adminstering bed bath and perineal care

Administering a Bed Bath and Perineal Care        
A complete bed bath is given when the patient is dependent and unable to provide hygiene self-care. Examples of such instances are patients with severe pain, injuries, or diseases that limit movement, or when the primary care provider has ordered that the patient not expend the energy needed to self-bathe. In some instances, perineal care is ordered by the health care provider.
Supplies
• Basin of warm water
• Soap
• Towels and washcloths
• Bath blanket
• Clean linens for bed
• Clean gown
• Body lotion
• Toilet articles
• Hamper or bag for soiled linens
• Bedpan or urinal, toilet paper
For Perineal Care
• Underpad
• Gauze pads or washcloths
• Pitcher and water or ordered solution
Review and carry out the Standard Steps in Appendix A.
Action (Rationale)
Assessment (Data Collection)

  1. Assess patient’s preferences, including cultural factors and acceptability. (Demonstrates respect for patient preference and encourages participation in care.)
    Planning

  2. Gather supplies. (Provides easy access to equipment needed for hygiene and personal care bathing.)

  3. Explain the procedure to the patient. (Decreases fear of the unknown and prepares patient.)

  4. Prepare environment for bathing: close doors and windows, adjust room temperature if necessary, pull curtains around bed, and place a sign (“Bath in progress”) on the door. (Promotes comfort by warming room and decreasing chance of drafts. Placing sign on door provides privacy.)

  5. Offer bedpan or urinal. (Provides comfort and decreases chance of interruption during bath.)
    Implementation

  6. Perform hand hygiene. Don gloves. (Reduces transfer of microorganisms.)

  7. Raise the side rails and raise the level of bed to a comfortable working height. Lower rail on side closest to you and position patient in a comfortable position close to you. (Promotes proper body alignment because work is at your center of gravity. Provides comfort for patient.)

  8. If a bath blanket is available, fan-fold the blanket horizontally and place it across patient’s chest. Ask the patient to hold the top edge of the bath blanket. Pull the blanket and the covers to the foot of the bed. Remove the top covers out from underneath the bath blanket. Use the top sheet if a bath blanket is not available for a drape. (Drapes patient, protecting privacy.)

Step 8
9. Remove linens as directed in Skill 20.2. (Prepares linens to be replaced on bed.)
10. Remove patient’s gown, being careful to keep patient draped. If the patient has an intravenous (IV) line in place, remove the gown by gently pulling the gown off the patient’s arm over the IV line without pulling on the line or disturbing the IV cannula. Lift the IV bag and tubing and thread them through the sleeve from the outside toward the inside of the gown to free the gown. If patient has a weak or paralyzed side, undress the unaffected side first. (Prepares patient for bathing. Careful removal of gown protects the IV site. Dressing is more comfortable and easier for the patient and you.)
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Step 10
11. Raise the side rail while preparing the bathwater. Water should be warm and checked with either a bath thermometer or the inside of your wrist. Do not leave the soap in the water. Change water when it cools or becomes soiled or when a soap film develops. (Provides for safety. Warm water is soothing, and maintaining warm, clean water is comforting.)
12. Lower rail and remove the pillow under the patient’s head or place a towel over the pillow. Make a bath mitt by grasping the washcloth at an edge and folding one-third of it over your fingers. Bring the opposite edge across your fingers and hold it with your thumb. Bring the top end of the cloth down to your palm and tuck that end under the lower edge. (Provides better control of the washcloth; loose ends do not drag across patient. Loose ends cool quickly and chill the patient.)

