commercially made foam-rubber toothbrushes are useful for patients with sensitive gums. However, swabbing fails to clean teeth adequately because plaque accumulates around the base of the teeth (Huskinson and Lloyd, 2009). Foam-rubber swabs should be used in moderation. Electric toothbrushes can be used, but the nurse working in an agency setting should check for electrical hazards. All tooth surfaces should be brushed thoroughly using fluoride toothpaste. Whether a brush or sponge is used, thorough rinsing after brushing is important to remove dislodged food particles and excess toothpaste. Some people enjoy using mouthwash for its pleasant taste. Used over a long period, however, mouthwash dries mucosa (Huskinson and Lloyd, 2009).

When teaching patients about mouth care, the nurse should recommend they do not share toothbrushes with family members or drink directly from a bottle of mouthwash. Cross-contamination occurs easily. The use of disclosure tablets or drops to stain the plaque that collects at the gum line can be useful for showing patients, and particularly children, how effectively they brush.

The amount of assistance needed by the patient when brushing the teeth may vary (Skill 34-6). Many patients can perform their own oral care and should be encouraged to do so. The nurse observes the patient to be sure proper techniques are used.

SKILL 34-6 Providing oral hygiene

DELEGATION CONSIDERATIONS

Brushing teeth can be delegated to nurse assistants under the guidance of the registered nurse (Division 1).

• Instruct caregiver in proper way to provide toothbrushing.

• Instruct caregiver in how to recognise impaired integrity of oral mucosa.

EQUIPMENT

• Soft-bristled toothbrush

• Non-abrasive fluoride toothpaste

• Dental floss

• Glass with cool water

• Normal saline or fluoride mouthwash (optional; follow patient’s preference)

• Emesis basin

• Face towel

• Paper towels

• Disposable gloves

STEPS	RATIONALE
1. Wash hands and put on disposable gloves.	Reduces transmission of microorganisms.
2. Inspect integrity of lips, teeth, buccal mucosa, gums, palate and tongue (see Chapter 27).	Determines status of patient’s oral cavity and extent of need for oral hygiene.
3. Identify presence of common oral problems: a. Dental caries—chalky white discolouration of tooth or presence of brown or black discolouration b. Gingivitis—inflammation of gums c. Periodontitis—receding gum lines, inflammation, gaps between teeth d. Halitosis—bad breath e. Cheilosis—cracking of lips f. Stomatitis—inflammation of the mouth	Helps determine type of hygiene patient requires and information patient requires for self-care.
4. Remove gloves and wash hands.	Prevents spread of microorganisms.
5. Assess risk of oral hygiene problems (see Table 34-7).	Certain conditions increase likelihood of impaired oral cavity integrity and need for preventive care.
6. Determine patient’s oral hygiene practices: a. Frequency of toothbrushing and flossing b. Type of toothpaste used c. Last dental visit d. Frequency of dental visits e. Type of mouthwash or moistening preparation.	Allows nurse to identify errors in technique, deficiencies in preventive oral hygiene and patient’s level of knowledge regarding dental care. Lemon–glycerin preparations can be detrimental. Glycerin is an astringent that dries and shrinks mucous membranes and gums. Lemon exhausts salivary reflex and can erode tooth enamel. Mouthwash provides pleasant aftertaste but can dry mucosa after extended use if it has an alcohol base.
7. Assess patient’s ability to grasp and manipulate toothbrush. (For older adult, try 30 seconds of toothbrush assessment).	Determines level of assistance required. Toothbrush test useful in assessing dexterity and strength.
8. Prepare equipment at bedside.
9. Explain procedure to patient and discuss preferences regarding use of hygiene aids.	Some patients feel uncomfortable about having the nurse care for their basic needs. Patient involvement with procedure minimises anxiety.
10. Place paper towels on overbed table, and arrange other equipment within easy reach.
11. Raise bed to comfortable working position. Raise head of bed (if allowed) and lower side rail. Move patient, or help patient move closer. Side-lying position can be used.	Raising bed and positioning patient prevent nurse from straining muscles. Semi-Fowler’s position helps prevent patient from choking or aspirating.
12. Place towel over patient’s chest.	Keeps patient’s clothing clean and dry.
13. Apply gloves.	Prevents contact with microorganisms or blood in saliva.
14. Apply toothpaste to brush, holding brush over emesis basin. Pour small amount of water over toothpaste.	Moisture helps distribute toothpaste over tooth surfaces.
15. Patient may help by brushing. Hold toothbrush bristles at 45-degree angle to gum line (see illustration). Be sure tips of bristles rest against and penetrate under gum line. Brush inner and outer surfaces of upper and lower teeth by brushing from gum to crown of each tooth. Clean biting surfaces of teeth by holding top of bristles parallel with teeth and brushing gently back and forth (see illustration). Brush sides of teeth by moving bristles back and forth (see illustration).	Angle allows brush to reach all tooth surfaces and to clean under gum line where plaque and tartar accumulate. Back-and-forth motion dislodges food particles caught between teeth and along chewing surfaces.
16. Have patient hold brush at 45-degree angle and lightly brush over surface and sides of tongue. Avoid initiating gag reflex.	Microorganisms collect and grow on tongue’s surface and contribute to bad breath. Gagging may cause aspiration of toothpaste.
17. Allow patient to rinse mouth thoroughly by taking several sips of water, swishing water across all tooth surfaces and spitting into emesis basin.	Irrigation removes food particles.
18. Allow patient to gargle to rinse mouth with mouthwash as desired.	Mouthwash leaves pleasant taste in mouth.
19. Help wipe patient’s mouth.	Promotes sense of comfort.
20. Allow patient to floss (see illustration).	Reduces tartar on tooth surfaces.
Step 15 Direction for toothbrush placement. A, 45-degree angle brushes gum line. B, Parallel position brushes biting surfaces. C, Lateral position brushes sides of teeth.	Step 20 Flossing between front teeth.
21. Allow patient to rinse mouth thoroughly with cool water and spit into emesis basin. Help wipe patient’s mouth.	Irrigation removes plaque and tartar from oral cavity.
22. Help patient into comfortable position, remove emesis basin and bedside table, raise side rail and lower bed to original position.	Provides for patient comfort and safety.
23. Wipe off overbed table, discard soiled linen and paper towels in appropriate containers, remove soiled gloves and return equipment to proper place.	Proper disposal of soiled equipment prevents spread of infection.
24. Wash hands.	Reduces transmission of microorganisms.
25. Ask patient whether any area of oral cavity feels uncomfortable or irritated.	Pain indicates more chronic problem.
26. Put on gloves and inspect condition of oral cavity.	Determines effectiveness of hygiene and rinsing.
27. Ask patient to describe proper hygiene techniques.	Evaluates patient’s learning.
28. Observe patient brushing.	Evaluates patient’s ability to use correct technique.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record procedure on flow sheet. Note condition of oral cavity in nurses’ notes. • Report bleeding or presence of lesions to nurse in charge or doctor.	• Assess oral cavity at each visit to determine the effects of medications on the structures of the oral cavity.

Patients will experience conditions that threaten the integrity of oral mucosa. For example, mucosal changes associated with ageing, use of chemotherapeutic drugs or dehydration require the nurse to adapt oral hygiene approaches. More-frequent mouth care and use of anti-infective agents are examples of ways the nurse will revise approaches to meet patient needs.

FLOSSING

Flossing involves inserting waxed or unwaxed dental floss between the teeth. The seesaw 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 vigorous flossing near the gum line. If toothpaste is applied to the teeth before flossing, fluoride can come in direct contact with tooth surfaces, aiding in cavity prevention. Flossing once a day is sufficient. Because it is important to clean all teeth surfaces thoroughly, the nurse should not rush to complete flossing. Placing a mirror in front of the patient will help the nurse to demonstrate the proper method for holding the floss and cleaning between the teeth. Floss holders are available for patients who have difficulty manipulating the floss.

PATIENTS WITH SPECIAL NEEDS

Some patients require special oral hygiene methods because of their level of dependence on the nurse or the presence of oral mucosa problems. Unconscious patients are susceptible to drying of mucus-thickened salivary secretions because they are unable to eat or drink, frequently breathe through the mouth and often receive oxygen therapy. The unconscious patient also cannot swallow salivary secretions that accumulate in the mouth. These secretions often contain Gram-negative bacteria that can cause pneumonia if aspirated into the lungs. While providing hygiene to an unconscious patient, the nurse must protect the patient from choking and aspiration. The safest technique is to have two nurses provide the care. One nurse does the actual cleaning, and the other removes secretions with suction equipment.

