Assisting Ill and Disabled Patients in Daily Activities

Oral Hygiene

• Brush all tooth surfaces thoroughly with a fluoride toothpaste.

Perineal Hygiene

• Explain the procedure to reassure the patient.
  • Male patients:
    1. Wash the head of the penis first using an outward circular motion.
    2. If uncircumcised, retract the foreskin. Wash, rinse, and dry.
  • Female patients:
    1. Wash from front to back, rinse, and pat dry.
    2. If a catheter is in place, carefully wash around it with soap and water.
    3. Rinse and dry carefully.

Baths

• Three purposes of bathing:
  • Cleanse the skin
  • Promote comfort and relaxation
  • Stimulate circulation

Assisting Patients with Daily Activities

• Place soiled linen in a laundry bag.
• Remove the patient's gown or pajamas.
• Raise the side rail and fill a clean washbasin two-thirds full with warm water.
  • Check the water temperature and have the patient test the temperature tolerance.
• Place the bath basin and supplies on the over-bed table.
• Lower the side rail and remove the pillow if allowed.
• Raise the head of the bed to 30 to 45 degrees.
• Place a bath towel under the patient's head and another over their chest.
• Immerse a washcloth in warm water and fold it around fingers to form a mitt.
• Wash the patient's eyes using a different section of the mitt for each eye.
• Move mitt from inner to outer canthus. Dry thoroughly but gently.
• Wash, rinse, and dry the forehead, cheeks, nose, neck, and ears.
• Expose the arm closest to you and place it under a bath towel lengthwise.
• Bathe the arm with soap and water using long, firm strokes from distal to proximal areas. Thoroughly wash the axilla.
• Rinse and dry the arm.
• Immerse the patient's hand in water before washing hands and fingernails.
• Remove the basin and dry the hand well.
• Raise the side rail and move to the other side of the bed.
• Lower the side rail and repeat the procedure for the other arm.
• Change the water as it becomes cloudy or as needed.
• Cover the patient's chest with a bath towel and fold the bath blanket down to the umbilicus.
• Lift the edge of the towel away from the chest and bathe the chest using long, firm strokes, paying special attention to skin folds. Breasts may need to be lifted with the back of the hand.
• Cleanse the foot, making sure to bathe between the toes.
• Raise the side rail and move to the other side of the bed.
• Lower the side rail and repeat the procedure for the other leg and foot.
• Cover the patient with a bath blanket, raise the side rail, and change the bath water.
• Lower the side rail and assist the patient to a prone position.
• Place a towel lengthwise along the patient's side.
• Wash, rinse, and dry the back from neck to buttocks using long, firm strokes.
• Pay special attention to folds of buttocks and anus.
• Change bath water.
• If gloves become soiled, remove, perform hand hygiene, and reapply.
• Assist the patient into a supine position.
• Cover the patient and expose the genitalia. If the patient is able to wash, covering the entire area is preferable.
• Provide perineal care, paying special attention to skin folds.
• Remove soiled linen.
• Remove gloves and perform hand hygiene.
• Empty, rinse, and wipe out the basin before returning it to storage. Disinfect as instructed by local policy. Disposable basins are preferred to minimize bacterial infection.
• Replace the call light and personal possessions. Place the bed in a low position with side rails raised as appropriate. Leave the room as clean and comfortable as possible.

Factors Influencing Hygiene

• Social practices: Social groups influence hygiene preferences and practices.
• Personal preferences: Each patient has preferences about when to bathe, shave, and perform hair care.
• Body image: A patient's general appearance reflects the importance hygiene holds for them.
• Socioeconomic status: Economic resources influence the type and extent of hygiene practices used.
• Health belief and motivation: Motivation is a key factor in the importance of hygiene. A lack of motivation can be caused by insufficient knowledge.
• Cultural variables: People from diverse cultural backgrounds follow different self-care practices.
• Physical condition: Certain types of physical limitations or disabilities often create difficulties.

Promoting Urination

• Run water in a nearby sink.
• Pour warm water over the perineum.
• Have the patient visualize a bubbling brook.
• Patients restricted to bed:
  • Use bedpans and urinals for defecation and urination (females only).
  • Sitting on a bedpan is extremely uncomfortable.
    • Two types of bedpans are available:
      1. Regular bedpan: Made of metal or hard plastic.
      2. Fracture pan: Designed for patients with lower extremity fractures.

