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Clinical Practice Keywords Hygiene/Bed bathing/ Infection prevention Practical procedures This article has been Essential care double-blind peer reviewed The underlying principles and procedure for bed bathing patients

upporting patients to maintain and eye care. These procedures are not cov- Author Sandra Lawton is nurse their hygiene needs while they ered in depth in this article. consultant dermatology, Rotherham are in hospital is a fundamental Foundation Trust; Eileen Shepherd is Saspect of nursing care, yet there Bed bathing a patient clinical editor, Nursing Times. is very little evidence to support practice Bed bathing is not as effective as show- (Coyer et al, 2011). Personal hygiene ering or bathing and should only be under- Abstract Good personal hygiene is includes care of the: taken when there is no alternative (Dough- essential for skin health but it also has l Hair; erty and Lister, 2015). If a bed bath is an important role in maintaining l Skin; required, it is important to offer patients self-esteem and quality of life. l Nails; the opportunity to participate in their Supporting patients to maintain l Mouth, eyes, ears and nose; own care, which helps to maintain their personal hygiene is a fundamental l Perineal areas (Dougherty and Lister, independence, self-esteem and dignity. aspect of nursing care. This article 2015); outlines the procedure for bed bathing l  Facial shaving (Ette and Gretton, 2019). Selecting appropriate equipment a patient. Hygiene and skin care should be con- Plastic wash bowls were routinely used in sidered as one entity, as both have a poten- hospitals for bed bathing but they can Citation Lawton S, Shepherd E (2019) tial impact on skin health and on patients’ easily become contaminated with micro- The underlying principles and comfort and wellbeing. organisms responsible for healthcare- procedure for bed bathing patients. Factors that have a negative effect on acquired infections (Marchaim et al, 2012). Nursing Times [online]; 115: 5, 45-47. skin health include: As such, single-use disposable bowls are l Excessive washing, particularly if harsh now commonly used. products are used; All patient should have their own toilet- l Lack of hygiene, causing build-up of ries or be supplied with single-patient use potential pathogens and increasing items until their own toiletries can be infection risk (Cowdell et al, 2014). brought into hospital. Box 1 lists other factors. Soap can alter skin pH, leading to dry- Helping patients to wash and dress is ness and skin breakdown, so it is suggested frequently delegated to junior staff, but that skin-cleansing emollient creams time spent attending to a patient’s hygiene should be used (Cowdell et al, 2014). These needs is a valuable opportunity for nurses should be prescribed for individual to carry out a holistic assessment (Dough- patients, and a spoon or spatula should be erty and Lister, 2015; Burns and Day, 2012). used to decant the product into a dispos- It also allows time to address any concerns able pot to prevent contamination; emol- patients have and provides a valuable lients in tubes or pump containers reduce opportunity to assess the condition of this risk. New supplies should be pre- their skin. scribed following treatment for a skin Patients will have their own values and infection (Lawton, 2016). practices relating to hygiene, which nurses Reusable washcloths should be avoided Box 1. Factors that negatively need to consider when planning care. For as they can harbour bacteria. This is par- affect skin health example, some patients may bathe in the ticularly important in patients who are evening as it helps them settle for the immunocompromised or critically ill, or l Poor nutrition and hydration night, while others may prefer to shower those whose skin integrity is compro- l Advancing age in the morning. Nurses should also discuss mised, for example, patients with burns l Incontinence with patients any religious and cultural (Dougherty and Lister, 2015). l Medical interventions, such as issues relating to personal care (Dougherty A relatively new development is pre- radiotherapy and chemotherapy and Lister, 2015). For example, ideally, packaged cloths for bed bathing (com- l Concurrent or underlying skin Muslim patients should be cared for by a monly known as the bag bath), which do conditions nurse of the same gender (Rassool, 2015), not require water. A systematic review l Surgical interventions, wounds and and Hindus may wish to wash before comparing bag baths with traditional bed drains prayer (Dougherty and Lister, 2015). baths concluded that ‘washing’ without l Poor mobility As part of routine hygiene care, some water may be an alternative to the tradi- Source: Dougherty and Lister (2015) patients may require urethral catheter tional bed bath, although more research is care, mouth and denture care, footcare required (Groven et al, 2017).