While cleaning the oral cavity, the nurse should never use fingers to hold the patient’s mouth open. A human bite is highly contaminated. It may be necessary to perform mouth care at least every 2 hours. The nurse explains the steps of mouth care and the sensations the patient will feel. The nurse also tells the patient when the procedure is completed (Skill 34-7).

SKILL 34-7 Performing mouth care for an unconscious or debilitated client

DELEGATION CONSIDERATIONS

Brushing teeth of an unconscious or debilitated patient can be delegated to nurse assistants under the supervision of the registered nurse (RN) (Division 1).

• After RN checks for gag reflex, inform caregiver about proper way to position patients for mouth care.

• Instruct caregiver in how to use the oral suction catheter for clearing oral secretions.

• Instruct caregiver in how to recognise impaired integrity of oral mucosa.

EQUIPMENT

• Anti-infective solution (e.g. diluted hydrogen peroxide) that loosens crusts

• Small soft-bristled toothbrush

• Sponge toothette or tongue blade wrapped in single layer of gauze

• Padded tongue depressor

• Face towel

• Paper towels

• Emesis basin

• Water glass with cool water

• Water-soluble lip lubricant

• Small-bulb syringe (optional)

• Suction machine equipment (optional)

• Disposable gloves (three pairs)

• Eye shield or goggles

STEPS	RATIONALE
1. Wash hands. Put on disposable gloves and goggles or eye shield.	Reduces transmission of microorganisms. Gloves prevent contact with microorganisms in blood or saliva.
2. Test for presence of gag reflex by placing tongue blade on back half of tongue. Patients with impaired gag reflex require oral care as well. The nurse determines the type of suction apparatus needed at the bedside to protect the patient’s airway against aspiration.	Reveals whether patient is at risk of aspiration.
3. Inspect condition of oral cavity (see Chapter 27).	Determines condition of oral cavity and need for hygiene.
4. Remove gloves. Wash hands.	Prevents spread of infection.
5. Assess patient’s risk of oral hygiene problems (see Table 34-7).	Certain conditions increase likelihood of alterations in integrity of oral cavity structures and may require more frequent care.
6. Position patient on side (Sims’ position) with head turned well towards dependent side and head of bed lowered. Raise side rail.	Allows secretions to drain from mouth instead of collecting in back of pharynx. Prevents aspiration.
7. Explain procedure to patient.	Allows debilitated patient to anticipate procedure without anxiety. Unconscious patient may retain ability to hear.
8. Wash hands and apply disposable gloves.	Reduces transfer of microorganisms.
9. Place paper towels on overbed table and arrange equipment. If needed, turn on suction machine and connect tubing to suction catheter.	Prevents soiling of table top. Equipment prepared in advance ensures smooth, safe procedure.
10. Pull curtain around bed, or close room door.	Provides privacy.
11. Raise bed to its highest horizontal level; lower side rail.	Use of good body mechanics with bed in high position prevents injury.
12. Position patient close to side of bed; turn patient’s head towards mattress.	Proper positioning of head prevents aspiration.
13. Place towel under patient’s head and emesis basin under chin.	Prevents soiling of bedclothes.
14. Carefully separate upper and lower teeth with padded tongue blade by inserting blade, quickly but gently, between back molars. Insert when patient is relaxed, if possible. Do not use force. Never use fingers to separate patient’s teeth.	Prevents patient from biting down on nurse’s fingers and provides access to oral cavity.
15. Clean mouth using brush or sponge toothettes moistened with peroxide and water (see illustration). Clean chewing and inner tooth surfaces first. Clean outer tooth surfaces. Swab roof of mouth, gums and inside cheeks. Gently swab or brush tongue but avoid stimulating gag reflex (if present). Moisten clean swab or toothette with water to rinse. (Bulb syringe may also be used to rinse.) Repeat rinse several times.	Brushing action removes food particles between teeth and along chewing surfaces. Swabbing helps remove secretions and crusts from mucosa and moistens mucosa. Repeated rinsing removes peroxide that can be irritating to mucosa.
Step 15 Using toothette to clean mouth of patient with oral airway.	Step 17 Applying water-soluble moisturiser to lips.
16. Suction secretions as they accumulate, if necessary.	Suction removes secretions and fluid that can collect in posterior pharynx.
17. Apply thin layer of water-soluble jelly to lips (see illustration).	Lubricates lips to prevent drying and cracking.
18. Inform patient that procedure is completed.	Provides meaningful stimulation to unconscious or less responsive patient.
19. Remove gloves and discard in proper receptacle.	Prevents transmission of infection.
20. Reposition patient comfortably, raise side rail and return bed to original position.	Maintains patient’s comfort and safety.
21. Clean equipment and return to its proper place. Place soiled linen in proper receptacle.	Proper disposal of soiled equipment prevents spread of infection.
22. Wash hands.	Reduces transmission of microorganisms.
23. Put on gloves, and inspect oral cavity.	Determines efficacy of cleansing. Once thick secretions are removed, underlying inflammation or lesions may be revealed.
24. Ask debilitated patient if mouth feels clean.	Evaluates level of comfort.
25. Assess patient’s respirations on an ongoing basis.	Ensures early recognition of aspiration.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record procedure, including pertinent observations (e.g. presence of bleeding gums, dry mucosa, ulcerations, crusts on tongue). • Report any unusual findings to nurse in charge or doctor.	• Irrigate cavity with bulb syringe. • Mouth care should be given at least twice a day. Caregivers can get non-prescription oral care solutions (e.g. carbamide peroxide solutions) at most chemists/pharmacies. Have caregivers demonstrate positioning patient to prevent aspiration.

Patients who receive chemotherapy, radiation or nasogastric tube intubation or who have an infection of the mouth can suffer from stomatitis. Inflammation of the oral mucosa can cause oral burning, pain and change in food tolerance. Gentle brushing and flossing are important in preventing bleeding of the gums. Patients should be advised to avoid alcohol and commercial mouthwash and to stop smoking. Normal saline rinses (approximately 30 mL) on waking in the morning, after each meal and at bedtime can effectively clean the oral cavity. The rinses can be increased to every 2 hours if necessary. The doctor may order a mild oral analgesic for pain control.

Patients with diabetes mellitus often have periodontal disease. Visits to the dentist are needed every 3–4 months. All tissues should be handled gently with a minimum of trauma. Patients should learn to follow rigid cleaning schedules, at least 4 times a day.

DENTURE CARE

Patients should be encouraged to clean their dentures on a regular basis to avoid gingival infection and irritation. When patients become disabled, the nurse or family caregiver can assume responsibility for denture care (Box 34-7).

BOX 34-7 PROCEDURAL GUIDELINES FOR CLEANING DENTURES

Equipment: Soft-bristled toothbrush, denture toothbrush, emesis basin or sink, denture toothpaste, glass, 10 cm × 10 cm gauze, washcloth, denture cup, disposable gloves.

1. Clean dentures for patient during routine mouth care. Dentures need to be cleaned as often as natural teeth.

2. Fill emesis basin with tepid water. (If using sink, place washcloth in bottom of sink and fill sink with approximately 2.5 cm of water.)

3. Remove dentures. If patient is unable to do this independently, don gloves, grasp upper plate at front with thumb and index finger wrapped in gauze and pull downwards. Gently lift lower denture from jaw, and rotate one side downwards to remove from patient’s mouth. Place dentures in emesis basin or sink.

4. Apply toothpaste to denture, and brush surfaces of dentures (see illustration). Hold dentures close to water. Hold brush horizontally, and use back-and-forth motion to clean biting surfaces. Use short strokes from top of denture to biting surfaces of teeth to clean outer tooth surface. Hold brush vertically, and use short strokes to clean inner tooth surfaces. Hold brush horizontally, and use back-and-forth motion to clean undersurface of dentures.

5. Rinse dentures thoroughly in tepid water.

6. Return dentures to patient, or store in tepid water in denture cup. Keep denture cup inside bedside cabinet.

Step 4

Dentures are the patient’s personal property and need to be handled with care because, apart from being easily broken, they are expensive items. Dentures must be removed at night to give the gums a rest and prevent bacterial build-up. To prevent warping, dentures should be kept covered in water when they are not worn, and they should always be stored in an enclosed, labelled cup with the cup placed in the patient’s bedside stand. Discourage patients from removing their dentures and placing them on a serviette or tissue because they could easily be thrown away.

BRUSHING AND COMBING

Frequent brushing helps to keep hair clean and distributes oil evenly along hair shafts. Combing prevents hair from tangling. The patient should be encouraged to maintain routine hair care. However, patients with limited mobility or weakness and those who are confused require help. Patients in a hospital or extended-care facility appreciate the opportunity to have their hair brushed and combed prior to visiting hours.

