FUNDA-PRELIM (CU&PPT&AKI) Two types of Microorganism found on the Skin

CU+ PPT+AKI 1. Transient flora

 ASEPSIS AND INFECTION CONTROL - Found on the outer layers of skin and are fairly easily
removed by hand washing.
Terminologies - They are the organisms most likely to result in
hospital-acquired infections.
1. Asepsis – Is the freedom from disease causing - Pandalian lang
microorganisms.
2. Resident flora
2. Nosocomial infection – Infections that are associated or
acquired in a hospital or other health care facility. (Sometimes - Are more deeply attached to the skin and are harder
called Hospital-acquired Infection) to remove.
- Always there or present.
3. Iatrogenic infection – Are the direct result of diagnostic or - When the skin is broken transient m.o penetrate the
therapeutic procedures (Kozier, 2008) inner layer of the body w/c is why one of defense of
m.o is intact skin
4. Communicable Disease – an illness caused by an
infectious agent or its toxins that occurs through the direct or Infection
indirect transmission of the infectious agent or its products
from an infected individual or via an animal vector or the -Implantation and successful replication of an organism in the
inanimate environment to a susceptible animal or human host. tissue of the host resulting in signs and symptoms.

Ex. Measles, hepatitis and HIV virus 2 types of infection:

5. Contagious Disease- disease that easily spreads directly
from one person to another.
6. Infectious Disease- disease not transmitted by ordinary
contact but require a direct inoculation through a break in a
previously intact mucous membrane. On the other hand, all
contagious diseases are infectious.
7. Carrier – is an individual who carries and can pass on a
genetic mutation associated with a disease.
8. Contact - is any person or animal who is in close
association with an infected person, animal, or freshly soiled
material.
9. Disinfection – destruction of pathogenic microorganism
outside the body through direct physical or chemical means.
1. Local infection – limited to a specific body part.
2. Systemic infection – when microorganism spread and
damage different body systems.
Types of Microorganism causing infection
 Bacteria
- Are single-cell microorganisms with well-defined cell
walls that can multiply independently on artificial
media without the need for other cells.
A) Spherical – cocci
B) Rod-shaped – bacilli
C) Spiral-shaped – spirilla