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Box 2. General principles ● Comb/brush; Only expose the part of the body that is of bed bathing ● Equipment for oral and denture care; being washed. ● Disposable wash bowls; l Keep the patient warm at all times ● Linen skip; 14. Starting with the arm farthest away, l Position a linen skip near the patient ● Non-sterile gloves if personal wash and dry the upper body, including and dispose of used linen protective equipment is required or for the arms, hands, axilla and torso. Moving immediately to reduce dispersal of intimate care. across the body in this way ensures the microorganisms and dead skin cells patient is clean and dry by the end of the into the environment The procedure procedure (Dougherty and Lister, 2015) l Only expose the area of the body 1. Review the patient’s care plan for (Fig 1b). Always wash down the body, for being washed (Fig 1) hygiene needs. Ensure that someone example from axilla to hands. l Change water if it becomes dirty or will be available to help you during the cold and always after washing the procedure. 15. Ask the patient if they would like to genitalia and sacrum soak their hands in water (Fig 1c). l Change wash cloths if they become 2. Decontaminate your hands. soiled and after washing the genitalia 16. Remove clothing from the lower body, and sacral area 3. Discuss the procedure with the patient, then wash and dry the legs and feet, l Check skin for pressure damage ask about their usual hygiene routine and starting with the leg farthest away and l Av oid contaminating dressings and gain informed consent for a bed bath. working from the top of the leg to the foot. drains with water Check feet for any problems such as cal- l Pat the skin dry to reduce the risk of 4. Check whether the patient has any pain. luses and dry skin. friction damage Administer analgesia if necessary and l Separa te skin folds, and wash and ensure it has taken effect before starting 17. Change the water and wash cloth and, if pat them dry the bed bath. This will help to relieve any required, apply non-sterile gloves before l Use the correct manual handling pain associated with moving the patient washing the patient’s genitalia. procedures and equipment to avoid during the procedure. injury to yourself and the patient 18. If appropriate, ask the patient if l If the patient is unconscious, 5. Ensure the patient’s privacy and check they wish to wash their own genitalia, or remember to talk them through what the environment is warm and draught free. gain consent to continue with the proce- you are doing; nurses should not talk dure. Female patients should be washed over the patient 6. Check whether the patient wishes to from front to back to reduce the risk of Source: Ersser et al (2005); Dougherty and empty their bowel or bladder before urinary tract infection (Fig 1d). The fore- Lister (2015) starting the bathing procedure. skin in uncircumcised men should be drawn back and the skin underneath 7. Assemble your equipment and ensure should be washed. Glove use everything is to hand to minimise the The World Health Organization (2009) amount of time the patient is exposed. 19. Dispose of water – and gloves if used. stated that non-sterile gloves are not Ensure the bed is at the correct working required routinely for washing and height. 20. Decontaminate your hands and fill a dressing patients. Nurses need to assess disposable bowl with warm water, individual patients for risk of exposure to 8. Decontaminate your hands and put on an checking the temperature again with the blood and body fluids (Royal College of apron. patient. Nursing, 2018) and be aware of local poli- cies for glove use. 9. Fill a disposable bowl with warm water 21. With help from a colleague (who has Evidence suggests that patients may and ask the patient to check the tempera- decontaminated their hands and put on an prefer nurses to wear gloves to provide ture is comfortable. apron), roll the patient onto one side using intimate care (Loveday et al, 2014a), for appropriate equipment. Assess if gloves example, washing genitalia. When gloves 10. If the patient is wearing a watch, are required for washing the sacrum. are required they must be single-use and hearing aid or glasses, remove them. Using a clean wash cloth and towel, wash be disposed of in accordance with local and dry the back then the sacral area, policy (Loveday et al, 2014b). 11. Place a towel under the patient’s chin moving from top to bottom (Fig 1e). and cleanse the patients eyes according to Undertaking a bed bath local policy. Wash the face, neck and ears, 22. Roll the patient back and both you and Box 2 outlines the general principles of bed checking whether the patient likes soap on your colleague decontaminate your hands. bathing. their face (Fig 1a). 23. Change the lower sheet according to Equipment needed 12. Clean hearing aids and glasses if worn, local procedures. ● Disposable apron; and return them to the patient to facilitate ● Clean bed linen and clothes; communication during the procedure. 24. Help the patient to get dressed. ● Two bath towels; ● Wash cloths; 13. Help the patient to remove their upper 25. Check the patient’s fingernails and toe-