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 will also affect how hair is combed and styled.

Long hair can easily become matted after a patient is confined to bed, even for a short period. When lacerations or incisions involve the scalp, blood and topical medications can also cause tangling. Frequent brushing and combing keep long hair neatly groomed. Plaiting can help to avoid repeated tangles, but plaits should be unplaited periodically and hair combed to ensure good hygiene. Plaits made too tightly can lead to discomfort and, ultimately, bald patches. The nurse obtains permission from the patient before plaiting hair.

To brush hair, the nurse parts the hair into several sections. It is easier to brush smaller sections of hair. Brushing from the scalp towards the hair ends minimises pulling. Moistening the hair with water or alcohol frees tangles for easier combing. The nurse never cuts a patient’s hair without written consent.

Patients who develop head lice (Pediculosis capitis) require special considerations in the way combing is performed. The lice are small, about the size of a sesame seed. Bright light or natural sunlight is necessary for the lice to be seen. Thorough combing is recommended and may be more effective than use of pediculicidal shampoos, which are often toxic and ineffective against resistant lice. Thick white conditioners have been demonstrated to stun lice for sufficient time for them, along with their eggs (nits), to be combed out with a nit comb (Martinez-Diaz and Mancini, 2010). Follow these steps:

When patients are being treated for head lice, the doctor will often prescribe a pediculicidal shampoo. Have patients consult with the doctor or a pharmacist carefully if they have questions about the toxicity of the shampoo.

SHAMPOOING

Frequency of shampooing depends on a person’s daily routines and the condition of the hair. The nurse should remind patients in hospitals or extended-care facilities that staying in bed, excessive perspiration, or treatments that leave blood or solutions in the hair may necessitate more-frequent shampooing. For patients at home, the nurse is challenged to find ways the patient can shampoo the hair without causing discomfort or even injury.

If the patient is able to take a shower or bath, the hair can usually be shampooed without difficulty. A shower or bath chair may be used for the mobile, weightbearing patient who becomes tired or faint. Handheld shower nozzles allow patients to easily wash hair in the bath or shower. Patients allowed to sit in a chair may choose to be shampooed in front of a sink or over a washbasin. However, bending is limited or contraindicated in certain conditions (e.g. eye surgery or neck injury). In these situations the nurse needs to teach the patient the degree of bending allowed.

If a patient is unable to sit but can be moved, the nurse may transfer the patient to a bath trolley for transport to a sink or shower equipped with a handheld nozzle. Extended-care facilities are commonly equipped with this option. Caution is again needed when the patient’s head and neck are positioned, particularly in patients with any form of head or neck injury.

In some agencies a doctor’s order is necessary for shampooing the hair of a totally dependent patient. If the patient is unable to sit in a chair or be transferred to a trolley, shampooing must be done with the patient in bed (Box 34-8). A special shampoo trough can be positioned under the patient’s head to catch water and suds. This method makes rinsing at the back of the head difficult.

BOX 34-8 PROCEDURAL GUIDELINES FOR SHAMPOOING HAIR OF BED-BOUND PATIENT

Equipment: Bath towels, washcloths, shampoo and hair conditioner (optional), water jug, plastic apron, plastic shampoo trough, washbasin, bath blanket, waterproof pad, clean comb and brush, hair dryer (optional).

1. Before washing patient’s hair, determine that there are no contraindications to this procedure. Certain medical conditions, such as head and neck injuries, spinal cord injuries and arthritis, could place the patient at risk of injury during shampooing because of positioning and manipulation of patient’s head and neck.

2. Inspect the hair and scalp before starting the procedure. This determines the presence of any conditions that may require the use of special shampoos or treatments (e.g. for dandruff or the removal of dried blood).

3. Place waterproof pad under patient’s shoulders, neck and head. Position patient supine, with head and shoulders at top edge of bed. Place plastic trough under patient’s head and washbasin at end of trough. Be sure trough spout extends beyond edge of mattress (see illustration).

Step 3

4. Place rolled towel under patient’s neck and bath towel over patient’s shoulders.

5. Brush and comb patient’s hair.

6. Obtain warm water.

7. Offer patient the option of holding face towel or washcloth over eyes.

8. Slowly pour water from jug over hair until it is completely wet (see illustration). If hair contains matted blood, don gloves and eye shield, apply peroxide to dissolve clots and then rinse hair with saline. Apply small amount of shampoo.

Step 8

9. Work up lather with both hands. Start at hairline, and work towards back of neck. Lift head slightly with one hand to wash back of head. Shampoo sides of head. Massage scalp by applying pressure with fingertips.

10. Rinse hair with water. Make sure water drains into basin. Repeat rinsing until hair is free of soap. Take care that hair at back of head is thoroughly rinsed.

11. Apply conditioner or cream rinse if requested, and rinse hair thoroughly.

12. Wrap patient’s head in bath towel. Dry patient’s face with cloth used to protect eyes. Dry off any moisture along neck or shoulders.

13. Dry patient’s hair and scalp. Use second towel if first becomes saturated.

14. Comb hair to remove tangles, and dry with dryer if desired.

15. Apply oil preparation or conditioning product to hair, if desired by patient.

16. Help patient into comfortable position, and complete styling of hair.

After rinsing, patients like having their hair styled and dried. Most healthcare centres have portable hair dryers. Dry shampoos that reduce the need to wet the patient’s hair are also available, but are not very effective.

SHAVING

Shaving facial hair can be done after the bath or shampoo. Women may prefer to shave their legs or axillae while bathing. When helping a patient, the nurse should take care to avoid cutting the patient with a razor blade. Patients prone to bleeding (e.g. those receiving anticoagulants or high doses of aspirin, or those with low platelet counts) should use an electric razor. Before using an electric razor, the nurse should check for frayed cords or other electrical hazards. Electric razors should be used on only one patient because of infection-control considerations.

When a razor blade is used for shaving, the skin must be moisturised to prevent pulling, scraping or cuts; for example, placing a warm washcloth over the male patient’s face for a few seconds, followed by application of shaving cream/gel/foam or a lathering of mild soap, decreases friction. If the patient is unable to shave, the nurse may perform the shave. To avoid causing discomfort or razor cuts, the nurse gently pulls the skin taut and uses short, firm razor strokes in the direction the hair grows (see Figure 34-8). Short downward strokes work best to remove hair over the upper lip. A patient can usually explain to the nurse the best way to move the razor across the skin.

FIGURE 34-8 Shave in the direction of hair growth. Use longer strokes on the larger areas of the face. Use short strokes around the chin and lips.

From Sorrentino SA, Remmert LN 2012 Mosby’s textbook for nursing assistants, ed 8. St Louis, Mosby.

MOUSTACHE AND BEARD CARE

Patients with moustaches or beards require daily grooming. Keeping these areas clean is important because food particles and mucus can easily collect in the hair. If the patient is unable to carry out self-care, the nurse should do so at the patient’s request. Beards can be gently combed out. A shaggy or unkempt moustache or beard can be trimmed. Shaving off a moustache or beard cannot be performed without the patient’s consent.

HAIR AND SCALP CARE

To best promote and restore hair and scalp health, patients should be instructed to keep hair clean, combed and brushed regularly. Patients may also need to know how to check for and remove parasites (see Table 34-4). The nurse should tell patients that they need to notify their primary caregiver of changes in the texture and distribution of hair, which may indicate a serious systemic problem.

BASIC EYE CARE

Cleaning the eyes simply involves washing with a clean washcloth moistened in water. Soap or shower gel may cause burning and irritation (see Skill 34-1). Direct pressure should never be applied over the eyeball because it may cause serious injury.

Unconscious patients often require more-frequent eye care. Secretions may collect along the lid margins and inner canthus when the blink reflex is absent or when the eye does not totally close. It may be necessary to place an eye patch over the involved eye to prevent corneal drying and irritation. Lubricating eye drops may be given according to the doctor’s orders.

Unconscious patients have lost the ability to protect their own corneas. Care must be taken to ensure that the eyelid covers the cornea or that the eyes are properly patched to prevent abrasion from bedclothes.

GLASSES

Glasses are made of hardened glass or plastic that is impact-resistant to prevent shattering. Nevertheless, because of the cost, the nurse should be careful when cleaning glasses and should protect them from breakage or other damage when they are not worn. Glasses should be put in a case in a drawer of the bedside table when not in use.

Cool water is sufficient for cleaning glass lenses. A soft cloth is best for drying to prevent scratching the lens; paper towels can scratch a lens. Plastic lenses in particular are scratched easily, and special cleaning solutions and drying tissues are available. Use whatever the patient’s eye-care specialist recommends.