(Physical: sunlight exposure, heat etc. Chemical: sodium  Virus

hypochlorite, alcohol, etc.) - Are subcellular organisms made up of only a
ribonucleic acid or a deoxyribonucleic acid nucleus
10. Sterilization – defined as the complete destruction of all covered with proteins.
microorganisms including the most resistant bacteria and  Fungi
spores. - Organisms that exist by feeding on organic material.
(Yeast and molds)
Two types of Asepsis - Eukaryotes like plants and animals, they have well
organized self.
Medical asepsis  Parasites
- Is an organism that lives on or in a host organism and
- Also known as Clean Technique
gets its food from or at the expense of its host.
- Procedures used to reduce the number of microbes
and prevents spread. A) Protozoa – which adapts to invade and live in cells and
tissues on their host. Ex. Amoebic dysenteric and malaria
Surgical Asepsis
b) Helminths – larger enough to be seen by the naked eye.
- Also known as Sterile Technique
- Procedures use to eliminate any microorganism. c) Ectoparasites – live on the external surface of host.
- Used in invasive procedure like in urinary catheter or
operating room. Nosocomial Infection & Healthcare associated Infections
- Free from all microorganism.
Common microorganism Causes
Principles of surgical asepsis
Urinary Tract Improper catheterization
 Moisture causes contamination. - Escherichia coli (E.coli) technique Inadequate
 Never assume that an object is sterile. - Pseudomonas aeriginosa hand washing
 Always face the sterile field Surgical Sites
Improper dressing change
 Sterile to sterile - Staphylococcus Aureus technique Inadequate
 Sterile areas must be above the waist. - Methicillin-resistant hand washing
 Prevent unnecessary traffic and air currents. strains (MRS)
 Open and unused sterile articles are no longer sterile Blood Stream
Improper I.V. catheterization,
after procedure. - Staphylococcus Aureus tubing & site care technique
 A person who is considered sterile must maintain
- Enterococcus
sterility. Pneumonia
Improper suctioning technique
- Staphylococcus Aureus
 Surgical techniques are a team effort. Inadequate hand hygiene
- Pseudomonas aeriginosa
 Chain of Infection
- A way of gathering the information needed to interrupt
or prevent an epidemic.
- Each of the links in the chain must be favorable to the
organism for the epidemic to continue.
- Breaking any link in the chain can disrupt the
epidemic. Which link it is most effective to target will
depend on the organism.
- Breaking chain of infection is vital to avoid the spread
of m.o
Germs/ the Organism/ Infectious Agent
- Bacteria, viruses, parasites
- Any microorganism that is capable of producing an
infectious process.
Factors to consider:
 Number of microorganism present
 Their ability to enter and survive inside a host.
 Virulence
 Susceptibility of the host
Reservoir (Where germs live)
- People, animals/pets, wild animals, food, soil, water
- Place where microorganism survive, multiply and wait
transfer to a susceptible host.
- Can be on surfaces like table tops, door knobs and
people
- Breaking this include washing hands and disinfecting
surfaces
Portal of Exit (How germs get out)
- Mouth (vomit, saliva), cuts in the skin, during
diapering and toileting (stool).
- Can include blood, skin and mucous membrane, respi
tract, GI tract, GI tract, Transplacental from mother to
baby.
- Exits through coughing and sneezing
Mode of transmission (Germs get around)
- Contact (hands, toys, sand), droplets (when you
speak, sneeze or cough)
1. Direct transmission – direct transfer of microorganism from
one person to another person. Through hands or kiss
2. Indirect transmission – vehicle borne (eating utensils or
clothes), vector borne (animal, insects). From touching one
object with m.o to touching yourself to break this link use face
covering face shield wash hands and disinfection like
chemicals that can reduce bacteria
3. Airborne transmission – dust and droplets (small particles)
4. Droplet transmission – large particles that travel up to 3 ft
when coughing and sneezing.
Portal of Entry (how germs get in)
- Mouth, cuts in the skin, eyes
- Example respiratory droplets produced from the lungs
when infected person cough it can traveled to 6ft then
lands to nose or mouth of other people to prevent this
practice social distancing or self-quarantine
Susceptible host (next person)
- Babies, children, elderly, people with a weakened
immune system, unimmunized people, anyone.
- Person who cannot defend against infection
- If we break chain of infection we can keep everyone
safe
Precautions
1. Standard precaution
- A set of infection control practices used to prevent
transmission of diseases that can be acquired by contact with
blood, body fluids (hand hygiene, use of PPE, gloves, mask,
goggles)
2. Transmission-based precaution
a) Airborne precaution
- These are used for microorganisms transmitted by small
particle droplets that can remain suspended and become
widely dispersed by air currents. (Patient placement, Respi
protection N95)
b) Droplet precaution
- These are used for microorganisms transmitted by large
particle droplets through coughing, sneezing, or talking which
disperse into air currents (PPE: Eye protection, mask, gown,
gloves)
c) Contact precaution
- These are used for organism that can be transmitted by hand
or skin-to-skin contact, such as during client care activities or
when touching the client's environmental surfaces or care
items (PPE: eye protection, mask, gown, gloves)
Body defenses against infection
1. Non-specific defenses
A) Skin & Mucous membrane – intactness, acidity- destroy m.o
b) Nasal Passages – moist mucous & cilia- filter dust
c) Lungs - alveolar macrophages- mononuclear phagocytes
d) Eyes – tears- wash out dirt and m.o
e) Vaginal canal – duoderlein bacilli
f) Inflammatory response
2. Specific Defenses
- Immunity: Antigen-antibody response
Preventing Infection: Levels of preventive care
1. Primary Prevention
- True prevention
- Applied to clients that are healthy.
- Health promotion/Health Educ
- Immunization, nutrition, physical fitness
2. Secondary prevention
- Focuses on ill or sick individuals, and those at risk of
developing complications.
- Directed towards diagnosis & intervention.
- Screenings, surgery, medications.
3. Tertiary Prevention
- Focuses on permanent or irreversible disability.
- Minimizing the long-term effects of illness
- Rehabilitation (PT)
 Disinfection
 Concurrent – Done while the individual is still the
source of infection.
 Terminal – The patient is no longer the source of
infection.
 Quarantine – Limitation of the freedom of movement
of persons or animals which have been exposed to a
communicable disease for a period of time equivalent
to the longest incubation period of that disease
Isolation
1. Strict isolation – prevention of highly contagious or virulent
infection (hand washing, PPEs).
2. Contact isolation – prevent infections transmitted primarily
by direct contact. Thru contact with open wounds. (you must
wear your gloves and PPE)
3. Respiratory isolation – prevent transmission over a short
distance through the air. Thru particles (required to wear mask)
4. Blood and body fluids Precaution – must wear gloves
5. Reverse isolation – siya lang yung walang sakit.
6. Enteric isolation – prevent the spread through direct
contact from feces.
HANDWASHING (AKI+PPT)
d) When moving from a contaminated to a clean body site
during care
e) After contact with surfaces or objects in the patient’s room
f) After removing gloves
Cleaning
- Physical removal of visible dirt and debris by washing,
dusting, or mopping surfaces that are contaminated.
Use of barriers
- Techniques that prevent the transfer of pathogens
from one person to another.
Isolation systems
- Techniques used to prevent or limit the spread of
infection.
 Hand washing and Donning, Doffing of PPE (CU)
HAND HYGIENE
- Is the simplest and most cost effective way of
preventing the transmission of infection and thus
reducing the incidence of health care associated
infections.
MEDICAL HAND HYGIENE

- The rubbing together of all surfaces and crevices of
the hands using a soap or chemical and water.
- It is a component of all types of isolation precautions
and is the most basic and effective infection control
measure that prevents and controls the transmission
of infections agents.
 Hand washing
 Antiseptic hand wash
 Antiseptic hand rub/surgical hand antisepsis
 Hand washing (CDC 2008) is the vigorous, brief
rubbing together of all surfaces of lathered hands,
followed by rinsing under a stream of water for 15
seconds.
 Antiseptic Hand wash (CDC 2008) – washing the
hands with warm water and soap or other detergents
containing antiseptic agent.
 Antiseptic Hand rub – applying a hand rub product
to all surfaces of the hands to reduce the number of
microorganisms present.
 Surgical Hand Antisepsis – antiseptic hand wash or
hand-rub technique that all surgical personnel perform
before surgery to eliminate transient and reduce
resident hand flora.
HAND HYGIENE GUIDELINES (Boyce, et al, 2003) and
WHO (2009)
- Hand washing is the rubbing together of all surfaces
and crevices of the hands using a soap or chemical
and water.
- It is a component of all types of isolation precautions
and is the most basic and effective infection control
measure that prevents and controls the transmission
of infections agents
The three essential elements of hand washing
 Soap
 Water
 Friction
Always wash your hands
 Before, during and after food preparation
 Before eating
 After using the bathroom
 After blowing your nose, or using tissue to wipe your
nose
 After handling animals and/or animal waste•
 After changing diapers
 Whenever your hands are dirty
 Often if someone in home is sick•
 Before and after contact with each patient