Assisting a Patient with Bedpan Use:

1. Perform hand hygiene and apply clean gloves.
2. Provide patient privacy
3. Have patient assume supine position
4. Position patient on bedpan
   • If patient is able to assist:
     1. Raise head of bed 30 degrees
     2. Have patient raise hips by bending knees and lifting hips upward
     3. Place a hand palm up under the sacrum to help lift and slip the pan under the patient.
   • If patient is unable to assist:
     1. Lower head of the bed flat
     2. Assist patient in rolling onto one side, buttocks toward Corpsman
     3. Apply powder to buttocks
5. Ensure that the patient is in the lowest position and safe.
6. Remove gloves and perform hand hygiene.
7. Allow the patient to be alone but monitor status and respond promptly to call signal so as to remove bedpan in timely manner.
8. Perform hand hygiene and apply a new pair of gloves.
9. Lower side rail and move aside upper linens; keep patient covered for others.
10. Determine whether patient is able to wipe own perineal area
11. Have patient roll off to the side or raise hips
12. Remove bedpan
13. Wipe patient's anal area using approved wipes
14. Observe for alterations in skin integrity
15. Return patient to a comfortable position
16. Document the procedure appropriately.

Assisting a Patient with a Urinal:

1. Perform hand hygiene and apply clean gloves.
2. Provide privacy by closing bedside curtain or room door
3. Place the urinal flat on the bed between patient's thighs.
4. If possible, the male patient should hold urinal and position penis in urinal himself. If patient is unable to position penis completely within urinal, provide needed assistance. Hold or assist in holding urinal in place
5. Remove urinal after the patient has finished voiding. Assist patient, if patient is able, to wash and dry penis or genitalia
6. If urinal does not have measurement markings, measure urine using graduated cylinder
7. Observe characteristics of urine
8. Save urine if needed for specimen testing or empty and cleanse urinal, and return it to patient for future use
9. Assist patient, as needed, to perform hand hygiene
10. Remove gloves and perform hand hygiene
11. Document the procedure in the patient's record

Enema Administration

• An enema is the introduction of fluid into the rectum and colon by means of a tube.
• Enemas are given to stimulate peristalsis and the urge to defecate or to wash out the waste products or feces.
• Cleansing enemas are given when the bowel is to be examined.

Preparing a Hospital Bed

• When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform.
• Place soiled linen in special linen bags before discarding in a hamper. To avoid spreading microorganisms, never shake the linen or place soiled linen on the floor. If clean linen touches the floor, immediately discard it.

Making an Unoccupied Bed:

1. Perform hand hygiene and apply clean gloves.
2. Lower both side rails, raise to a comfortable working level and place the bed in a flat position
3. Place a finger on the sheet where it meets the mattress
4. Lower the top of the sheet over the finger
5. Remove the finger without disturbing the folds
6. Tuck the sheet under the mattress
7. Apply a drawsheet, laying center fold along middle of bed lengthwise
8. Smooth drawsheet over mattress and tuck excess edge under mattress, keeping palms down
9. Move to opposite side of bed, and spread bottom sheet smoothly over edge of mattress from head to foot of bed
10. Miter top corner of bottom sheet
11. Grasp remaining edge of bottom sheet and tuck tightly under mattress while moving from head to foot of bed
12. Smooth folded drawsheet over bottom sheet and tuck under mattress, first at middle, then at top, and then at bottom
13. Place top sheet over bed with vertical center 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
14. Make horizontal toe pleat:
    1. Stand at foot of bed and fanfold sheet 5 to 10 cm (2 to 4 inches) across bed
    2. Pull sheet up from bottom to make fold approximately 15 cm (6 inches) from bottom edge of mattress
    3. Tuck in remaining portion of sheet under foot of mattress
15. Place blanket over bed with top edge parallel to top edge of sheet and 15 to 20 cm (6 to 8 inches) down from edge of sheet
16. Make cuff by turning edge of top sheet down over top edge of blanket
17. Standing on one side at foot of bed, lift mattress corner slightly with one hand; with other hand, tuck top sheet and blanket under mattress. Be sure toe pleats are not pulled out
18. Miter corner with top sheet and blanket
19. Repeat with other side of bed
20. Apply clean pillowcase over the pillow
21. Return bed to lowest position, allowing for patient transfer
22. Discard used supplies, remove gloves (if worn), and perform hand hygiene
23. Document the procedure in the patient's record

