Comprehensive Nursing Fundamentals: Bed Making, Comfort, and Hygiene Standards

Foundations and Goals of Bed Making

• Definition of Bed Making: Bed making is the clinical technique of preparing various types of beds to ensure patient or client comfort and to place the patient in a position suitable for their specific medical condition.

• Goals of Bed Making:

  • Promote patient comfort and rest.

  • Prevent the development of pressure ulcers and skin breakdown.

  • Maintain a surface that is clean and entirely wrinkle-free.

  • Reduce the transfer of microorganisms within the healthcare environment.

  • Provide a safe and organized environment for patient recovery.

• Purposes of Bed Making:

  • Conserve the client's energy and maintain their current healthy status.

  • Promote the client's comfort.

  • Provide a clean and neat environment.

  • Provide a smooth, wrinkle-free foundation to minimize sources of skin irritation.

  • Promote hygiene and rigorous infection control.

  • Enhances the overall well-being and comfort of the patient.

• Importance of Bed Making:

  • Sense of Well-being: Contributes to the patient's psychological well-being by maintaining an orderly room.

  • Health and Refreshment: Cleanliness helps the patient secure rest essential for health.

  • Microorganism Control: Prevents or avoids microorganisms from contacting the patient, which prevents further illness.

  • Skin Integrity: Minimizes irritation by ensuring the bed foundation is smooth.

Bed Making Linen Configuration and Technical Standards

• Sequence of Linen Layers:

  1. Bottom Sheet: White color; applied using a Full Miter technique.

  2. Rubber Sheet or Waterproof Pad: Colored Red and Green; the Green side is placed on top to make blood more visible.

  3. Draw Sheet: Pink color.

  4. Top Sheet: Yellow color; applied using a Half Miter technique.

  5. Pillowcase: Final layer.

• Critical Notes on Linen Placement:

  • Wrinkle-free: Linen must be perfectly smooth to avoid impeding the patient's blood circulation.

  • Pillowcase Orientation: The opening of the pillowcase must face away from the door to avoid contamination from the hallway.

  • Toe Pleat Variations:

    • Horizontal Toe Pleat: Designed for tall patients to provide more space.

    • Vertical Toe Pleat: Designed for obese patients to provide more space.

• Standard Bed Dimensions:

  • Length: $1.9\,m$ ($6.5\,ft$).

  • Width (Transcript listed as weight): $0.9\,m$ ($3\,ft$).

  • Height: $66\,cm$ ($26\,in$) (Note: Height may vary depending on the specific circumstances).

Terminology and Classifications of Hospital Beds

• Key Terminologies:

  • Fanfold: A method of grasping the upper edge of the linen with both hands and folding the edge of the sheet used in the bed $6-8\,inches$ outward.

  • Mitered Corner: A specific method of folding bedclothes at the corners to secure them in place. It involves tucking the sheet under the mattress and folding excess material diagonally.

  • Toe Pleat: A fold made in the top bedclothes to provide additional space for the patient's toes.

  • Foot Drop: A condition where the foot drops due to paralysis of the anterior leg muscles, characterized by plantar flexion with permanent contracture of the gastrocnemius (calf) muscle and tendon.

• Classification: Unoccupied Bed (Patient is not confined to the bed):

  1. Open Bed: The top covers are folded back. This allows the client to get into bed easily and is used for ambulatory patients.

  2. Closed Bed: Top covers are pulled up to the head of the mattress. Prepared before a new patient is admitted.

  3. Surgical Bed (Recovery or Postoperative Bed): A modified open bed where top linens are arranged for easy transfer from a stretcher (often fanfolded to the bottom third or folded to one side).

• Classification: Occupied Bed:

  • A bed made while the patient remains in it. This requires specific techniques to maintain safety and comfort.

• Special Types of Beds:

  1. Water Bed: Filled with water; controls temperature and reduces pressure on body parts. Indicated for patients confined for long periods.

  2. Turning Frames (Stryker Wedge): Allows for repeated changes between supine and prone positions without disturbing spinal alignment. Used to prevent atelectasis, pneumonia, decubitus ulcers, and renal calculi.

  3. Rotation Bed: Promotes postural drainage and peristalsis while preventing immobility complications. Indicated for spinal cord injuries and severe burns.

  4. Cyclometric Bed: Permits frequent turning of injured or immobilized patients with minimal movement. Helps treat pressure ulcers and respiratory/circulatory complications.

  5. Clinton Therapy Bed (Air-fluidized Bed): Used for managing burns and various disabilities.

  6. Air Therapy Bed: Provides different levels of support to various body parts to prevent skin breakdown.

Procedural Differences between Occupied and Unoccupied Beds

• Patient Position:

  • Unoccupied: Out of bed.

