I have spent practically my entire life caring for patients. I began my career as a nursing assistant in an extended care facility. That was a tough job. I spent most of my day either getting patients clean, or keeping patients clean. After attending nursing school, I went to work in a hospital. That was a tough job too. I spent most of my day either getting patients clean, or keeping patients clean. It's 25 years later, and I just retired from my practice as an orthopaedic nurse clinician. It was my job to redesign nursing care to manage expanded duties with fewer caregivers. You know, health care reform, where we are expected to do more with less. It was a really tough job. Still, the nursing staff spent most of their day either getting patients clean, or keeping patients clean. What is this preoccupation with patient washing and how did it become such an important focus of clinical nursing?
The daily soap and water bed bath has been identified as a practice firmly implanted in the curriculum presented to nursing students (Walsh & Ford, 1989) as a procedure carried out with an almost religious regularity, often more than once a day. Florence Nightingale considered the failure to wash a patient as interference with the natural process of health and tantamount to administering poison (Nightingale, 1859). In a study of patient and nurse attitudes toward the bath, nurses strongly denied that they had more important tasks than bathing patients; however, the importance attributed to bathing by nurses was not matched by patient response (Webster, Thompson, Bowman, & Sutton, 1988).
Both nursing and medical literature cite the frequency of bathing and the use of non-therapeutic soap to be a major risk factor putting the elderly at risk for dry skin (Gioella & Bevil, 1985). Measures recommended to limit dry skin and itching associated with the aging process include limiting bathing to that necessary for hygienic needs. The Clinical Practice Guideline, #3, published by the Agency for Health Care Policy and Research (AHCPR) titled "Pressure Ulcer in Adults: Prediction and Prevention" states that "Skin should be cleansed at time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or patient preference." However, who defines "routine intervals" and who defines "need"?
Melia (1987) studied 40 student nurses at different stages of their education. A strong theme of "getting the work done" emerged. Individualization of care to meet patients' needs was stressed in the academic setting. However, in practice, a "good" routine was perceived when completed tasks occurred at certain times during the day (Jones, 1995). Complete bed bath, partial bed bath, tub bath, and shower are among the bathing methods used in health care facilities. Barsevick and Llewellyn (1982) consider that the choice of bathing procedure is rarely based on therapeutic value to the patient, but tends to depend on the amount of time the nurse has available and the patient's ability to care for him or herself (Webster, Thompson, Bowman, & Sutton, 1988). In the long-term care setting, the standard of care is that most, if not all, nursing home residents are bathed in the shower or tub on routinely assigned days (Rader, 1994). Little regard or accommodation is given to the patient, who, for whatever reason, does not wish to bathe on schedule.
Do patients really need a daily bath? Bathing is often done to satisfy the nursing staff's sense of responsibility, need to complete tasks or desire to have a resident "look good" (Rader, 1994). We know that daily bathing is based more on cultural norms than on clinical requirements. North Americans place a high value on cleanliness and consider bathing incomplete without the use of multiple cleansers and deodorants. Other cultures, however, consider weekly bathing sufficient and feel no need to mask normal body odors with perfumed products. Washing is important, although the daily routine cannot be legitimately defended (Jones, 1995). If one bath a day is difficult to defend, two can certainly be considered excessive. But in some hospitals this is the practice. With the advent of 12-hour shifts, AM care and PM care are often done by the same caregiver who will often duplicate the morning bath at bedtime. Subjecting elderly patients to soap and water several times a day in a hospital, when they are only used to a wash down once or twice a week at home, can cause them to develop asteototic eczema, with its dryness, cracking and occasional excoriation (Pembroke, 1983). Preliminary research suggests some association between dry, flaky, or scaling skin and an increased incidence of pressure ulcers (Guralnik, Harris, White, Cornoni-Huntley, 1988).