● Patient toiletries; clothes and use a sheet to cover the patient. nails, and offer nail care if it is required. LAMB PETER

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Fig 1. The procedure: bed bathing a patient

1a. Place a towel under the patient’s chin. 1b. Starting with the arm farthest away, 1c. Patients may enjoy soaking their Wash their eyes, face, neck and ears, wash and dry the top half of the body. Only hands and feet in a bowl of water placed check whether they like soap on their face expose the part of the body being washed on the bed

Clitoris Urethral opening Labia majora Labia minora Vagina Perineum Anus

1d. Wash the genital area of female patients from front to back 1e. Wash the patient’s back and sacrum, moving from top to to reduce the risk of urinary tract infection bottom

26. Help the patient to clean their teeth References Loveday H et al (2014a) Clinical glove use: healthcare and/or dentures, or assist them with Burns S, Day T (2012) A return to the basics: workers’ actions and perceptions. Journal of Hospital interventional patient hygiene (a call for papers). Infection; 86: 2, 110-116. mouth care following local procedures. Intensive and Critical Care Nursing; 28: 4, 193-196. Loveday HP et al (2014b) epic3: National Cowdell F et al (2014) Hygiene and emollient evidence-based guidelines for preventing 27. Comb or brush the patient’s hair. Offer interventions for maintaining skin integrity in older healthcare-associated infections in NHS hospitals in people in hospital and residential care settings England. Journal of Hospital Infection; 86: S1, S1-70. to help male patients with shaving if this is (Protocol). Cochrane Database of Systematic Marchaim D et al (2012) Hospital bath basins are part of their normal routine. Reviews; Issue 12: CD011377. frequently contaminated with multidrug-resistant Coyer FM et al (2011) The provision of patient human pathogens. American Journal of Infection Control; 40: 6, 562-564. personal hygiene in the intensive care unit: a Rassool GH (2015) Cultural competence in nursing 28. Finish making the bed and ensure descriptive exploratory study of bed-bathing Muslim patients. Nursing Times; 111: 14, 12-15. the patient is warm and comfortable practice. Australian Critical Care; 24: 3, 198-209. Royal College of Nursing (2018) Tools of the with a call bell and a drink (if allowed). Dougherty L, Lister S (2015) The Royal Marsden Trade: Guidance for Health Care Staff on Glove Ensure that their belongings are within Hospital Manual of Clinical Nursing Procedures. Use and the Prevention of Contact Dermatitis. Oxford: Wiley-Blackwell. Bit.ly/RCNGloves reach. Ersser SJ et al (2005) A critical review of the World Health Organization (2009) WHO inter-relationship between skin vulnerability and Guidelines on Hand Hygiene in Health Care. urinary incontinence and related nursing Bit.ly/WHOHands2009 29. Remove and dispose of aprons and intervention. International Journal of Nursing decontaminate your hands. Studies; 42: 7, 823-835. Ette L, Gretton M (2019) The significance of facial Professional responsibilities 30. Record the care that has been under- shaving as fundamental nursing care. Nursing This procedure should be undertaken Times; 115: 1, 40-42. taken, along with any abnormal finding(s), Groven FM et al (2017) How does washing without only after approved training, supervised and ensure you update the patient’s care water perform compared to the traditional bed practice and competency assessment, plan. Contact the tissue viability specialist bath: a systematic review. BMC Geriatrics; 17: 31. and carried out in accordance with local Lawton S (2016) Emollients and ageing skin: if you have any concerns about the optimising effectiveness and safety. British Journal policies and protocols.

PETER LAMB PETER patient’s skin. NT of Nursing; 25: 11, 596-598.

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