  • Occupied: Remains in bed throughout.

• Number of Steps:

  • Unoccupied: $12\,\text{steps}$.

  • Occupied: $14\,\text{steps}$ (more complex).

• Side Rails:

  • Unoccupied: Both sides lowered.

  • Occupied: Far side rail must be raised at all times.

• Privacy/Dignity:

  • Unoccupied: Standard precautions.

  • Occupied: Bath blanket required throughout.

• Skin Assessment:

  • Unoccupied: Before or after procedure.

  • Occupied: Conducted while the patient is on their side.

• Linen Technique:

  • Unoccupied: Fanfold method across the bed center.

  • Occupied: Both sides tucked separately.

• Main Hazards:

  • Unoccupied: Infection (handling soiled linen).

  • Occupied: Falls, skin shear, and circulatory restriction.

• Nursing Principle:

  • Unoccupied: Efficiency and infection control.

  • Occupied: Safety, comfort, and communication.

Detailed Procedure for Unoccupied Bed Making

1. Hand Hygiene & Equipment: Wash hands/don gloves. Collect linen on a clean chair/trolley (not the floor). Rationale: Reduces microorganism transfer and conserves energy.

2. Bed Height: Raise bed to waist level and lock wheels. Rationale: Prevents musculoskeletal injury to the nurse.

3. Remove Soiled Linen: Loosen from head. Roll inward so soiled surfaces are inside. Do not shake. Rationale: Prevents dispersal of pathogens.

4. Mattress Protector: Center a clean pad lengthwise. Rationale: Protects against moisture/pressure.

5. Bottom Sheet: Place center fold along mattress center. Tuck head first, miter corner, then tuck side. Complete one side fully before moving. Rationale: Conserves energy; tight sheets prevent skin shear.

6. Drawsheet & Waterproof Pad: Center across middle third (hip area). Tuck near side; fanfold far side. Rationale: Facilitates repositioning and moisture protection.

7. Opposite Side: Move to the other side, pull taut, and tuck from head to foot. Miter head corner. Rationale: Taut surface prevents pressure on bony prominences.

8. Top Layers: Apply top sheet (wide hem at head, $20-25\,cm$ or $8-10\,inches$ overlap), blanket ($15\,cm$ or $6\,inches$ below sheet hem), and spread. Tuck at foot and miter corners. Rationale: Cuff protects face from rough blanket.

9. Toe Pleat: Create a $5-10\,cm$ ($2-4\,inches$) vertical fold across linens, $15-20\,cm$ ($6-8\,inches$) from the foot. Rationale: Prevents plantar flexion contractures.

10. Pillowcase: Turn inside out, grasp pillow, pull case over. Do not touch to uniform. Position at head. Rationale: Prevents microorganism transfer.

11. Safety Check: Return bed to lowest position; restore call light. Rationale: Reduces fall risk and promotes autonomy.

12. Documentation: Remove gloves, wash hands, and document the change and skin findings. Rationale: Provides a legal record and continuity of care.

Detailed Procedure for Occupied Bed Making

1. Communication: Hand hygiene, don gloves, and explain steps. Ask about pain. Rationale: Informed consent respects autonomy.

2. Safety: Raise bed to waist level; lower only the near side rail. Keep far rail up. Rationale: Prevents falls and nurse injury.

3. Privacy: Remove top covers while using a bath blanket for warmth. Rationale: Maintains dignity.

4. Positioning: Move patient to lateral position facing the far rail. Support with pillows. Rationale: Allows access to bottom linen.

5. Soiled Linen Handling: Loosen near side and fanfold soiled linens towards the patient's back. Rationale: Bundles contaminants into a compact surface.

6. Clean Bottom Sheet: Apply centered clean sheet; fanfold the far half against the soiled linen bundle. Rationale: Allows sheet to be pulled through when patient turns.

7. Clean Drawsheet: Apply to mid-section; fanfold towards patient's back. Rationale: Minimizes shear on the sacrum and heels.

8. Skin Assessment: Inspect back, sacrum, coccyx, trochanters, scapulae, and heels for redness/breakdown. Rationale: Early detection of pressure injuries.

9. Repositioning: Raise the near rail, move to the opposite side, and assist the patient to roll over the linen bundle toward you. Rationale: Critical safety measure to prevent falls.

10. Final Linen Adjustment: Remove soiled linen; pull clean fanfolded linen through and tuck tightly with mitered corners. Rationale: A wrinkle-free surface is essential for skin safety.