CONTACT LENSES

A contact lens is a small, round, transparent and sometimes coloured disk that fits directly over the cornea of the eye. Contact lenses are designed specifically to correct refractive errors of the eye or abnormalities in the cornea’s shape. They are relatively easy to apply and remove.

There are three basic types of contact lenses: rigid (hard), soft and rigid gas-permeable (RGP), also known as oxygen-permeable. They differ in size, material, and amount of oxygen flow they permit to the eye’s surface. For example, rigid lenses ride on the tear-film layer of the cornea and are held in place by surface tension. The tear film moves under and over the lens during blinking to provide oxygen to the cornea. Soft lenses cover the entire cornea and a small rim of the sclera; they do not ride on the corneal tear film. The cornea receives oxygen through the soft lens, which is oxygen-permeable. RGP lenses are made of plastic that allows oxygen to pass through to the cornea. All three lenses are available as clear (untinted) or tinted.

Contact lenses are available for daily wear or extended wear and may be disposable. In terms of a patient’s hygiene care, it is important to know that all lenses must be removed periodically to prevent ocular infection and corneal ulcers or abrasions. Common infectious agents are Pseudomonas aeruginosa and staphylococci. Patient education must include a discussion of proper lens care techniques (Box 34-9). Daily-wear lenses should be removed overnight for cleaning and disinfection and should not be worn for more than 10–14 hours daily (Lemp and Bielory, 2008). Although it is recommended that extended-wear lenses be worn no longer than 6 consecutive nights without cleaning and disinfecting, there is a 30-day/night continued-wear lens available. Disposable lenses are available for daily wear and extended wear and are usually replaced every 1–2 weeks. Pain, eye-watering, discomfort and redness of the conjunctivae may be symptoms of lens overwear for any type of lens. Persistence of symptoms even after lens removal is abnormal, however, and may indicate serious ocular damage.

As contact lenses are worn, they accumulate secretions and foreign matter. This material deteriorates and then irritates the eye, causing distorted vision and risk of infection. Once removed, contact lenses should be cleaned and thoroughly disinfected. Patients should be cautioned never to use saliva, homemade saline or tap-water when cleaning lenses, as these solutions may contain microorganisms that can cause serious infection. Skill 34-8 reviews steps for contact lens removal, cleaning and reinsertion.

SKILL 34-8 Caring for the patient with contact lenses

DELEGATION CONSIDERATIONS

Caring for eye prostheses can be delegated to nurse assistants.

• Instruct caregiver in proper way to care for eye prostheses.

• Stress to caregiver that careful handling of these devices is of utmost importance to prevent physical injury to the patient and damage to the devices.

• Inform caregiver of types of findings to report (e.g. eye pain, eye socket drainage).

EQUIPMENT

• Clean lens storage container

• Bath towel

• Suction cup (optional)

• Sterile saline solution

• Sterile lens cleaning solution

• Sterile lens rinsing solution

• Sterile lens disinfectant

• Sterile enzyme solution (depends on care regimen)

• Sterile wetting solution (depends on care regimen)

• Cotton ball or cotton bud

• Emesis basin

• Disposable gloves

STEPS			RATIONALE
1. Place towel just below patient’s face.			Catches lens if one should accidentally fall from eye.
2. Stand at patient’s side. Inspect eye, or ask patient whether contact lens is in place. Unconscious or confused patients should be carefully assessed; lenses are often difficult to assess if clear (untinted).			Lenses are generally comfortable to wear, and patient may forget they are in place. Prolonged wear may cause injury to eye.
3. Ask whether patient feels any eye discomfort, and assess length of time patient normally wears lenses.			Scratched lens can cause corneal irritation and abrasion. Accumulation of dust or debris between lens and cornea causes irritation. Continuous wearing of certain types of lenses can irritate cornea.
4. Ask whether patient is able to manipulate and hold contact lens.			Determines level of assistance required in care.
5. Assess patient for any unusual visual signs/symptoms (reduced visual acuity, blurred vision, pain photophobia).			May indicate underlying visual alteration or need to change lens prescription. A reduction in visual acuity calls for referral.
6. Assess types of medications prescribed for patient: sedatives, hypnotics, muscle relaxants, antihistamines, anticholinergics and antidepressants.			Sedatives, hypnotics and muscle relaxants reduce blink reflex and thus reduce lubrication of cornea. Antihistamines, anticholinergics and antidepressants can reduce tear production.
7. After lenses are removed (see Step 11), inspect eye for signs of corneal irritation (e.g. redness, pain, swelling of eyelids and conjunctivae, discharge and excess watering). If pain persists or worsens after removal of lenses, an immediate referral to the ophthalmologist should be made.			Signs/symptoms indicate corneal irritation or abrasion. Severe pain may indicate corneal epithelium disruption or infection.
8. Discuss procedure with patient.			Patient can help plan by explaining technique that may aid removal and insertion. Patient may be anxious as nurse retracts eyelids and manipulates lenses.
9. Have patient assume supine or sitting position in bed or chair.			Provides easy access for nurse while retracting eyelids and manipulating lenses.
10. Assemble supplies at bedside.			Provides easy access to supplies.
11. Remove lenses.
	A. Soft lenses
		(1)Wash hands. Put on disposable gloves if there are cuts, scratches or dermatological lesions on nurse’s hands.	Reduces transmission of microorganisms.
		(2)Add a few drops of sterile saline solution to patient’s eye.	Lubricates eye to facilitate lens removal.
		(3)Tell patient to look straight ahead.	Eases tipping of lens during removal.
		(4)Using middle finger, retract lower eyelid.	Exposes lower edge of lens.
		(5)With pad of index finger of same hand, slide lens off cornea onto white of eye.	Positions lens for easy grasping. Use of finger pad (rather than fingernail) prevents injury to cornea and damage to lens.
		(6)Pull upper eyelid down gently with thumb of other hand, and compress lens slightly between thumb and index finger.	Causes soft lens to double up. Air enters underneath lens to release suction.
		(7)Gently pinch lens, and lift out.	Protects lens from damage. Avoid allowing lens edges to stick together. Soft lenses can be easily torn.
Step 11A(8) Ensure lenses are placed in correct storage compartments.
		(8)Clean and rinse lens. Place lens in proper storage case compartment: R for right lens and L for left lens (see illustration).	Ensures proper lens will be reinserted into correct eye. Proper storage prevents cracking or tearing.
		a. After removing one lens from case, apply one or two drops of cleaning solution to lens in palm of hand (use cleaner recommended by lens manufacturer or eye-care practitioner).	Removes tear components, including mucus, lipids and proteins that collect on lens.
		b. Rub lens gently but thoroughly on both sides for 20–30 seconds. Use index finger (soft lenses) or little finger or cotton bud soaked with cleaning solution (rigid lenses) to clean inside lens. Be careful not to turn lens wrong side out or touch or scratch lens with fingernail.	It is easier to manipulate and clean lens using fingertips. Cleans microorganisms from all surfaces.
		c. Holding lens over emesis basin, rinse thoroughly with manufacturer-recommended rinsing solution (soft lenses) or cold tap water (rigid lenses).	Removes debris and cleaning solution from lens surface. Rinsing methods and solutions differ for each type of lens.
		d. Place lens in proper storage case compartment and fill with storage solution recommended by manufacturer or eye-care practitioner.	Disinfects lens, removes residue, enhances wetability of lens and prevents scratches to lens that can be caused by a dry case.
		(9)Repeat Steps (2) to (8) for other lens. Secure cover over storage case. Label with patient’s name and room number.	Proper storage prevents damage to or loss of lenses.
		(10)Dispose of towel, remove gloves and wash hands.	Reduces transmission of infection.
	B. Rigid lenses
		(1)Wash hands, and put on gloves if needed.	Reduces transmission of microorganisms.
		(2)Be sure lens is positioned directly over cornea. If lens is not positioned directly over cornea, have patient close eyelids, place index and middle fingers of one hand on eyelid just beside the lens and beneath it and gently but firmly massage lens back into place.	Correct position of lens allows easy removal from eye.
		(3)Place index finger on outer corner of patient’s eye, and draw skin gently back towards ear.	Tightens eyelid against eyeball.
		(4)Tell patient to blink. Do not release pressure on eyelid until blink is completed.	Manoeuvre should cause lens to dislodge and pop out. Lid margins must clear top and bottom of lens until the blink.
		(5)If lens fails to pop out, gently retract eyelid beyond edges of lens. Press lower eyelid gently against lower edge of lens.	Pressure causes upper edge of lens to tip forwards.
		(6)Allow both eyelids to close slightly, and grasp lens as it rises from eye. Cup lens in hand.	Manoeuvre causes lens to slide off easily. Protects lens from breakage.
		(7)A lens suction cup can be used to remove lenses from the eyes of confused or unconscious patients. Gently apply suction cup to lens surface, and lift out.
		(8)Clean and rinse lens (see Step 11A(8)). Place lens in proper storage case compartment: R for right lens and L for left lens. Centre lens in storage case, convex side down.	The lenses may not have the same prescription. Proper storage prevents breaking, scratching, chipping and discolouration.
		(9)Repeat Steps (2) to (8) for other lens. Secure cover over storage case. Label with patient’s name and room number.	Proper storage prevents damage to or loss of lenses.
		(10)Dispose of towel, remove gloves and wash hands.	Reduces spread of infection and keeps patient’s environment neat.
		12. Insert lenses
	A. Soft lenses
		(1)Remove right lens from storage case and rinse with recommended rinsing solution; inspect lens for foreign materials, tears or other damage.
		(2)Check that lens is not inverted (inside out). Apply wetting agent (sterile saline).	Soft lens is inverted if the edge has a lip; it is in proper position if curve is even from base to rim.
		(3)Using middle or index finger of opposite hand, retract upper lid until iris is exposed.
		(4)Use middle finger of the hand holding lens to pull down lower lid.
		(5)Tell patient to look straight ahead; gently place lens directly on cornea; release lids slowly, starting with lower lid.	Ensures lens is centred, free of trapped air and comfortable.
		(6)Tell patient to close eyes slowly and roll them towards lens if not on the cornea.
		(7)Tell patient to blink a few times.
		(8)Ask patient to open eyes. Check for blurred vision or discomfort.
		(9)Repeat Steps (1) to (8) for left eye.
		(10)Discard used solution in the storage case.
		(11)Wash lens case with soap and a scrubber. Rinse case in sterile saline or a known disinfectant. Store dry.	Prevents multiplication of amoebae and bacteria.
	B. Rigid lenses
		(1)Remove right lens from storage case; attempt to lift lens straight up (see illustration).	Sliding lens out of case can cause scratches on the surface.
		(2)Rinse with recommended rinsing solution; inspect lens for foreign material or chips.	Hot water causes lens to warp.
		(3)Wet lens on both sides, using prescribed wetting solution.
		(4)Place right lens concave side up on tip of index finger of dominant hand (see illustration).	Inner surface of lens should face up so that it is applied against cornea.
		(5)Instruct patient to look straight ahead while retracting both upper and lower lids; place lens gently over centre of cornea (see illustration).
		(6)Ask patient to close eyes briefly and avoid blinking.	Helps to secure position of lens.
		(7)Ask patient to open eyes. Check for blurred vision or discomfort.
		(8)Repeat Steps (1) to (7) for left eye.
		(9)Discard used solution. See Step 12A(11) for case cleansing.
Step 12B(1) Rinsing lens lifted from storage case.			Step 12B(4) Placement of rigid lens on index finger of dominant hand.
Step 12B(5) Patient looks straight ahead as lens is placed over centre of cornea.
13. Ask patient whether lens feels comfortable after removal and reinsertion of lenses.			Determines if any debris is caught between lens and cornea. Lens should be removed if patient experiences discomfort.
14. Inspect eye (over time) for signs of ocular infection.
15. Assess patient’s visual acuity (see Chapter 27).			Determines improvement in visual perception.
16. Observe patient for signs of eye injury.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Record or report any signs/symptoms of visual alterations or corneal irritation noted during procedure.	• Patients must be taught not to wear lenses in presence of noxious or irritating vapours or fumes because these irritants can cause damage to lens surface.
• Record on nursing care plan times of lens insertion and removal if patient is going to surgery or special procedure.