Making a Surgical Bed (Recovery Bed):

1. Raise the bed to the highest position
2. Place bottom sheet on bed, using same method for making an unoccupied bed
3. Place a draw sheet on bed
4. Lap top sheet and blanket and spread over top of bed
5. Fan fold linen to side or the bottom of the bed

Making an Occupied Bed:

1. Perform hand hygiene and apply clean gloves
2. Raise bed to a comfortable working level; lower head of bed, keeping patient comfortable
3. Lower side rail on the Corpsman side of bed loosen top linen at foot of bed
4. Remove blanket separately. If soiled, place in linen bag. If to be reused, fold into square and place over back of chair
5. Cover patient with bath blanket, placing over top sheet. Have patient hold top edge of bath blanket, or tuck blanket under shoulders
6. Reach beneath blanket, and remove top sheet. Discard in linen bag
7. Assist patient to side-lying position facing away from the Corpsman
8. Loosen bottom linens, moving from head to foot. Fanfold bottom sheet, drawsheet, and any cloth pads toward and under patient
9. Tuck edges of old bottom linen alongside patient's buttocks, back, and shoulders
10. Clean, disinfect, and dry mattress surface if needed
11. Unfold bottom sheet lengthwise so that the center crease is lengthwise along the center of the bed
12. Fan fold the sheet for the other side of the bed with the center fold at the center of the mattress
13. Push the folded linen under rolled, soiled bottom sheets that are being removed
14. Tuck the near side of the bottom sheet under the head of the mattress and miter the corner
15. Tuck the sheet under the mattress from the head to the foot of the bed
16. Place a drawsheet on the bed (if indicated) centering it on the mattress so it reaches from the patient's shoulders to below the hips
17. Fan fold the far side of the drawsheet and push it under the rolled bottom sheets
18. Tuck the sheets under the mattress and raise the side rail
19. Go to the other side of the bed, lower the rail, and move the patient to the far side of the bed. If the patient can turn easily, ask the patient to roll to the opposite side
20. Loosen the bottom linens and roll them up
21. Place the linens in a linen hamper, bag, or used pillowcase
22. Pull the bottom sheet across the mattress, and fold over the top of the mattress. Smooth, tighten, and tuck the excess sheet under the mattress and miter the corner
23. Pull the drawsheet from the center of the bed
24. To pull tightly, place your knee against the mattress while pulling
25. Tighten, smooth, and tuck the sheets under the side of the mattress from head to foot
26. Allow the patient to roll onto their back
27. Place a top sheet over the patient with the top edge folded down a few inches beneath the chin
28. Have the patient hold the top of the sheet and remove the soiled top sheet or bath blanket if bed making is done after a bed bath
29. Position the blanket and spread it in the same manner
30. Smooth the top linens and tuck the excess at the foot under the bottom of the mattress
31. Miter the corner on the near side then the far side
32. Fold the top edge of the sheet over the blanket and spread to form a cuff
33. Make a toe pleat in the top sheet and blanket
34. Remove the used pillow case and place it in the linen hamper
35. Apply a clean pillow case
36. Place the pillow beneath the patient's head with the open end away from the door
37. Lower the bed, replace the call light, and restore the unit
38. Remove the linen hamper and place it in the appropriate area
39. Document the procedure in the patient's record

Assisting Patients with Mobility

Bed/Gurney Gait Belt and Commode

1. Perform hand hygiene and apply clean gloves.
2. Verify correct patient using two identifiers
3. Provide patient privacy
4. Assist patient to sitting position on side of bed.
5. Allow patient to sit on side of the bed (dangling legs) for a few minutes before transferring patient.
6. Position commode at 45-degree angle to bed
7. Apply gait (transfer) belt.
8. Place the patient's weight-bearing, or strong, leg forward, with weak foot back
9. Spread your feet apart and flex hips and knees, aligning knees with patient's knees.
10. Grasp transfer belt along patient's sides
11. Rock patient up to standing position on count of three while straightening hips and legs and keeping knees slightly
12. Maintain stability of patient's weak or paralyzed leg with your knee.
13. Pivot on foot farthest from commode.
14. Ask the patient to step back until they feel the back of their legs touching the commode.
15. Lower patient onto commode and give the patient the call bell and place toilet paper within reach.