1. When hands are visibly dirty, soiled with blood or other body Purposes of Hand Washing
fluids, before eating, after using the toilet, wash hands with
water and either a microbial or non-microbial soap 1. To reduce the number of microorganisms of the hands.

2. Wash hands when exposed to spore-forming organisms 2. To reduce the risk of transmission of microorganisms to
such as C.difficile, Bacillus anthracis, or Norovirus (CDC, clients
2014)
3. To reduce the risk of cross-contamination among clients
3. If hands are not visibly soiled (WHO, 2009), use an alcohol-
4. To reduce risk of transmission of infectious organisms to
based waterless antiseptic for routine decontamination of
oneself.
hands in the following situations:
MATERIALS
a) Before, after and between direct patient contact
 Laboratory Gown
b) Before putting on sterile gloves and before inserting invasive
devices  Soap: Plain, Mild or Anti-microbial soap
 Soap dish
c) After contact with body fluids or excretions, mucous  Orange Wood Stick or Toothpick
membranes, non-intact skin and wound dressings (even if  Hand Towel or Tissue Paper
gloves were worn)  Oil-free Lotion (optional)
 Receptacle
  Near the faucet or water container
Steps of Medical Hand Hygiene
1. Prepare the materials and assess your hands.
 Cut the nails short
 Remove jewelry
 Check hands for break in the skin, such as hangnails
or cuts.
2. Stand in front of the sink. Do not allow your uniform to touch
the sink during the washing procedure.
 Flex knees slightly if the sink is low.
3. Turn on water and adjust the flow.
4. Wet the hands and wrist areas. Keep hand lower than
elbows to allow water to flow toward fingertips.
5. Use about 1 – 2 teaspoons of liquid soap from dispenser or
lather thoroughly with bar soap. Rinse bar and return to soap
dish.
6. With a firm rubbing and circular motions, wash palms and
back of hands, each finger, the areas between the fingers, the
knuckles, wrist and forearms.
 Wash at least 1 inch above area of contamination. If
hands are not visibly soiled, wash to 1 inch above
wrist.
 Wash up the forearms at least as high as
contamination is likely to be present.
- Right palm over left, left over right
- Palm to palm fingers interlaced
- Back fingers to opposing fingers interlocked
- Rotational rubbing of right thumb clasped in left palm
and vice versa
- Rotational rubbing backwards and forwards with tops
of fingers and thumb of right hand in left and vice
versa.
7. Interlace the fingers and thumbs. Move the hands back and
forth.
 Continue the friction motion for 10 – 30 seconds.
8. Interlock the fingers of the opposing hands.
 Do rotational rubbing of each thumb.
9. With a firm rubbing and circular motion against the palm of
the other hand then do the same to the other hand.
10. Clean the fingernails using an orange wood stick or tooth
pick.
11. Rinse thoroughly using an upward motion from the
fingertips down to the wrist. Wash hands for a minimum of 15
seconds. For a more thorough hand washing, extend the time
for wetting, washing and rinsing.
12. Pat - dry the hands and wrists thoroughly with a hand
towel.
13. Turn off water. Use paper- towel to turn- off the faucet.
14. Use oil free lotion on hands if desired.
Five Common Types of Faucet Control
1. Hand-operated handles
2. Knee-lever faucet control
3. Foot-pedal faucet control
4. Elbow controls
5. Infrared control
Use of Barriers (Personal Protection Equipment/PPE)
Techniques that prevent the transfer of pathogens from one
person to another
Most commonly used barriers are as follows:
1. Mask
 Mask should fit tightly to the face, covering the nose
and the mouth
 They lose their effectiveness if they are WET, WORN
for a long periods, and when they are not changed
after caring for each client.
2. Gowns
 Gowns should be worn when caregiver’s clothing is
likely to be soiled by infected material.
 Use it only once and discard them
3. Caps and shoe coverings
 Caps are used to cover the hard, special covers are
available for shoes
 These shield body parts from accidental exposure to
contaminated body secretions.
4. Gloves
 Protects the hands for acquiring infective organisms
5. Private rooms
 Separation of clients into private rooms decreases the
chance of transmission of infection by all routes.
6. Equipment and Refuse handling
7. INFECTION WASTE
 Blood and body products, pathology laboratory
specimen, laboratory cultures, contaminated
equipment, food and unrinsed infant and adult diapers
8. INJURIOUS WASTE
 Needles, scalpel blades, lancets, broken glass
9. HAZARDOUS WASTE:
 radioactive materials, chemotherapy solutions and
their containers and other caustic chemical
 Provision of Comfort: Bed making (CU)
TERMINOLOGIES
Bed making
- The ability of the nurse to keep the bed clean and
comfortable.
- It is the technique of preparing different types of bed
in making patients/clients comfortable in his/her
suitable position for a particular condition
Fanfold
- It is done by grasping the upper edge of the linen with
both hands; specifically folding the edge of the sheet
used in the bed 6-8 inches outward
Mitered corner
- A means of anchoring sheets on mattresses; a
method of folding the bed clothes at the corners to
secure them in place while the bed is occupied.
- It is accomplished on the bottom sheet by placing the
end of the sheet evenly under the mattress.
Toe pleat
- A fold made in the top bed clothes to provide
additional space for patient’s toes
Foot drop