ARTIFICIAL EYES

Patients with artificial eyes have had an enucleation of an entire eyeball as a result of tumour growth, severe infection or eye trauma. Some artificial eyes are permanently implanted. Others can be removed for routine cleaning. Patients with artificial eyes usually prefer to care for their own eyes. The nurse should respect the patient’s wishes and help by assembling needed equipment.

Patients may at times require assistance in prosthesis removal and cleaning. To remove an artificial eye, the nurse retracts the lower eyelid and exerts slight pressure just below the eye (Figure 34-9). This action causes the artificial eye to rise from the socket because the suction holding the eye in place has been broken. The nurse may also use a small, rubber bulb syringe or medicine dropper bulb to create a suction effect. The suction created by placing the bulb tip directly over the eye and squeezing lifts the eye from the socket.

FIGURE 34-9 Removal of prosthetic eye.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

The artificial eye is usually made of glass or plastic. Warm Normal saline cleans the prosthesis effectively. The nurse also cleans the edges of the eye socket and surrounding tissues with soft gauze moistened in saline or clean tap-water. Signs of infection should be reported immediately because bacteria can spread to the neighbouring eye, underlying sinuses or even underlying brain tissue. To reinsert the eye, retract the upper and lower lids and gently slip the eye into the socket, fitting it neatly under the upper eyelid. An artificial eye may be stored in a labelled container filled with tap-water or saline.

HEARING-AID CARE

Chapter 26 discusses the need for and use of hearing aids. Hearing aids are instruments made up of miniature parts working together as a system to amplify sound in a controlled manner. The aid receives normal low-intensity sound inputs and delivers them to the patient’s ear as louder outputs. Newer classes of hearing aids can reduce background noise interference; computer chips placed in the aids allow for fine adjustments to the specific patient’s hearing needs. Hearing aids are used by people both hard-of-hearing (slight or moderate hearing loss) and deaf (severe hearing loss).

There are three popular types of hearing aids. An in-the-canal (ITC) aid (see Figure 34-10A) is the newest, smallest and least visible and fits entirely in the ear canal. It has cosmetic appeal, is easy to manipulate and place in the ear, does not interfere with wearing glasses or using the telephone and can be worn during most types of physical exercise. However, it requires adequate ear diameter and depth for proper fit. It does not accommodate progressive hearing loss, and it requires manual dexterity to operate, insert and remove, and change batteries. Also, cerumen tends to plug this model more than the others.

FIGURE 34-10 Three common types of hearing aids. A, In-the-canal (ITC). B, In-the-ear (ITE). C, Behind-the-ear (BTE).

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

An in-the-ear (ITE, or intra-aural) aid (see Figure 34-10B) fits into the external auditory canal and allows for more fine-tuning. The auditory augmentation is more powerful and stronger, and it is therefore useful for a wider range of hearing loss than the ITC aid. It is easy to position and adjust and does not interfere with wearing glasses. It is, however, more noticeable than the ITC aid and is not recommended for people with moisture or skin problems in the ear canal.

A behind-the-ear (BTE, or post-aural) aid (see Figure 34-10C) hooks around and behind the ear and is connected by a short, clear, hollow plastic tube to an ear mould inserted into the external auditory canal. It allows for fine-tuning. It is the largest of the three aids and is useful for patients with rapidly progressive hearing loss or manual dexterity difficulties, or those who find partial ear occlusion intolerable. Disadvantages are that it is more visible and may interfere with wearing glasses and using a phone and it is more difficult to keep in place during physical exercise.

Box 34-10 reviews guidelines for the care and cleaning of a hearing aid.

MAINTAINING COMFORT

The nature of what constitutes a comfortable environment depends on the patient’s age, severity of illness and level of normal daily activity. Depending on the patient’s age and physical condition, the room temperature should be maintained between 20°C and 23°C. Infants, older adults and the acutely ill may need a warmer room. However, certain ill patients benefit from cooler room temperatures to lower the body’s metabolic demands.

A good ventilation system keeps stale air and odours from lingering in the room. The nurse must protect the acutely ill, infants and older adults from draughts by ensuring that they are adequately dressed and covered with a lightweight blanket.

Good ventilation also reduces lingering odours caused by draining wounds, vomitus, bowel movements and unemptied urinals. Nurses should always empty and rinse bed pans or urinals promptly. Thorough hygiene measures are the best way to control body or breath odours. Healthcare institutions prohibit smoking within the facility. Room deodorisers can help remove many unpleasant odours but should be used with discretion in consideration of the patient’s possible embarrassment. As well, many people who are ill seem to be more sensitive to odours. Before using room deodorisers the nurse should determine that the patient is not allergic to or sensitive to the deodoriser itself. Strong personal odours on the nurse (perfumes, lingering cigarette odours, halitosis, body odour) are offensive and disturbing to many ill patients, and nurses need to practise excellent hygiene as well.