11. Support: Assist to supine/semi-Fowler's position; reassess comfort. Rationale: Promotes physiological alignment.

12. Top Linens: Apply top sheet, blanket, and spread over the bath blanket, then slide the bath blanket out. Make toe pleat and cuff. Rationale: Cuff protects the patient's face.

13. Completion: Change pillowcase; lower bed; raise rails as per care plan; ensure call light is reachable.

14. Document: Record procedure, skin condition, and patient response.

Clinical Safety and Comfort Measures

• The "Never" List (Prohibited Actions):

  • Never shake linen (aerosolizes pathogens).

  • Never place soiled linen on the floor.

  • Never hold linen against your uniform.

  • Never leave the far side rail down during occupied bed care.

  • Never leave the bed in a high position after care is completed.

• The "Always" List (Mandatory Actions):

  • Perform hand hygiene both before and after the procedure.

  • Work from head to foot, completing one side at a time.

  • Maintain patient warmth and privacy at all times.

  • Use proper body mechanics throughout (straight back, bent knees, wide base).

  • Assess the patient's skin during every linen change.

Bed Bathing: Purpose, Assessment, and Procedure

• Purposes of Bed Bath:

  • Remove microorganisms, secretions, excretions, and dead skin cells.

  • Stimulate skin circulation.

  • Promote relaxation, comfort, and well-being.

  • Eliminate unpleasant odors.

• Necessary Materials:

  • Basin with warm water ($43\,^{\circ}\text{C}$ to $46\,^{\circ}\text{C}$ or $110\,^{\circ}\text{F}$ to $115\,^{\circ}\text{F}$).

  • Hypoallergenic, moisturizing soap.

  • Bath blanket, two bath towels, washcloth, clean gown.

  • Gloves, deodorant, lotion, shaving equipment, laundry bag.

• Pre-Bath Assessment:

  • Determine physical/emotional factors (anxiety, fatigue).

  • Check skin condition (texture, turgor, lesions, abrasions, erythema on bony prominences).

  • Assess range of motion and mobility.

  • Check for IV lines; use snap-fastener gowns for patients with IVs.

• Procedure Sequence:

  1. Face (Start at the cleanest area).

  2. Neck.

  3. Arms (Far-Near, Distal-Proximal to stimulate venous return).

  4. Chest (Girls: Inner to Outer; Boys: Zigzag).

  5. Abdomen (Zigzag, circling the navel).

  6. Legs (Ankle to Thigh).

  7. Back (Zigzag).

  8. Perineum ("J" Method).

• Methods to Remember:

  • RSR: Rinse-Soap-Rinse.

  • S Method: Used for cleaning the face (forehead, cheeks, nose, chin, and behind ears).

  • Mitt Technique: Fold washcloth into a mitt to prevent ends from dragging and to retain heat.

  • Eyes: Clean from inner to outer canthus without soap.

Therapeutic Hygiene: Shampooing and Back Rubs

• Shampooing:

  • Purpose: Cleans hair, stimulates circulation, and allows for scalp assessment.

  • Materials: Kelly Pad, inflatable wash basin, rubber sheet, towels.

  • Technique: Tilt patient to lateral position; place Kelly pad beneath the head; cover eyes; massage while assessing.

• Back Rub Types and Effects:

  1. Effleurage: Light, long, stroking movements using fingers/flat hand. Effect: Stimulates circulation by following blood flow toward the heart.

  2. Petrissage (Kneading): Deep pressure using a squeezing technique. Effect: Stretches muscle fibers and breaks up adhesions ("knots").

  3. Tapotement: Rhythmic tapping using a cupped hand or the edge of the hand. Effect: Stimulates nerve endings, rapidly increases blood flow, and helps loosen respiratory mucus.

• Instruction: Avoid back rubs over the spine and bony prominences.

Oral Hygiene and Denture Care

• Purposes:

  • Maintains healthy mouth state; removes food, plaque, and bacteria.

  • Massages gums and relieves malodor to stimulate appetite.

• Frequency: Typically twice a day or after meals; every $2\,\text{hours}$ for patients with dry mouth.

• Specific Procedures:

  • Conscious Patient: Upright or High Fowler's position to prevent aspiration.

  • Unconscious Patient: Lateral or side-lying position. Head tipped forward so secretions flow out. Use a padded tongue blade to open the mouth; never use fingers as the biting-down reflex can cause injury. Keep suction equipment/bulb syringe nearby.

• Denture Care:

  • Handle with care as they are personal property.

  • Remove at night to allow gums to rest.

  • Store in a labeled container covered in water.

  • Cleaning: Use gauze to grasp dentures; line the sink with a towel to prevent breakage if dropped; use tepid water ($40\,^{\circ}\text{C}$ to $43\,^{\circ}\text{C}$).