- Dropping of the foot from paralysis of the anterior

muscle of the leg; plantar flexion of the foot with
permanent contracture of the gastrocnemius (calf)
muscle and tendon.

Bed cradle

- It is a curved, semi-circular device made of metal that Unoccupied bed

can be placed over a portion of the patient’s body and
is sometimes called an Anderson frame,
- is a device designed to keep the top bedclothes off
the feet, legs, and even abdomen of a client
Open bed
PURPOSE OF BED MAKING
A. On changing an unoccupied bed
- to promote the client's comfort
- to provide a clean near environment for the client
- to provide a smooth, wrinkle-free bed foundation, thus
minimizing sources of skin irritation
 the unoccupied bed is made when there is no patient
confined in bed
 the top covers are generally folded back so that a
client can easily get into bed
 surgical, recovery and postoperative bed is a modified
version of the open bed; the top bed line is arranged
for easy transfer of the client from a stretcher to the
bed
 the top sheets are folded to one side or fan folded to
the bottom third of the bed

B. On changing an occupied bed

- to conserve the client's energy and maintain

current healthy status
- to promote the client's comfort
- to provide a clean near environment for the
client
- to provide a smooth, wrinkle-free bed
foundation, thus minimizing sources of skin Closed bed
irritation
 the top sheet blankets and bedspreads are drawn up
IMPORTANCE OF BED MAKING
to the head of the mattress and
1. It helps maintain a clean, orderly and comfortable room  under the pillows, this is prepared in a hospital room
which contributes to the patient’s sense of well-being. before a new client is admitted to that room

2. Helps the patient secure proper rest and comfort which are
essential for health and refresh him/her by providing
cleanliness

3. It helps prevent or avoid microorganisms to come in contact

with the patient which could cause tribulations.

4. It minimizes the sources of skin irritation by providing

smooth, wrinkle-free bed foundation.

TYPES OF BED Cradle Bed

Bed - is primarily divided into 3 sections  Contains cradle, a device for holding the top covers
off.
 Length: 1.9m (6.5ft).  The outer cradle is made of wood, metal or at home
 weight: 0.9m (3ft.) for a brief period, a cardboard art to shape.
 high: 66cm (26in.)
 but sometimes varies depending on circumstances