MAINTAINING HEALTHY SKIN
As we age, there is a reduction in all the processes that keep our skin moist. There is a loss of blood supply to the skin which, in turn, is thought to contribute to decreased sebaceous secretions. Sebaceous glands secrete sebum through the hair follicle to the skin surface. Sebum acts as an emollient trapping moisture into the skin. A decrease in sebum results in dry skin and hair. The primary objective when caring for elderly skin is to maintain hydration. Moisture is critical for wound healing as well as for maintenance of healthy intact skin. Moist skin is stronger and heals more quickly than dry skin. It is important to understand how skin is hydrated when making a bathing decision. Keratinocytes constitute 95% of the epidermis and are capable of absorbing huge amounts of water. This is why you look like a prune after a long soak in the tub, your keratinocytes are waterlogged. The ideal time to moisturize is immediately after bathing when as much of this water as possible can be trapped in the skin. Emollient creams and lotions, especially when applied to skin that is still moist, prevent evaporation and increase the moisture of the stratum corneum, thereby helping to protect the underlying layer (Porthe & Kapke, 1983). Bath oil should not be added to bath water until 15 to 20 minutes after immersion. Otherwise, the oil only serves to coat the individual, effectively preventing an adequate amount of water from hydrating the skin (Eaglstein, McKay, & Pariser, 1994). Any technique or product that causes moisture loss should be avoided. Powder absorbs oil and is a hazardous inhalant. Corn starch should also be avoided because in the presence of moisture it breaks down into glucose supporting the growth of organisms.
SAY NOPE TO SOAP
I often hear..."There's nothing like good old-fashioned soap and water!" Soap is alkaline with a pH as high as 10 to 11. The pH of human skin is 4.5 to 5.5. This acidity is maintained by a protective film called the acid mantle which is an effective antimicrobial barrier. Soap can alter the pH of skin, especially if not well rinsed, thus impairing this natural defense mechanism. Soap also emulsifies fats which remove lipids from skin. Lipids are natural moisturizers that help bind water. Washing with soap can also strip the skin of naturally occurring oils resulting in dry, flaky skin. It has been estimated that 59% to 75% of the elderly have preexisting pruritic skin conditions (Eliopoulos, 1988). Washing with soap only intensifies the problem.
Selection of skin cleansers and topicals should be made on the basis of ingrethents and how they affect skin physiology. Avoid harsh soaps, choosing mild liquid surfactant based cleansers instead. Surfactants emulsify waste and gently cleanse skin. The pH of surfactant cleansers are generally close to the pH of skin and will not strip oils that prevent dryness. Avoid products containing alcohol and select those that contain emollients. Emollients should be selected on the basis of effectiveness rather than cost. Expensive does not necessarily mean good. Vegetable and mineral oil are inexpensive natural ingrethents that protect patients against allergic dematitides that commercial lotions may provoke.
Patient bathing using reusable plastic basins is the standard of care in most hospitals. In the mid-1960s plastic reusables replaced the aluminum version of basins, bedpans, etc. An increased incidence of infections has forced hospital administrators to rethink plastic reusable patient care kits (Panting, 1994). We all remember learning how to perform the bed bath in "fundamentals of nursing." I vividly remember Ms. Palmer's skillful and lengthy demonstration on how to perform a basin bath. What struck me was how different her technique was from what I saw being done in the clinical area. The basin bath, if performed correctly, is time-consuming and labor-intensive. Because we have so many patients to care for, the patient is sacrificed to the routine of the organization. Inevitably, we are forced to develop shortcuts that can lead to problems. Soapy water isn't changed enough and leaves a residue behind, resulting in dry, flaky and sometimes irritated skin. The bath water becomes a broth of bacteria that can actually leave a patient more heavily colonized with organisms than before the bath.
Tub Baths and Showers
Tub baths or showers are rarely an option in hospitals because patients are usually too sick and staffing is inadequate; however these techniques are the standard of care in most nursing homes. Cognitively impaired patients are often showered at 2 or 3 AM, in an attempt to divide the work load among shifts. Consider the following excerpt from an article written by Joanne Rader:
It struck me that from the perspective of a person with apraxia, agnosia, aphasia, and limited insight the standard nursing home bathing experience may be perceived as a physical assault. A person the resident does not recognize comes into her room, wakens her, says something she does not understand, drags her out of bed, and takes off her clothes. The resident is moved down a public corridor on something that resembles a toilet seat, covered only with a thin sheet so that her private parts are exposed to the breeze. Calls for help are ignored or greeted with "Good morning." Then she is taken to a strange, cold room that looks like a car wash, the sheet is ripped off, and she is sprayed in the face with cold and then scalding water. Continued calls for help go unheeded. Her most private parts are touched by a stranger. In another context this would be assault, yet it remains the standard of care in most settings (Rader, 1994).