Step 12
13. Fold drape to expose only the area being cleaned. Spread a towel across the patient’s chest. (Protects patient privacy and prevents chills.)
14. Ask the patient about preference of using soap on the face. Moisten the bath mitt with water and wash one eye area from the nose to the outer edge near the ear; use a separate part of the mitt to wash the other eye area. Do not use soap near eyes. Wash patient’s face and neck. Dry well. Rinse cloth and wash forehead from the center to each side; wash the rest of face, using a circular motion around the mouth. Rinse and dry the face well. Wash, rinse, and dry each ear and the neck. Patient may wash own face if able. (Using different parts of the cloth to wash eye area prevents moving bacteria from one eye to the other. Rinsing well prevents the soap from drying the skin.)
15. Place a towel under the far arm, make a bath mitt, use soap, and wash the entire arm with long, sweeping strokes from distal to proximal (toward the axilla). Give special care to the axilla with extra soaping. Rinse and pat dry well. Wash the hands and fingers, rinse, and dry. Move the towel and wash and dry the near arm and hand in the same manner. (Towel protects the mattress from getting wet and is available for drying. Washing distal to proximal promotes circulation. Bacteria collect in the sweat gland areas, and extra cleansing of axilla is needed to remove secretions and decrease body odor.)

Step 15
16. Keep the towel in place over the patient’s chest and pull the drape down to the waistline. Make a bath mitt and wash under the towel over the entire chest; wash breasts with a circular movement. Wash skin folds under the female patient’s breasts by lifting each breast. Rinse and dry well, paying special attention to skin fold areas. Fold the drape to the top of the pubic bone and wash the lower abdomen. Rinse and dry well. (Washing in sections provides privacy and protects the patient from chills.)
17. Expose the far leg and tuck the bath blanket around the patient to prevent chilling. Flex the leg and place a towel lengthwise on the bed. Wash from the foot to the knee with long, sweeping strokes and then from the knee to the hip in the same manner. Rinse and dry the leg well. Place the bath basin on the towel and lift the foot, placing your hand under the heel, and place it into the water. Wash the foot and dry it. Dry each toe separately and place the leg and foot under the drape. Wash the near leg in the same manner. (Tucking bath blanket around patient keeps the patient warm. Stroking from distal to proximal encourages venous return. Placing the foot into warm water is soothing and comforting to the patient.)
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Step 17
18. Change the bathwater after washing the legs and feet. (Prevents using water that has been used on the feet on other parts of the body.)
19. Turn the patient to the side, place a towel lengthwise along the back, and wash the back with long, sweeping motions. Rinse and dry well. Offer a back rub at this time. Wash the folds of the buttocks and anus well. (Towel protects mattress from moisture.)
20. Change water, washcloth, and gloves. Provide privacy for the patient to wash the genital area. If patient is unable, place an underpad beneath the perineum to protect the mattress and wash the area thoroughly, rinse well, and pat dry carefully. For the female patient, wash from the front to the back. For the uncircumcised male patient, retract the foreskin and clean the head of the penis, rinse, and reposition the foreskin. Lift the scrotum and clean the area well. If a catheter is in place, carefully wash around it with soap and water, and rinse the area. Dry the penis and scrotum. Remove the underpad. (Promotes privacy because many patients wish to wash their own perineum. Cleanses areas patient cannot manage. Washing around a catheter removes body secretions.)

Step 20
For Prescription Female Perineal Care
21. Place patient in the dorsal recumbent position in bed. Drape with a bath blanket diagonally (it should look like a diamond resting on the patient). Take the point of the bath blanket by the patient’s feet and fold it up to the pubic area. Place the outer sides of the bath blanket over patient’s knees and wrap the corners around each foot. (Provides privacy and prevents chills.)
22. With gloves in place, remove any peripad or dressings and observe characteristics of the drainage. Discard soiled items in a sealable plastic bag. (Standard Precautions must be used when handling items soiled with body substances.)
23. Slip an underpad under the patient’s hips and position patient on the bedpan as described in Chapter 29. Raise the head of the bed slightly or use pillows to support the patient’s head. (Underpad prevents soiling the linens and mattress. Positioning the patient prevents back strain by supporting the head and shoulders.)
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24. Carefully pour warm water or the prescribed solution over the perineal area to rinse off urine, feces, or vaginal drainage. (Cleanses outer perineum.)
25. Use the nondominant hand to separate the labia majora and, with downward strokes from the pubic area to the rectum, cleanse the skin folds with cotton balls, gauze pads, or a washcloth. Use only one downward stroke with each gauze pad, cotton ball, or portion of the washcloth. Rinse and pat the area dry with clean towel or fresh gauze pads. Remove the underpad and replace peripad or redress as needed. (Cleaning with downward strokes prevents carrying bacteria from the dirty rectal area up to the vaginal area and urinary meatus. Peripad or dressing provides for collection of secretions.)