Ill patients seem to be more sensitive to common hospital noises (e.g. intravenous pump alarms, suction apparatus or trolleys leaving a lift). Until the patient is familiar with hospital noises, the nurse should try to control the noise level. This can also help the patient gain necessary sleep. The nurse also explains the source of any unfamiliar noise to the patient and family members.

Proper lighting is necessary for everyone’s safety and comfort. A brightly lit room is usually stimulating, but a darkened room is best for rest and sleep. Room lighting can be adjusted by closing or opening curtains, regulating overbed and floor lights and closing or opening room doors. When entering a patient’s room at night, refrain from abruptly turning on an overhead light unless necessary.

ROOM EQUIPMENT

A typical hospital room contains the following basic pieces of furniture: overbed table, bedside locker, chairs, lamp and bed (Figure 34-11). Extended-care and rehabilitation facilities may have similar equipment. The overbed table rolls on wheels and can be adjusted to various heights over the bed or a chair. Usually two storage areas are under the tabletop. The table provides ideal working space for the nurse performing procedures. It also provides a surface on which to place meal trays, toiletry items and objects frequently used by the patient. The bed pan and urinal should not be placed on the overbed table. The bedside locker is used to store the patient’s personal possessions and hygiene equipment. The telephone, water jug and drinking cup are commonly found on a bedside locker.

FIGURE 34-11 Typical hospital room.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Most hospital rooms contain an armless straight-backed chair and an upholstered lounge chair with arms. The lounge chair is used by the patient and visitors and is usually placed at the foot of the bed or beside it. Straight-backed chairs are convenient when temporarily transferring the patient from the bed, such as during bedmaking.

Each room usually has an overbed light and a floor or table lamp. Movable lights that extend over the bed from the wall should be positioned for easy reach but moved aside when not in use. Gooseneck or special examination lights are portable standing lamps used to provide extra light during bedside procedures.

Other equipment usually found in a patient’s room includes a call light, a television set, a blood-pressure gauge, oxygen and vacuum wall outlets and personal-care items. Special equipment designed for comfort or positioning patients includes foot boots (Figure 34-12) and footboards, special mattresses (see Chapter 30) and bed boards.

FIGURE 34-12 A, Foot boot. B, Foot boot with lower leg extension.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

BEDS

Seriously ill patients may remain in bed for a long time. Because a bed is the piece of equipment used most by a hospitalised patient, it should be designed for comfort, safety and adaptability for changing positions.

The typical hospital bed has a firm mattress on a metal frame that can be raised and lowered horizontally. More and more hospitals are converting the standard hospital bed to one in which the mattress surface can be electronically adjusted for patient comfort. Different bed positions are used to promote patient comfort, minimise symptoms, promote lung expansion and improve access during certain procedures (Table 34-8).

TABLE 34-8 COMMON BED POSITIONS

POSITION	DESCRIPTION	USES
Fowler ’s	Head of bed raised to angle of 45 degrees or more; semi-sitting position; foot of bed may also be raised at knee	Preferred while patient eats Used during nasogastric tube insertion and nasotracheal suction Promotes lung expansion
Semi-Fowler’s	Head of bed raised approximately 30 degrees; inclination less than Fowler’s position; foot of bed may also be raised at knee	Promotes lung expansion Used when patients receive gastric feedings to reduce regurgitation and risk of aspiration
Trendelenburg’s	Entire bed frame tilted with head of bed down	Used for postural drainage Facilitates venous return in patients with poor peripheral perfusion
Reverse Trendelenburg’s	Entire bed frame tilted with foot of bed down	Used infrequently Promotes gastric emptying Prevents oesophageal reflux
Flat	Entire bed frame horizontally parallel with floor	Used for patients with vertebral injuries and in cervical traction Used for patients who are hypotensive Generally preferred by patients for sleeping

The position of a bed is usually changed by electrical controls incorporated into the patient’s call light and in a panel on the side or foot of the bed. It is important for the nurse to become familiar with use of the bed controls. Ease in raising and lowering a bed and in changing position of the head and foot eliminates undue musculoskeletal strain on the nurse. Nurses should instruct patients in the proper use of controls and caution them against raising the bed to a position that might cause harm.

Beds contain safety features such as locks on the wheels or castors. Wheels should be locked when the bed is stationary to prevent accidental movement. Side rails usually protect patients from accidental falls, but they may actually cause a confused patient to fall (as the patient tries to climb over them). The headboard can be removed from most beds—this is important when the medical team must have easy access to the head, such as during cardiopulmonary resuscitation.

Bedmaking

A patient’s bed should be kept clean and comfortable. This requires frequent inspections to be sure linen is clean, dry and free of wrinkles. When patients are diaphoretic, have draining wounds or are incontinent, the nurse should check often for soiled bedclothes, and change them accordingly.

The nurse usually makes a bed in the morning after the patient’s bath or while the patient is showering, sitting in a chair eating or out of the room for procedures or tests. Throughout the day the nurse straightens bedclothes that become loose or wrinkled. The bedclothes should be checked for food particles after meals and for wetness or soiling. Bedclothes that are soiled or wet should be changed.

When changing bedclothes, the nurse follows principles of medical asepsis by keeping soiled sheets away from the uniform (Figure 34-13). Soiled linen is placed in special linen bags before discarding in a dirty linen basket. To avoid air currents, which can spread microorganisms, the nurse never fans linen. To avoid transmitting infection, the nurse should not place soiled linen on the floor. If clean linen touches the floor, it is immediately discarded.

FIGURE 34-13 Holding sheets away from the uniform prevents contact with microorganisms.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 7. St Louis, Mosby.

During bedmaking, the nurse must use proper body mechanics (Chapter 33). The bed should always be raised to the level of the groin of the nurse, or if two nurses are making the bed to the level of the groin of the shorter of the two nurses, before changing linen so that the nurse does not have to bend or stretch over the mattress. The nurse moves back and forth to opposite sides of the bed when applying new linen. Body mechanics also become important when turning or repositioning the patient in bed.

When patients are confined to bed, the nurse organises bedmaking activities to conserve time and energy (Skill 34-9). The patient’s privacy, comfort and safety are all-important when making a bed. Using side rails, keeping call lights within the patient’s reach and maintaining the proper bed position help promote comfort and safety. After making a bed, the nurse always returns it to the lowest horizontal position to prevent accidental falls should the patient get in and out of the bed alone.

SKILL 34-9 Making an occupied bed

DELEGATION CONSIDERATIONS

Making an occupied bed can be undertaken by nurse assistants under the guidance of the registered nurse (Division 1).

• Inform caregiver how to properly position patients during occupied bedmaking procedure.

• Tell caregiver what to do if wound drainage, dressing material, drainage tubes or intravenous (IV) tubing becomes dislodged or is found in the bedclothes.

• Instruct caregiver on what to do if patient becomes tired.

• Stress safety procedures, e.g. location of call system for easy access in the event that staff assistance is needed.

• Instruct caregiver to report any changes in patient’s level of consciousness, breathing patterns, level of pain or dizziness.

EQUIPMENT

• Dirty linen bag(s)

• Mattress pad (needs to be changed only when soiled)

• Bottom sheet (flat or fitted)

• Drawsheet

• Top sheet

• Blanket

• Bedspread

• Waterproof pads and/or bath blankets (optional)

• Pillowcases

• Bedside chair or table

• Disposable gloves (optional)