Weekly tub bathing is hazardous for both nurse and patient. The rigors of assisting elderly patients in and out of tubs are a leading cause of disability for nurses. Tub bathing also removes natural protective oils from patients' skin. Some studies suggest that drains and tubs harbor organisms that could be potential pathogens for the immunocompromised elderly patients. Tap water itself has become suspect. "Although the Centers for Disease Control and Prevention has not issued formal recommendations regarding the use of tap water for bathing patients, it seems advisable that patients with fresh surgical wounds, mediastinal tubes, or chest tubes should not be routinely bathed with tap water...(which) can easily contaminate a wound site when even extremely small amounts of water are used and the surgical wound is intentionally avoided." (Lowry & Tompkins, 1993). We're spending an inordinate amount of our valuable time performing a task that can be stressful and harmful to patients
Figure. The Bag Baffi.™
I have experimented with a variety of bathing techniques and products. Knowing that elderly skin suffers from daily bathing, the initial experiment was to bathe patients every other day. In spite of patient and nurse education, this modification of "the routine" was unsuccessful. Some nurses felt they weren't doing a "good job" if they didn't bathe every patient every day. Cultural norms and consumer expectations led some patients and families to feel they weren't getting what they were paying for. The ritual of daily bathing of the hospitalized patient was so deeply rooted in hospital "routine" that both nurse and patient felt uncomfortable without it.
The Bag Bath™ (Figure) was developed to satisfy the cultural requirement of daily bathing without the harmful side effects of traditional bathing. It is a pre-packaged disposable patient bathing system that cleanses while it hydrates. Eight premoistened cloths are used to cleanse separate parts of the body to reduce or eliminate cross contamination of non-resident bacteria. The cleansing solution is a surfactant base with tissue-friendly emollients that help maintain moisture in skin. This solution quickly evaporates off the skin making towel drying unnecessary. The result is a fast, efficient bathing system that satisfies nurse and patient requirements for hygiene without endangering delicate skin. The entire bath should take 5 to 8 minutes and leaves skin clean and soft. Because the Bag Bath™ is a self-contained bathing system, it lends itself uniquely to other applications. It simplifies bathing for the frail elderly in the home setting. Additionally, the Bag Bath™ has been used in water emergencies resulting from natural disasters and shortages.
This is a challenging time for nursing. Health care reform is making it increasingly difficult to maintain quality patient care. Patient-tonurse ratios are climbing as ? resources dwindle. Patients are sicker and require a more acute level of care. Nursing practice must adapt to a changing health care environment. Conversely, the way that nurses bathe patients has remained essentially unchanged for the past 150 years. We need to use the limited time we have with our patients wisely. It's time to make sense of patient bathing.
- Barsevick, A., & Llewellyn, J. (1982). A comparison of the anxiety-reducing potential of two techniques of bathing. Nursing Research, 82(31), 22-27.
- Eaglstein, W., McKay, M., & Pariser, D. (1994). The problems that plague aging skin. Patient Care, 28(7), 89-92, 95-96, 101-107.
- Eliopoulous, C. (1988). Gerontological nursing (2nd ed.). Philadelphia, PA: J.B. Lippincott.
- Gioella, E. & Bevil, C. (1985). Nursing care of the aged client, Norwalk, CT: Appleton, Century, Crofts.
- Guralnik, J., Harris, T, White, L., & Comoni-Huntley, J. (1988). Occurrence and predictors of pressure sores in the National Health and Nutrition examination survey follow-up. Journal of the American Geriatrics Society, 36(9), 807-812.
- Jones, A. (1995). Reflective process in action: The uncovering of the ritual of washing in clinical nursing practice. Journal of Clinical Nursing, 4(5), 283-288.
- Lowry, P. & Tompkins, L. (1993). Nosocomial legjonellosis: A review of pulmonary and extrapulmonary syndromes. American Journal of Infection Control, 21(1), 21-27.
- Melia, K. (1987). Learning and working. The occupational socialisation of nurses. London: Tavistock.
- Nightingale, F. (1859). Noies on nursing: What it is and what it is not. London: Harrison and Sons.
- Panting, K. (1994). OBRA regulations and nosocomial infection. Ostomy & Wound Management, 40(7), 62-63.
- Pembroke, A. (1983). Preventing skin problems. Geriatric Mediane, 13, 797-781.
- Porthe, C. & Kapke, K. (1983). Aging and the skin. Geriatric Nursing, 4, 158-162.
- Rader, J. (1994). To bathe or not to bathe: That is the question. Journal of Gerontological Nursing, 20(9), 53-54.
- Walsh, M. & Ford, P. (1989). We always do it this way. Nursing Times, 85(41), 26-35.
- Webster, R, Thompson, D. Bowman, G, & Sutton, T. (1988). Patients' and nurses' opinions about bathing, Nursing Times, 84(37), 54-57.