Reference: 10/06 / HCC AS 03/08
HCC AS 21/06 / HCC H&S Issue 2 Jan 07 / NMC Code of Professional Conduct
GSCC Code of Practice
Marsden Manual of Clinical Nursing Procedures
Delivery of Personal Care – Washing and Bathing
This summarises the practical issues when assisting service users to wash or bathe. This guideline must be read in conjunction with practices 141, Dignity, Choice and Respect, 143 Dressing, Grooming, Hair, Mouth and Foot care, 144 Toileting, 145 Eating and Drinking, 146 mobility.
Skin is the largest of the body organs and changes with age and health. It provides a flexible, waterproof protective shield for the other body organs and performs the functions of temperature regulation; waste elimination; production of Vitamin D for absorption of calcium and helps the body respond to stress. It also, by means of sensation, helps to locate the body in relation to other people and objects, which is particularly important in the maintenance of mobility and balance.
With ageing, the skin becomes thinner, drier and more permeable. General dehydration causes loss of elasticity and greater vulnerability to damage and infection, with slower healing of wounds. Temperature control becomes less efficient, there is a reduction in sweating, and superficial blood vessels are more easily damaged, leading to easy bruising.
The personal standards and requirements of each service user will be dictated by a number of factors, religious; cultural; family and peer group practice; economic and social background; personal body image. All of these must be discussed and considered before being recorded in the Care Plan and before any amendments are made to bathing plans.
A risk assessment should be carried out to identify potential scalding risks from hot water temperatures and to assess the vulnerability of all those who have access to bathing and washing facilities.
• Can the person get in/out of the bath, sit up and/or wash themselves unaided?
• Does the person have impaired sensitivity to temperature?
• Is the person able to recognise that water is too hot?
• Is the person capable of summoning assistance if needed?
• Will any lifting or other aids limit the person’s mobility in the bath or shower?
In general :-
· At all times the service user should be afforded privacy for washing, bathing or showering. Staff assisting individuals should ensure that doors are secured or signed to prevent other persons entering without permission, whether this is the individual’s bedroom or a communal bathroom.
· In the event that it is necessary for someone to enter the room whilst a bath is in progress, e.g. to provide further assistance, all efforts should be made to protect the dignity of the service user, and to cover them to prevent exposure to view.
· Ensure that you are aware of any cultural or religious requirements for this activity.
· Check the moving and handling risk assessment to see if more than one person is needed to give assistance.
· Ensure that the room to be used is warm and free from draughts.
· The individual should be encouraged to assemble the necessary items themselves, with prompting and assistance to carry them if needed. Suitable soaps, shower gels, ‘bubble baths’ and other cosmetics to be used can be reviewed in discussion at this time, along with sponges and wash cloths. Record any changes in preference.
· Ensure clean clothing has been chosen and is to hand.
· Regardless of whether this takes place in a designated bathroom or in the service user’s room or bed, s/he should be encouraged to undertake as much as possible to prevent deskilling.
· Some people may be happy to walk to the bathroom in their dressing gowns, some prefer to undress when they get to the bathroom, always check their preference. Where a bath is scheduled for early morning, the individual may prefer to have their breakfast in their room, rather than sit at the breakfast table in their dressing gown.
· If bed making is combined with washing, ensure that clean bedding is in the room and a container for soiled bedding is outside of the room.
Bathing or washing in bed or in the service user’s room
1. Where bathing and washing take place in a service user’s room, this can be combined with bed making to minimize disruption.
2. All general principles will still apply, particularly ensuring the person is aware of what you are about to do, which can be incorporated into conversation to help them relax and enjoy the activity.
3. Whilst following this procedure, the person’s pressure areas should be observed and checked for redness, which should be reported and recorded, in accordance with Practice 139.
4. Wash hands and put on a disposable apron. It may be good practice to wear disposable gloves for at least part of the procedure, as a measure for infection control, e.g. where the service user has an infection or prefers not to be touched; where the care staff have cuts or abrasions that need to be protected; when washing areas which are likely to be soiled by body fluids or excreta.