STEPS		RATIONALE
1. Determine whether patient is incontinent or has excess drainage on bedclothes.		Determines need for protective waterproof pads or extra bath blankets on bed.
2. Check chart for orders or specific precautions for movement and positioning.		Ensures safety and use of proper body mechanics for nurse and patient.
3. Explain procedure to patient, noting that patient will be asked to turn on side to roll over bedclothes.		Minimises anxiety and promotes cooperation.
4. Prepare needed equipment and supplies.
5. Wash hands.		Minimises spread of infection.
6. Assemble and arrange equipment on bedside chair or table. Remove unnecessary equipment.		Provides for smooth procedure and ensures comfort.
7. Draw room curtain around bed or close door.		Maintains privacy, thus promoting emotional and physical comfort.
8. Lower side rail on near side of bed. Remove call light.		Provides easy access to bed and bedclothes.
9. Adjust bed height to comfortable working position.		Minimises strain on nurse’s back. It is easier to remove and apply bedclothes evenly to bed in flat position.
10. Loosen top sheet at foot of bed.		Makes bedclothes easier to remove.
11. Remove bedspread and blanket separately by folding them into squares and placing them in dirty linen bag (if not to be reused). Do not allow bedclothes to contact uniform. Do not fan or shake bedclothes.		Reduces transmission of microorganisms.
12. If blanket and bedspread are to be reused, fold by bringing top and bottom edges together. Fold into neat squares and place over back of chair.		Facilitates replacement and prevents wrinkling.
13. Cover patient with bath blanket in following manner. Unfold bath blanket over top sheet. Ask patient to hold top edge of bath blanket. If patient is unable to help, tuck top of bath blanket under shoulder. Grasp top sheet under bath blanket at patient’s shoulders, and bring down to foot of bed. Remove, and discard it into linen bag. Optional: Patient may be covered with loosened top sheet if bath blanket is not available.		Bath blanket provides warmth and keeps body parts covered during bedclothes removal.
14. With help from another nurse, slide mattress towards head of bed.		If mattress slides towards foot of bed when head of bed is raised, it is difficult to tuck bedclothes in and is uncomfortable for patient.
15. Position patient on their side on far side of bed, facing away. Adjust pillow under head. Be sure furthest side rail is up.		Provides space for placement of clean linen. Side rail ensures safety.
16. Loosen bottom sheet, moving from head to foot of bed.
17. Fanfold first drawsheet and then bottom sheet towards patient (see illustration). Tuck edges of linen just under buttocks, back and shoulders. Do not fanfold mattress pad if it is to be reused.		Provides maximum work space for placing clean linen. Later, when patient turns to other side, soiled linen can easily be removed.
18. Wipe off moisture on mattress with towel and appropriate disinfectant.		Reduces transmission of microorganisms.
19. Apply clean linen to exposed half of bed:
	a. Place clean mattress pad on bed by folding it lengthwise with centre crease in middle of bed. Fanfold top layer over mattress. (If pad is reused, simply smooth out wrinkles.)	Applying linen over bed in successive layers minimises energy and time nurse uses in bedmaking.
	b. Unfold bottom sheet lengthwise so centre crease is situated lengthwise along centre of bed. Fanfold sheet’s top layer towards centre of bed alongside patient (see illustration). Smooth bottom layer of sheet over mattress, and bring edge over near side. Allow sheet’s edge to hang about 25 cm over mattress edge. Lower hem of bottom sheet should lie seam down and even with bottom edge of mattress.	Proper positioning of linen on one side ensures that adequate linen will be available to cover opposite side of bed. Keeping seam edges down eliminates irritation to patient’s skin.
Step 17 Fanfold used linen and tuck under patient.		Step 19b Fanfold clean linen towards centre of bed.
20. Mitre bottom sheet at head of bed: a. Face head of bed diagonally. Place hand away from head of bed under top corner of mattress, near mattress edge, and lift. b. With other hand, tuck top edge of bottom sheet smoothly under mattress so side edges of sheet above and below mattress would meet if brought together. c. Face side of bed, and pick up top edge of sheet at approximately 45 cm down from top of mattress (see illustration). d. Lift sheet, and lay it on top of mattress to form neat triangular fold, with lower base of triangle even with mattress side edge (see illustration). e. Tuck lower edge of sheet, which is hanging free below mattress, under mattress (see illustration). Tuck with palms down without pulling triangular fold. f. Hold part of sheet covering side edge of mattress in place with one hand. With other hand, pick up top of triangular linen fold, and bring it down over side of mattress. Tuck this portion of sheet under mattress (see illustrations).		Mitred corner cannot be loosened easily, even if patient moves about frequently in bed.
Step 20c Pick up top edge of sheet.		Step 20d Lay sheet over bed to form triangular fold.
Step 20e Tuck free end of sheet under.
Step 20f Bring triangular fold neatly down over side of mattress and tuck in.
21. Tuck remaining part of sheet under mattress, moving towards foot of bed. Keep sheet smooth.		Folds of sheet are a source of irritation.
22. Optional: Open drawsheet so it unfolds in half. Lay centre fold along middle of bed lengthwise, and position sheet so it will be under buttocks and torso (see illustration). Fanfold top layer towards patient with edge alongside back. Smooth bottom layer out over mattress and tuck excess edge under mattress (keep palms down).		Drawsheet is used to lift and reposition patient. Placement distributes most of bodyweight over sheet.
23. Place waterproof pad over drawsheet with centre fold against patient’s side. Fanfold far half towards patient.		Used to protect bedclothes from soiling.
24. Raise side rail on working side, and go to other side.		Maintains safety.
25. Lower side rail. Help patient to roll slowly onto other side, over folds of linen (see illustration).		Exposes opposite side of bed for removal of soiled linen and placement of clean linen.
Step 22 Positioning drawsheet.		Step 25 Assisting patient to roll onto other side to expose folds of clean linen.
26. Loosen edge of soiled linen from underneath mattress.		Makes linen easier to remove.
27. Without allowing dirty linen to touch uniform, remove soiled linen by folding it into a bundle or square, with soiled side turned in. Discard it into linen bag.		Reduces transmission of microorganisms.
28. Spread clean, fanfolded linen smoothly over edge of mattress from head to foot of bed (see illustration).		Smooth linen will not irritate patient’s skin.
29. Help patient roll back into supine position. Reposition pillow.		Patient’s comfort is maintained.
30. Mitre corner of bottom sheet at foot of bed (see Step 20). When tucking corner, be sure sheet is smooth and free of wrinkles.		Wrinkles and folds can cause mechanical irritation to skin.
31. Facing side of bed, grasp remaining edge of bottom sheet, keep back straight, and pull as excess linen is tucked under mattress. Proceed from head to foot of bed. (Avoid lifting mattress during tucking to ensure fit.) Mitre remaining corners, keeping bottom sheet smooth.		Proper use of body mechanics while tucking linen prevents injury to nurse.
32. Smooth fanfolded drawsheet over bottom sheet. Grasp edge of sheet with palms down, lean back and tuck sheet under mattress. Tuck from middle to top and to bottom.		Tucking first at top or bottom may pull sheet sideways, causing poor fit.
33. Place top sheet over patient with centre fold lengthwise down middle of bed. Open sheet from head to foot, and unfold it over patient (see illustration).		Sheet should be equally distributed over bed by correctly positioning centre fold.
Step 28 Spreading out folds of clean linen over other half of bed.		Step 33 Unfolding top sheet over patient.
34. Without allowing dirty linen to touch uniform, ask patient to hold clean top sheet, or tuck sheet around shoulders. Remove bath blanket, and discard it into linen bag.		Sheet prevents exposure of body parts. Having patient hold sheet encourages participation in care.
35. Place blanket on bed, unfolding it so that crease runs lengthwise along middle of bed. Unfold blanket to cover patient. Top edge should be parallel with edge of top sheet and 15–20 cm down from top sheet’s edge.		Blanket should be placed to cover patient completely and provide adequate warmth.
36. Place bedspread over bed according to Step 35. Be sure top edge extends about 2.5 cm above blanket’s edge. Tuck top edge over and under top edge of blanket.		Bedspread gives bed neat appearance and provides extra warmth.
37. Make cuff by turning edge of top sheet down over top edge of blanket and bedspread.		Smooth cuff protects patient’s face from rubbing against blanket or bedspread.
38. Standing on one side at foot of bed, lift mattress corner slightly with one hand, and tuck top bedclothes under mattress. Top sheet and blanket are tucked under together. Be sure they are loose enough to allow for movement of patient’s feet. Horizontal toe pleat may be made (see illustration).		Tucking all top bedclothes together gives neat appearance. Pressure sores can develop on patient’s toes and heels from feet rubbing between tight-fitting bed sheets.
		Step 38 Optional toe pleat.
39. Make modified mitred corner with top sheet, blanket and bedspread: a. Pick up side edge of top sheet, blanket and bedspread approximately 45 cm up from foot of mattress. Lift to form triangular fold, and lay it on bed. b. Tuck lower edge of sheet, which is hanging free below mattress, under mattress. Do not pull triangular fold. c. Pick up triangular fold, and bring it down over mattress while holding bedclothes in place along side of mattress. Do not tuck tip of triangle.		Modified mitred corner secures top bedclothes but keeps an even edge of blanket and top sheet draped over mattress.
40. Raise side rail. Make other side of bed; spread top sheet, blanket and bedspread out evenly; fold top edge of bedspread over blanket, and make cuff with top sheet (see Step 37); make modified mitred corner at foot of bed (see Step 39).		Side rail protects patient from accidental falls.
41. Change pillowcase: a. Have patient raise head. While supporting neck with one hand, remove pillow. b. Remove soiled case and discard into linen bag. c. Grasp clean pillowcase at centre of closed end. Gather case, turning it inside out over hand holding it. With same hand, pick up middle of one end of pillow. Pull pillowcase down over pillow with other hand and be sure pillow corners fit evenly in corners of pillowcase.		Prevents injury during flexion and extension of neck. Method makes it easy to slide pillowcase over pillow. Poorly fitting case constricts fluffing and expansion of pillow.
42. Support patient’s head under neck, and place pillow under head.		Prevents hyperextension of neck muscles.
43. Place call light within patient’s reach; return bed to comfortable position.		Ensures safety and comfort.
44. Open room curtains. Rearrange furniture. Place personal items within easy reach on overbed table or bedside stand. Return bed to comfortable height.		Promotes sense of wellbeing.
45. Place dirty linen in main dirty linen bag or chute; wash hands.		Prevents transmission of microorganisms.