Step 25
Completing Care
26. Put a clean gown on the patient. If the patient has an IV in place, lift the IV bag and line and put it through the sleeve of the gown from the inside of the gown to the outside, just as the arm will go through the sleeve. Then carefully place the patient’s arm through the sleeve of the gown. If a patient has a weak or paralyzed side, dress this extremity first. (Maintains IV site and prevents the IV cannula and tubing from coming apart. Dressing is more comfortable and easier for the patient and you.)
27. Complete personal care by combing the patient’s hair, caring for fingernails and toenails, and permitting the male patient to either shave himself or be shaved (see Steps 19.2). (Increases patient’s sense of well-being and self-esteem.)
28. Lower the bed, lower unneeded side rails, and restore the unit. Empty, rinse, and wipe out the basin before returning to storage. (Makes patient comfortable and safe. Cleaning basin prepares it for the next use; wiping removes soap residue that rinsing alone leaves behind.)
29. Make the occupied bed if needed (see Skill 20.2). (The patient who needs a bed bath may not be able to get out of bed.)
Evaluation
30. Observe the newly bathed patient. Is the patient comfortable? Did the bath tire the patient? Are there any modifications you would make in providing future hygiene care for this patient? (Determines if any changes are needed.)
Documentation
31. Document on the flow sheet or in the nurse’s notes depending on agency policy. Note the type of bath performed or given, the patient’s tolerance of the procedure, any patient education done, and any abnormalities found during the bath. (Validates effectiveness of nursing care and notes patient education provided.)
Documentation Example
6/25 0930 Complete bed bath given and back rub performed. Reddened area 2 cm in diameter found on sacrum. Repositioned on right side in correct body alignment and maintained with pillows. Educated patient on importance of avoiding pressure on the sacral area. Bed down. Call light in reach. (Nurse’s electronic signature)
Home Care Considerations
• Close doors and windows to prevent drafts during the bath.
• Ensure that safety bars and nonskid tub and shower pads are in place in the home bathing area.
• Caution patients to always check the water temperature before entering the bathtub or shower.
• Trim nails after bathing while the nails are soft.
• Check fingernails and toenails once a week to decide if they need to be trimmed.
• Inform patients that many hairdressers will come to the home for those with an extended illness.
• Refer the patient to an appropriate agency if there is a need for bathing assistance at home.
• Instruct the patient and/or the caregiver to assess the perineum for signs or symptoms of infection, such as redness, drainage, odor, burning, or itching. Explain the importance of checking the skin integrity of the perineal area.
Lifespan Considerations
Older Adults
• Soap is not generally used on the older adult’s skin every day. On alternate days, use soap only on areas visibly soiled.
• Older women who cannot reach and bend easily need to have the nurse perform perineal care. Rather than giving this patient a choice, say, “I’m going to clean the areas that are difficult to reach.” If the patient protests, allow her to wash herself.

A complete bed bath is performed for patients unable to self-bathe due to conditions like pain or limited movement. The procedure includes various supplies: warm water, soap, towels, washcloths, and clean linens. The process involves assessment of patient preferences, gathering supplies, explaining the procedure, preparing the environment, and ensuring privacy. It includes systematic washing from face to feet, with special attention to skin folds and personal areas. Perineal care is provided as needed, maintaining hygiene and dignity. After completion, the patient's comfort is evaluated, and documentation is recorded in accordance with agency policy. For home care, ensure safety and assess the perineum regularly for signs of infection. Older adults require special considerations, such as less frequent soap use and assistance for those with limited mobility.