Patient Positioning (Commode to Wheelchair/Chair to Automobile/Bed)

1. Position the wheelchair beside the toilet at a 90-degree angle, on the patient's strong side and lock brakes
2. Place the patient's weight-bearing, or strong, leg forward, with weak foot back
3. Spread your feet apart and flex hips and knees, aligning knees with patient's knees
4. Rock patient up to standing position on count of three while straightening hips and legs and keeping knees slightly
5. Maintain stability of patient's weak or paralyzed leg with your knee.
6. Pivot on foot farthest from chair
7. Instruct patient to use armrests on chair for support, and ease him/herself into chair
8. Flex hips and knees while lowering patient into chair
9. Assess patient for proper alignment in sitting position
10. Cover patient with blanket.
11. Replace front rigging and footplates.
12. Transport patient to automobile/bed (simulated)

Patient Positioning (Wheelchair/Chair to Bed)

1. Position wheelchair at 45-degree angle to bed
2. Place gait belt around the patient's waist. Make sure belt is secure enough to sustain hold on patient but not too tight
3. Assist patient to a standing position.
4. Pivot the patient until the patient's back is to the bed
5. Ask the patient to step back until they feel the back of their legs touching the bed
6. Flex hips and knees while lowering patient onto bed.
7. Place drawsheet under patient, extending it from shoulders to thighs
8. Place patient on back and remove pillow
9. Position one Technician/Corpsman at each side of patient.
10. Fanfold the drawsheet on both sides, and grasp firmly near patient.
11. Facing head of bed, both Technician/Corpsman place feet apart in forward-backward stance (foot nearest bed in front).
12. Flex knees and hips
13. On count of three, shift weight from front to back leg, and then move patient and drawsheet simultaneously
14. Lower head of bed completely or as low as patient can tolerate.
15. Position patient's body closest to the side of the bed that is opposite to the direction patient is to be turned.
16. Raise side rail and go to opposite side of bed
17. Flex patient's knee that will not be next to mattress after turning on side.
18. Place patient's arm that is closest to the mattress above patient's head or forward on the mattress.
19. Place one hand on patient's hip and one hand on patient's shoulder and roll patient onto side toward you
20. Place pillow under patient's head and neck
21. Position both arms in slightly flexed position
22. Bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees
23. Place small tuck-back pillow behind patient's back.

Ambulatory Devices

• Assistive devices can prevent harmful falls upon recovery from a lower extremity orthopedic injury.
• Selection is based upon the amount of stability and support required and the patient's strength, cognition, balance, and coordination.

Uses of Assistive Devices

1. Redistribute and unload a weight-bearing lower limb
2. Improve balance
3. Reduce lower limb pain
4. Provide sensory feedback

Types of Assistive Devices

Canes

• Often used to widen the base of support and decrease stress on the opposite lower extremity

1. Fitting
   1. Instruct patient to hold cane on the stronger side of the body
   2. The cane should extend from the greater trochanter to floor with a 15 to 30 degrees for elbow flexion
   3. Use the unaffected side, approximate cane height can be determined by measuring distance from wrist to floor, when standing with arms at the sides
2. Techniques for Use
   1. Cane should support 15-25% of patient's body weight
   2. Place cane about 12 inches in front of the foot and slightly to the outside
   3. Move cane four inches in front of patient and then move affected leg forward, even with the cane
   4. Instruct patient to shift their weight to affected leg and cane.
   5. Move unaffected leg forward, ahead of cane.
   6. Move cane forward, and then bring affected leg forward until it is even with cane. Repeat these steps when walking with the cane.
   7. Help patient practice the gait. Be ready to help with balance if necessary.
   8. Correct mistakes if they occur
   9. Advance cane simultaneously with the affected leg
   10. To climb up stairs
       1. Put the cane in the hand closest to the unaffected (i.e. healthy or good) leg
       2. Step up on the good leg first, If possible, grasp the handrail and step up on the good leg first
       3. Step up on the injured leg and the cane at the same time
   11. To come down stairs
       1. Put the cane in the hand closest to the unaffected leg
       2. Put the cane on the step first
       3. Step down with the injured leg
       4. Finally, step down with the good leg

Crutches

• Provide better stability than do canes and have 2 points of contact with the body.