RECORDING AND REPORTING	HOME CARE CONSIDERATIONS
• Bedmaking need not be documented. Record the patient’s vital signs and symptoms only if there are changes.	• Assess the primary caregiver’s ability to safely make an occupied bed. • Assess the home laundry facilities to plan for the frequency with which the linen can be laundered. • Assess the amount of linen in the home for the anticipated amount of linen changes needed.

When possible, the nurse should make the bed while it is unoccupied (Box 34-11). The nurse uses judgment in choosing the best time to have the patient sit up in a chair while the bed is made. When making an unoccupied bed, the nurse follows the same basic principles as for when the bed is occupied.

BOX 34-11 PROCEDURAL GUIDELINES FOR MAKING AN UNOCCUPIED BED

Equipment: Linen bag, mattress pad (change only when soiled), bottom sheet (flat or fitted), drawsheet (optional), top sheet, blanket, bedspread, waterproof pads (optional), pillowcases, bedside chair or table, disposable gloves (if linen is soiled), washcloth and antiseptic cleanser.

1. Determine whether patient has been incontinent or whether excess drainage is on sheets. Gloves will be necessary.

2. Assess activity orders or restrictions in mobility in planning whether patient can get out of bed for procedure. Assist to bedside chair or recliner.

3. Lower side rails on both sides of bed and raise bed to comfortable working position.

4. Remove soiled linen and place in laundry bag. Avoid shaking or fanning linen.

5. Reposition mattress and wipe off any moisture using a washcloth moistened in antiseptic solution. Dry thoroughly.

6. Apply all bottom linen on one side of bed before moving to opposite side.

7. Be sure fitted sheet is placed smoothly over mattress. To apply a flat unfitted sheet, allow about 25 cm to hang over mattress edge. Lower hem of sheet should lie seam down, even with bottom edge of mattress. Pull remaining top portion of sheet over top edge of mattress.

8. While standing at head of bed, mitre top corner of bottom sheet (see Skill 33-9, Step 20).

9. Tuck remaining portion of unfitted sheet under mattress.

10. Optional: Apply drawsheet, laying centre fold along middle of bed lengthwise. Smooth drawsheet over mattress and tuck excess edge under mattress, keeping palms down.

11. Move to opposite side of bed and spread bottom sheet smoothly over edge of mattress from head to foot of bed.

12. Apply fitted sheet smoothly over each mattress corner. For an unfitted sheet, mitre top corner of bottom sheet, making sure corner is taut.

13. Grasp remaining edge of unfitted bottom sheet and tuck tightly under mattress while moving from head to foot of bed. Smooth folded drawsheet over bottom sheet and tuck under mattress, first at middle, then at top and then at bottom.

14. If needed, apply waterproof pad over bottom sheet or drawsheet.

15. Place top sheet over bed with vertical centre fold lengthwise down middle of bed. Open sheet out from head to foot, being sure top edge of sheet is even with top edge of mattress.

16. Make horizontal toe pleat: stand at foot of bed and fanfold sheet 5–10 cm across bed. Pull sheet up from bottom to make fold approximately 15 cm from bottom edge of mattress (see Skill 34-9, Step 38).

17. Tuck in remaining part of sheet under foot of mattress. Then place blanket over bed with top edge parallel to top edge of sheet and 15–20 cm down from edge of sheet. (Optional: Place additional blanket over bed.)

18. Make cuff by turning edge of top sheet down over top edge of blanket and bedspread.

19. Standing on one side at foot of bed, lift mattress corner slightly with one hand, and with other hand tuck top sheet, blanket and bedspread under mattress. Be sure toe pleats are not pulled out.

20. Make modified mitred corner with top sheet, blanket and bedspread. After triangular fold is made, do not tuck tip of triangle (see illustration).

21. Go to other side of bed. Spread sheet, blanket and bedspread out evenly. Make cuff with top sheet and blanket. Make modified corner at foot of bed.

22. Apply clean pillowcase.

23. Place call light within patient’s reach on bed rail or pillow and return bed to height allowing for patient transfer. Help patient into bed.

24. Arrange patient’s room. Remove and discard supplies. Wash hands.

An unoccupied bed can be open or closed. In an open bed, the top covers are folded back so that a patient can easily get into bed. In a closed bed, the top edges of the top sheet, blanket and bedspread are drawn up to the head of the mattress and under the pillows. A closed bed is prepared in a hospital room before a new patient is admitted to that room. A surgical, recovery or postoperative bed is a modified version of the open bed. The top bedclothes are arranged for easy transfer of the patient from a stretcher to the bed. The top sheets and bedspread are not tucked in or mitred at the corners. Instead, the top sheets are folded to one side or fanfolded to the bottom third of the bed (Figure 33-14). This makes it easier to transfer the patient into the bed.

Linen

In any healthcare agency, it is important to have an adequate supply of linen to care appropriately for patients. Many agencies have what are called ‘nurse servers’ either within or just outside a patient’s room, where a daily supply of linen is stored. Because of the importance of cost control in healthcare, it is important not to bring excess linen into a patient’s room, because even if it is unused, it must be discarded for washing. This can increase an agency’s costs. Excess linen lying around a patient’s room creates clutter and obstacles for patient care activities.

Before bedmaking, it is important to collect the necessary bedclothes and the patient’s personal items. In this way the nurse will have all equipment accessible to prepare the bed and room. Linen is pressed and folded to prevent the spread of microorganisms and to make bedmaking easier. When fitted sheets are not available, flat sheets are usually pressed with a centre crease to be placed down the centre of the bed. The sheets unfold easily to the sides, with creases often fitting over the mattress edge. A complete bedclothes change is not always necessary. The nurse may reuse the mattress pad, sheet, blanket and bedspread for the same patient if they are not wet or soiled.

FIGURE 34-14 Surgical or recovery bed.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 7. St Louis, Mosby.

Linen must be disposed of correctly to minimise the spread of infection (Chapter 29). Agency policies provide guidelines for the proper way to bag and dispose of soiled linen. When a patient is discharged, all the bedclothes are sent to the laundry, the mattress and bed are cleaned by housekeeping staff and fresh bedclothes are put on the bed.

Patient care

Evaluation of hygiene measures occurs both during and after performance of each particular skill. For example, as the nurse bathes a patient, close inspection of the skin reveals whether drainage or other soiling is effectively removed from the skin’s surface. Once the bath is complete, the nurse asks whether the patient’s comfort and relaxation have improved. When evaluating the effectiveness of hygiene measures, the nurse observes for changes in the patient’s behaviour. Does the patient assume a more relaxed position? Is the patient free of body odour? Is the patient able to fall asleep? Does the patient’s facial expression convey a sense of comfort?

Often it takes time for hygiene care to result in an improvement in the patient’s condition. The presence of oral lesions, a scalp infestation or skin excoriation will often require repeated measures and a combination of nursing interventions. The nurse will evaluate for improvement in the patient’s condition over time and determine whether existing therapies are effective.

Throughout evaluation, the nurse considers the goals of care and gauges whether expected outcomes are achieved. A critical-thinking approach ensures that the nurse considers all factors when evaluating the patient’s care (Figure 34-15). The nurse’s knowledge base and experience provide important perspectives when the nurse analyses observations made about a patient. For example, if the nurse has seen how dehydration of the oral mucosa clears with repeated hygiene, this helps in recognising when another patient’s progress is slow. The standards for evaluation are the expected outcomes established in the planning stage of the patient’s care. If outcomes are not met, the care plan may need to be revised. The nurse continues to apply critical-thinking attitudes when considering all evaluation findings.

FIGURE 34-15 Critical thinking model for the evaluation phase.

Patient expectations

The final part of the evaluation considers whether the patient’s expectations were met through hygiene care. The nurse might ask: ‘How do you feel since your bath and massage?’, ‘Are there ways you feel we can do a better job with your foot care?’, ‘What further measures do you think are necessary to keep your mouth clean and refreshed?’

The patient’s expectations are important guidelines in determining patient satisfaction. The nurse must feel comfortable discussing the patient’s concerns and expectations. A caring approach can help facilitate discussion of these issues.