A. Common Types of Bed

Occupied bed

 The occupied bed is made when the patient is not

able or not permitted to get out of the bed
 the important part of making an occupied bed is to get
the sheets smooth and tight under
 the patient so that there will be no wrinkles to rub
against the patient’s skin
 the client’s privacy, comfort and safety is also
important when making the bed
Postoperative Bed
 Also known as recovery bed or anesthetic bed.
 Used not only for clients who have undergone
surgical procedures but also for clients who have
given anesthetics for a certain examination.
 Used for a patient with a large cast or other
circumstance that would make it difficult for him to
transfer easily into bed
B. Special Types of Beds
1. Water bed
• Special mattress filled with water.
• It controls temperature of water, reducing pressure on
body parts.
• Indications:
 Patients confined to bed for long periods
2. Turning Frames (Stryker Wedge)
6. Air Therapy Bed
 It allows repeated changes between the supine and
prone positions without disturbing spinal alignment.
 Indications:
 Complication of immobility such as atelectasis,
pneumonia, decubitus ulcer and renal calculi.
MAKING BEDS
3. Rotation Bed
 promote postural drainage, peristalsis and helps
prevent the complications of mobility
 Indication:
 patients with spinal cord injury, severe burns
Unoccupied Bed
4. Circolectric Bed
 Permits frequent turning of several injured or
immobilized patient with minimal trauma or
extraneous movement.
 Helps prevent and treat pressure ulcers, respiratory
and circulatory complications
 Indications:
 Patients confined to bed for long periods of time
. 
5. Clinton Therapy Bed
 Also called the air-fluidized bed
 Indications:
 Patients with managing burns and patients with
various disabilities
 Provide different levels of support to different body
parts.
 Indications:
 Patients who are at risk to skin breakdown
- Nurses need to be able to prepare hospital beds in
different ways for specific purposes. In most
instances, beds are made after the client receives
hygienic care and when beds are unoccupied.
- At times, however, nurses need to make an occupied
bed or prepare a bed for a client who is having
surgery (an anesthetic, postoperative, or surgical
bed). Regardless of what type of bed equipment is
available, whether the bed is occupied or unoccupied,
or the purpose for which the bed is being prepared,
certain practice guidelines pertain to all bed-making.
 An unoccupied bed can be either closed or open.
Generally, the top covers of an open bed are folded
back (thus the term open bed) to make it easier for a
client to get in.
 Open and closed beds are made the same way,
except that the top sheet, blanket, and bedspread of a
closed bed are drawn up to the top of the bed and
under the pillows.
 Beds are often changed after bed baths. The
replacement clean linen can be collected before the
bath.
 The linen is not usually changed unless it is soiled.
Check the policy at each clinical agency.
Unfitted sheets, blankets, and bedspreads are
mitered at the corners of the bed.
  The purpose of mitering is to secure the bedclothes
while the bed is occupied.
Mitering the corner of a bed
A. Tuck in the bedcover (sheet, blanket, and/or spread)
firmly under the mattress at the bottom of the bed.
B. Lift the bedcover so that it forms a triangle with the
side edge of the bed and the edge of the bedcover is
parallel to the end of the bed.
C. Tuck the part of the cover that hangs below the
mattress under the mattress while holding the triangle
up or against the bed.
D. Bring the tip of the triangle down toward the floor
while holding the fold of the cover against the side of
the mattress.
E. Remove the hand and tuck the remainder of the cover
under the mattress, if appropriate. The sides of the
top sheet, blanket, and bedspread may be left
hanging freely rather than tucked in, if desired.
Unoccupied/Closed Bed Making
Equipment
 Clean gloves, if needed
 Two flat sheets or one fitted and one flat sheet
 Cloth drawsheet (optional)
 One blanket
 One bedspread
 Incontinent pads (optional)
 Pillowcase(s) for the head pillow(s)
 Plastic laundry bag or portable linen hamper, if
available
Procedure
1.Knock before entering the room. Identify and greet the resident.
Explain procedure. Wash your hands. Provide for privacy.
2.Raise the bed to best level for good body mechanics. *(this is a
CRITICAL STEP!)
3.Remove linens from the bed, rolling them away from you so that
the surface that touched the resident is inside the roll.
4.Place the bottom sheet on the mattress. Unfold it lengthwise.
Place the center crease in the middle of the bed. Position the lower
edge evenly with the bottom of the mattress. Face hem stitching
downward.
5. Pick the sheet up from the side to open it. Fanfold it toward the
other side of the bed.
6.Go to the head of the bed. Tuck the sheet under the mattress.
Make sure the sheet is tight and smooth. Make a mitered corner.
7.Place the draw sheet on the middle 1/3 of the mattress.
8.Open the draw sheet and fanfold to the other side of the bed.
9.Tuck draw sheet and go to the other side of the bed, miter
corners.
15.Place the bedspread on the bed with the upper hem even with
the top of the mattress. Open and fanfold extra to the other side.
16.Make sure the bedspread facing the door is even and covers all
the top linens.
17.Tuck the linens together at the foot of the bed. Make a mitered
corner.
18.Go to the other side of the bed. Straighten all top linens, tucking
in top linens. Make a mitered corner.
19.Put the pillowcase on the pillow and place on the bed with open
end away from the door.
20. Lower the bed. Attach signal light within the residents
reach.*(this is a CRITICAL STEP!)
21.Wash hands and report and record observations
Occupied Bed
Some clients may be too weak to get out of bed. Either the
nature of their illness may contraindicate their sitting out of
bed, or they may be restricted in bed by the presence of
traction or other therapies.
When changing an occupied bed, the nurse works quickly and
disturbs the client as little as possible to conserve the client’s
energy, using the following guidelines:
 Maintain the client in good body alignment. Never move
or position a client in a manner that is contraindicated by
the client’s health. Obtain help if necessary to ensure
safety.
  Move the client gently and smoothly. Rough handling
can cause the client discomfort and abrade the skin.
 Explain what you plan to do throughout the procedure
before you do it. Use terms that the client can
understand. Encourage client participation when
appropriate.
 Use the bed-making time, like the bed bath time, to
assess and meet the client’s needs.
Equipment
 Two flat sheets or one fitted and one flat
sheet
 Cloth draw sheet (optional)
 One blanket
 One bedspread • Incontinent pads (optional)
 Pillowcase(s) for the head pillow(s)
 Plastic laundry bag or portable linen hamper,
if available
Procedure
1. Prior to performing the procedure introduce self and verify
the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how he or
she can participate.
2. Perform hand hygiene and observe other appropriate
infection control procedures. Apply clean gloves if linen is
soiled with body fluids.
3. Provide for client privacy.
4. Remove the top bedding.
 Remove any equipment attached to the bed
linen, such as a signal light.
 Loosen all top linen at the foot of the bed,
and remove the spread and the blanket.
 Leave the top sheet over the client (the top
sheet can remain over the client if it is being
changed and if it will provide suf- ficient
warmth), or replace it with a bath blanket as