1. Types of crutches. There are two basic types of crutches
   1. Axillary Crutches
      1. Wooden or aluminum models can be adjusted easily to the overall height and hand height
      2. For temporary use (acute injuries)
      3. Requires significant upper body strength
   2. Forearm Crutches
      1. The increased flexion allows the arm to bear greater weight
      2. For active patients with severe leg weakness
      3. Offers easier mobility than with axillary crutches
      4. Brace fixes crutch to forearm and hands grasp handles
      5. Allows use of hands without dropping crutches
2. Fitting - Axillary
   1. Ask the patient to stand against the wall with the feet slightly apart and slightly away from the wall
   2. Axillary, or underarm, crutches are measured with the crutch tips flat on the ground and approximately 6 inches lateral to and 6 inches in front of the foot.
   3. The axillary pad should be 1.5 to 2 inches below the axilla
   4. Adjust the handgrip to allow for an approximate 20 degrees to 30 degrees bend at the elbow.
   5. Proper crutch height should allow two to three fingers space between top of the crutch and axilla.
   6. Axilla should not rest on top of the crutch.
   7. Patient comfort is a top priority. Don't assume that just because the patient is 6'2" then their crutches will measure the same. Measure by physical inspection and patient comfort and mobility
3. Techniques for Use
   1. Gait patterns. There are six types of gait patterns that a patient can use. This gait provides a slow, stable gait as three points of floor contact are maintained. Weight is borne on both lower extremities and typically is used with bilateral involvement due to poor balance, in coordination, or muscle weakness.
      1. Instruct patient to advance both crutches and the injured leg
      2. Instruct patient to advance the uninjured leg to the crutches
      3. Observe patient practice three-point gait
      4. Position yourself to help patient with balance when necessary
      5. Provide patient with corrections as needed
   2. Stair-climbing
      1. To climb up stairs
         1. The uninjured or good leg steps up first as you bear weight through the crutches ("Up with the good")
         2. The injured leg follows with the crutches
         3. Make sure that you are close to the step before you start and that the injured leg clears the step as you step up
      2. To come down stairs
         1. Place the crutches on the step below, and then step down with the injured leg ("Down with the bad")
         2. The good leg then follows
         3. Make sure the crutch tips are not too close to the edge of the step
         4. If a handrail is available, then the crutches can be used as one on the opposite side of the handrail
         5. The sequence remains the same as without using a handrail
   3. Sitting
      1. Back-up to a sturdy chair
      2. Put both crutches in one hand
      3. Put the injured foot in front
      4. With the other hand, feel for the chair arm rest or seat of the chair
      5. Slowly lower yourself into the chair
   4. Standing
      1. Scoot to the front of the chair
      2. Hold both crutches with the hand closest to the unaffected leg
      3. Push up and stand on the good leg

Walkers

• When patients require maximum stability and support from an ambulation device, walkers are typically indicated. There are five types of walkers, this lesson will discuss the standard walkers. Standard walkers are very durable, light weight, typically made of aluminum, for ambulation the user must lift the device and move it forward and it also requires a degree of upper extremity strength and coordination.

1. Fitting
   1. Place the front of the walker 12 inches in front of the patient.
   2. The walker should partially surround the patient.
   3. The hand grip of the walker should sit at the wrist crease, (ulnar styloid process), or greater trochanter of the patient standing erect with hands down at the side.
   4. Measure the proper height of the walker by having the patient stand upright with elbows flexed 20 degree
   5. To confirm that a proper fit has been attained, the walker should be positioned so that the rear feet of the walker are set at about the midpoint of the patient's shoes (viewed in the sagittal plane).
   6. The fit should be assessed as the user ambulates to ensure that the walker functions properly with the desired gait pattern
2. Techniques for use
   1. Hold in front of the patient with hands on the side
   2. The patient lifts the walker about six inches forward and places it firmly on the floor
   3. The patient moves forward into the walker by stepping toward the walker.
   4. Help patient practice the gait.
   5. Be ready to help with balance, if necessary

Manual wheelchairs

1. Your hands and arms operate this type of wheelchair.
2. You need to have good upper body strength to use one of these.