5. Ask if the person wishes to go to the toilet before washing and provide assistance if needed.
6. Rinse the washing bowl in hot water and prepare a bowl of warm water, ensuring that it is no hotter than ‘hand hot’. The service user may like to check this for themselves. GREAT CARE must be taken to ensure the water is not too hot, especially where skin sensation may be impaired. The temperature should be NO HOTTER THAN 41O C.
7. Where necessary, assist the individual to remove clothing and cover them with a spare towel to preserve body temperature and dignity.
8. Start with washing, rinsing and drying the face, checking if soap or plain water is preferred. The individual may prefer to do this for themselves, using their hands or a face cloth. At all times, ensure that areas not being washed are kept covered and warm.
9. Wash, rinse and dry the top half of the person’s body, starting with the side furthest from you and assisting the person to move as required.
10. Change the water, checking as before. Put on disposable gloves if not already wearing them.
11. Using a separate washcloth, and checking if the person would prefer to do this for themselves, wash the genitalia, front to back for females and ensuring the foreskin is cleansed for males. If the person is washing at the sink, assist them to stand securely whilst this is done.
12. Remove or change gloves and change the water.
13. Where catheters or stoma bags are in situ, these should be cleaned at this point by a member of staff who is trained to do so.
14. Using a separate washcloth, wash the back, sacral area and legs.
15. If the person is in bed and the bed is to be changed, the bottom sheet can be replaced whilst the person is on their side.
16. On completion of the wash, assist the person to apply skin creams or body lotions as prescribed or preferred and to dress as appropriate.
17. Provide any assistance needed with mouth and hair care and with use of cosmetics. (Practice 143)
18. For gentlemen, assist as needed with shaving. (Practice 143)
19. Make the person comfortable in bed or in a chair and remove any washing bowl or equipment.
20. Complete bed making.
21. Replace belongings and equipment in the appropriate places and ensure any call bell is within reach.
22. Dispose of soiled bedding, empty and wash out the bowl with bactericide and replace all equipment used.
23. Remove and dispose of gloves and apron.
24. Wash hands.
25. Report and record as required.
Using the Bathroom (Baths and Showers)
The processes of preparation of the room and person and the order of washing are the same as those employed above. However there are additional considerations around of use of the bath and mobility equipment such as bath chairs.
The risk assessment will indicate any specific issues to be considered.
· Do not leave bathrooms unlocked when there is water in the bath. This is high risk, especially around service users with frail mental or physical health. The bathroom should be locked when in or out of use.
· Prepare the bath before the person undresses
o Ensure that the water level is suitable for the individual and is not too little, leaving them exposed and chilled, or too much leaving them insecure.
o Check the water temperature before using the bath – it should not be hotter than 44o C (Forty four degrees centigrade). Frail skin is more permeable and more susceptible to burns and scalds. Reliance should not be placed on the thermostatic mixing valves and the temperature should be checked by using the bath thermometer.
o When using bath chairs and hoists, ensure that they are correctly fitted to the individual and in working order. All staff using such equipment must be trained to do so.
o When using this equipment, keep the service user warm and covered until they are ready to enter the water.
o Discuss the use of any ‘spa’ attachments and if they are to be used, warn the person before they are turned on.
o If water is added to the bath during bathing, it should be added slowly and monitored constantly. This should be avoided wherever possible.
o When using a shower, the water temperature should be NO HOTTER THAN 41o C.
o When the person gets out of the bath, ensure they are covered and warm whilst being dried.
o Where possible, assist with dressing and grooming in the bathroom.
o If it is necessary to dress and groom in the person’s room, ensure that they are fully covered and warm whilst being transferred.
Bathing should be an enjoyable activity for the service user. Where there is reluctance to take a bath or shower, there may be a simple solution and the reasons should be discussed with the individual if this occurs.