follows:
A. Spread the bath blanket over the top sheet.
B. Ask the client to hold the top edge of the blanket.
C. Reaching under the blanket from the side, grasp the
top edge of the sheet and draw it down to the foot of
the bed, leaving the blanket in place.
D. Remove the sheet from the bed and place it in the
soiled linen hamper.
5. Change the bottom sheet and draw sheet.
 Raise the side rail that the client will turn toward.
Rationale:
- This protects clients from falling and allows them to
support themselves in the side-lying position.
- If there is no side rail, have another nurse support the
client at the edge of the bed.
 Assist the client to turn on the side away from the
nurse and toward the raised side rail.
 Loosen the bottom linens on the side of the bed near
the nurse.
 Fanfold the dirty linen (i.e., draw sheet and the bottom
sheet) toward the center of the bed as close to and
under the client as possible. Rationale: Doing this
leaves the near half of the bed free to be changed.
 Place the new bottom sheet on the bed, and vertically
fan- fold the half to be used on the far side of the bed
as close to the client as possible. Tuck the sheet
under the near half of the bed and miter the corner if a
contour sheet is not being used.
 Place the clean draw sheet on the bed with the center
fold at the center of the bed. Fanfold the uppermost
half vertically at the center of the bed and tuck the
near side edge under the side of the mattress.
 Assist the client to roll over toward you, over the fan
folded bed linens at the center of the bed, onto the
clean side of the bed.
 Move the pillows to the clean side for the client’s use.
Raise the side rail before leaving the side of the bed.
 Move to the other side of the bed and lower the side
rail.
 Remove the used linen and place it in the portable
hamper.
 Unfold the fan folded bottom sheet from the center of
the bed.
 Facing the side of the bed, use both hands to pull the
bottom sheet so that it is smooth and tuck the excess
under the side of the mattress.
 Unfold the draw sheet fan folded at the center of the
bed and pull it tightly with both hands. Pull the sheet
in three divisions:
(a) Face the side of the bed to pull the middle division,
(b) face the far top corner to pull the bottom division,
and
(c) Face the far bottom corner to pull the top division.
 Tuck the excess draw sheet under the side of the
mattress.
6. Reposition the client in the center of the bed.
 Reposition the pillows at the center of the bed.
 Assist the client to the center of the bed. Determine
what position the client requires or prefers and assist
the client to that position.
7. Apply or complete the top bedding.
 Spread the top sheet over the client and either ask
the client to hold the top edge of the sheet or tuck it
under the shoulders. The sheet should remain over
the client when the bath blanket or used sheet is
removed.
 Complete the top of the bed.
8. Ensure continued safety of the client.
 Raise the side rails. Place the bed in the low position
before leaving the bedside.
 Attach the call light to the bed linen within the client’s
reach.
 Put items used by the client within easy reach.
9. Bed-making is not normally recorded.
 Provision of Comfort: Complete Bed bath and Body
Positioning (CU)
TERMINOLOGIES
Hygiene
- Hygiene is the science of health and its maintenance.
Personal hygiene is the self-care by which people
attend to such functions as bathing, toileting, general
body hygiene, and grooming. Hygiene is a highly
personal matter determined by individual values and
practices.
 - It involves care of the skin, feet, nails, oral and nasal
cavities, teeth, hair, eyes, ears, and perineal-genital
areas.
Task-centered approach
- The task-centered model is a short-term problem-
solving approach in which the focus is. On tasks that
clients and practitioners carry out to resolve problems.
Clients have agreed to work on.
Person-centered approach
- Person-centered approach to nursing focuses on the
individual's personal needs, wants, desires and goals
so that they become central to the care and nursing
process. This can mean putting the person's needs,
as they define them, above those identified as
priorities by healthcare professionals
What comfort means to patients
- According to Wensley (2017), comfort is
multidimensional experienced by patients as a sense
of positivity and strength characterized not only by the
relief (even if only temporary) of physical discomfort
but an integration of positive emotions that include
feeling confident, competent, having a sense of
personal control, feeling cared for, valued, safe (able
to trust) and at ease.
- Patients’ description of comfort varied within these
common themes. For example, patients with terminal
illness described comfort in terms of feeling at ease or
at peace, patients receiving emergency care
described comfort in terms of feeling safe, cared for
and able to relax and children described comfort in
terms of feeling better, safe and not sad.
THREE TYPES OF COMFORT
The three technical senses of comfort that we presented at
Sigma Theta Tau (STT) were relief, ease, and renewal; the
term renewal was later changed to transcendence. Relief was
defined then as the experience of a patient who has had a
specific comfort need met. Ease was defined as state of calm
or contentment. Renewal (transcendence) was defined as the
state in which one rises above problems or pain. (Kolcaba,
1991).
HYGIENIC CARE
 Nurses commonly use the following terms to describe
types of hygienic care. Early morning care is
provided to clients as they awaken in the morning.
This care consists of providing a urinal or bedpan to
the client confined to bed, washing the face and
hands, and giving oral care.
 Morning care is often provided after clients have
breakfast, although it may be provided before
breakfast. It usually includes providing for elimination
needs, a bath or shower, perineal care, back
massages, and oral, nail, and hair care.
 Making the client’s bed is part of morning care. Hour
of sleep or PM care is provided to clients before they
retire for the night. It usually involves providing for
elimination needs, washing face and hands, giving
oral care, and giving a back massage. As-needed
(prn) care is provided as required by the client. For
example, a client who is diaphoretic (sweating
profusely) may need more frequent bathing and a
change of clothes and linen.
BATHING
 Bathing removes accumulated oil, perspiration, dead
skin cells, and some bacteria. The nurse can
appreciate the quantity of oil and dead skin cells
produced when observing a person after the removal
of a cast that has been on for 6 weeks.
 The skin is crusty, flaky, and dry underneath the cast.
Applications of oil over several days are usually
necessary to remove the debris. Excessive bathing,
however, can interfere with the intended lubricating
effect of the sebum, causing dryness of the skin. This
is an important consideration, especially for older
adults, who produce less sebum.
 In addition to cleaning the skin, bathing also
stimulates circulation. A warm or hot bath dilates
superficial arterioles, bringing more blood and
nourishment to the skin. Vigorous rubbing has the
same effect. Rubbing with long smooth strokes from
the distal to proximal parts of extremities (from the
point farthest from the body to the point closest) is
particularly effective in facilitating venous blood flow
return unless there is some underlying condition (e.g.,
thrombosis) that would preclude this.
 Bathing also produces a sense of well-being. It is
refreshing and relaxing and frequently improves
morale, appearance, and self- respect. Some people
take a morning shower for its refreshing, stimulating
effect. Others prefer an evening bath because it is
relaxing. These effects are more evident when a
person is ill. For example, it is not uncommon for
clients who have had a restless or sleepless night to
feel relaxed, comfortable, and sleepy after a morning
bath. Bathing offers an excellent opportunity for the
nurse to assess clients and opens the door for
establishing trust.
 The nurse can observe the client’s skin for conditions
such as sacral edema or rashes. While assisting a
client with a bath, the nurse can also assess the
client’s psychosocial needs, such as orientation to
time and ability to cope with the illness. Learning
needs, such as the need for a client who has diabetes
to learn foot care, can also be assessed.
LONG-TERM CARE SETTING
 From a historical perspective, the bath has always
been a part of the art of nursing care and considered
a component of nursing. In today’s nursing world,
however, the bath is seen as a necessary, routine
task and is often delegated to nonprofessionals.
 In spite of the previously listed beneficial values
associated with bathing, the choice of bathing
procedure often depends on the amount of time
available to the nurses or unlicensed assistive
personnel (UAP) and the client’s self-care ability. The
bath routine (e.g., day, time, and number per week)
for clients in health care settings is often determined
by agency policy, which often results in the bath
becoming routine and depersonalized versus
therapeutic, satisfying, and person centered.
 New models and a culture change process are
occurring in long-term care and residential care
settings. That is, these settings are trying to become
less about tasks and more about people and the
relationships between people. This person-centered
approach to bathing is especially important for the
older client in a long-term care setting. Bathing needs
to focus on the experience for the client rather than
the outcome (i.e., getting a bath or shower).
  A nurse who provides person-centered care asks
questions such as these: What is the client’s usual
method of maintaining cleanliness? Are there any
past negative experiences related to bathing? Are
factors such as pain or fatigue increasing the client’s
difficulty with the demands and stimuli associated with
bathing or showering? A client’s resistance to the
bathing experience can be a cue to the nurse to con-
sider other methods of maintaining cleanliness. For
example, if the shower causes distress, is there
another form of bathing (such as the bag or towel
bath) that may be more therapeutic and comforting?
 An individualized approach focusing on therapeutic
and comforting outcomes of bathing is especially
important for clients with dementia. Alzheimer’s
disease is the most common cause o dementia
among people ages 65 and older. As the incidence of
dementia increases, so does the need to preserve the
dignity of people with dementia. Preserving dignity is
especially a priority in the residential care
environment where more than two thirds of residents
have some form of dementia (Gaspard & Cox, 2012,
p. 43).
 This statistic has implications for nursing care. For
example, people with dementia may become agitated
as soon as they are told it is time to bathe and many
are afraid of the noise of running water and of water
on their face (Hoban, 2012).
 In addition, collaboration between the nurse and UAP
is a critical element to implementing the individualized
person-focused approach for clients with cognitive
impairments who exhibit aggressive behavior during
bathing. The nurse, after observing a difficult bathing
situation, should discuss with the UAP possible
alternative strategies or methods they might
implement for the client. More than one intervention
may be required (e.g., reassurance, simple
explanations, moving slowly).
 It is important for the nurse to subsequently evaluate
the person’s response to the new intervention(s). The
nurse has a role in educating UAP about dementia
and collaboratively problem solving bathing
challenges (Gaspard & Cox, 2012)
SKILL: BATHING AN ADULT CLIENT
PURPOSES
 To remove transient microorganisms, body secretions
and excretions, and dead skin cells
 To stimulate circulation to the skin
 To promote a sense of well-being
 To produce relaxation and comfort
 To prevent and eliminate unpleasant body odors
ASSESSMENT:
Assess
 Physical or emotional factors (e.g., fatigue, sensitivity
to cold, need for control, anxiety or fear)
 Condition of the skin (color, texture and turgor,
presence of pigmented spots, temperature, lesions,
excoriations, abrasions, and bruises).
[Areas of erythema (redness) on the sacrum, bony
prominences, and heels should be assessed for
possible pressure sores]
 Presence of pain and need for adjunctive measures
(e.g., an analgesic) before the bath
 Range of motion of the joints
 Any other aspect of health that may affect the client’s
bathing process (e.g., mobility, strength, cognition)
 Need for use of clean gloves during the bath
PLANNING
DELEGATION
- The nurse often delegates the skill of bathing to UAP.
However, the nurse remains responsible for
assessment and client care.
The nurse needs to do the following:
a. Inform the UAP of the type of bath appropriate for the client
and precautions, if any, specific to the needs of the client.
b. Remind the UAP to notify the nurse of any concerns or
changes (e.g., redness, skin breakdown, rash) so the nurse
can assess, intervene if needed, and document.
c. Instruct the UAP to encourage the client to perform as much
self-care as appropriate in order to promote independence and
self-esteem.
d. Obtain a complete report about the bathing experience from
the UAP.
Equipment
 Basin or sink with warm water (between 43°C and
46°C [110°F and
 115°F])
 Soap and soap dish
 Linens: bath blanket, two bath towels, washcloth,
clean gown or pajamas or clothes as needed,
additional bed linen and towels, if required
 Clean gloves, if appropriate (e.g., presence of body
fluids or open lesions)
 Personal hygiene articles (e.g., deodorant, lotions)
 Shaving equipment
 Table for bathing equipment
 Laundry bag
IMPLEMENTATION
Preparation
Before bathing a client, determine
(a) The purpose and type of bath the client needs;
(b) Self-care ability of the client;
(c) Any movement or positioning precautions specific to the
client;
(d) Other care the client may be receiving, such as physical
therapy or x-rays, in order to coordinate all aspects of health
care and prevent unnecessary fatigue;
(e) Client’s comfort level with being bathed by someone else;
and
(f) Necessary bath equipment and linens.
Caution is needed when bathing clients who are receiving
IV therapy. Easy-to-remove gowns that have Velcro or snap
fasteners along the sleeves may be used.
If a special gown is not available, the nurse needs to pay
special attention when changing the client’s gown after the
bath (or whenever the gown becomes soiled).
In addition, special attention is needed to reassess the IV site
for security of IV connections and appropriate taping around
the IV site.
The nurse should use universal precautions when bathing a
client, particularly when performing perineal care. It is not
necessary, however, to wear gloves while providing a bath and
the nurse should use clinical judgment when deciding to wear
gloves and offer an explanation to the client.
Performance A.Lay your hand on the washcloth and fold one side over
your hand
1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how he or
she can participate. Discuss with the client their preferences
for bathing and explain any unfamiliar procedures.

2. Perform hand hygiene and observe other appropriate

infection prevention procedures.
B. folds the second side over your hand
3. Provide for client privacy by drawing the curtains around the
bed or closing the door to the room. Some agencies provide
signs indicating the need for privacy. Rationale: Hygiene is a
personal matter.

4. Prepare the client and the environment.

 Invite a family member or significant other to

participate if desired or requested by the client. C. fold the top of the cloth down and tuck it under the
 Close windows and doors to ensure the room is a folded side against your palm to secure the mitt.
comfortable temperature. Rationale: Air currents
increase loss of heat from the body by convection.
 Offer the client a bedpan or urinal or ask whether the
client wishes to use the toilet or commode.
Rationale: Warm water and activity can stimulate the
need to void. The client will be more comfortable after
voiding, and voiding before cleaning the perineum is
advisable.
7. Wash the face.
Encourage the client to perform as much personal self-care as
possible. Rationale: This promotes independence, exercise, Rationale: Begin the bath at the cleanest area and
and self-esteem. work downward toward the feet.
 Place towel under client’s head.
During the bath, assess each area of the skin carefully.  Wash the client’s eyes with water only and dry them
well.
For a Bed Bath
 Use a separate corner of the washcloth for each eye.
5. Prepare the bed and position the client appropriately.  Rationale: Using separate corners prevent
transmitting microorganisms from one eye to the
 Position the bed at a comfortable working height. other.
Lower the side rail on the side close to you. Keep the  Wipe from the inner to the outer canthus.
other side rail up. Assist the client to move near you. Rationale: This prevents secretions from entering the
 Rationale: This avoids undue reaching and straining nasolacrimal ducts.
and promotes good body mechanics. It also ensures
client safety.
 Place bath blanket over top sheet. Remove the top
sheet from under the bath blanket by starting at client’s
shoulders and moving linen down toward client’s feet.
Ask the client to grasp and hold the top of the bath
blanket while pulling linen to the foot of the bed.

Rationale: The bath blanket provides comfort, warmth, and

privacy.

 Ask whether the client wants soap used on the face.

Rationale: Soap has a drying effect, and the face,
which is exposed to the air more than other body
parts, tends to be drier.
 Wash, rinse, and dry the client’s face, ears, and neck.
 Remove the towel from under the client’s head.

8. Wash the arms and hands. (Omit the arms for a partial
bath.)

 Remove client’s gown while keeping the client covered
with the bath blanket. Place gown in linen hamper.
6. Make a bath mitt with the washcloth.
Rationale: A bath mitt retains water and heat better than a
cloth loosely held and pre- vents ends of washcloth from
dragging across the skin.
 Place a towel lengthwise under the arm away from
you. Rationale: It protects the bed from becoming wet.
 Wash, rinse, and dry the arm by elevating the client’s
arm and supporting the client’s wrist and elbow. Use
long, firm strokes from wrist to shoulder, including the
axillary area.
Rationale: Firm strokes from distal to proximal areas
promote circulation by increasing venous blood
return.

 Apply deodorant or powder if desired. Special caution
is needed for clients with respiratory alterations.
Rationale: Powder is not recommended for these
clients due to the potential respiratory adverse effects.
 Optional: Place a towel on the bed and put a
washbasin on it. Place the client’s hands in the basin.
Rationale: Many clients enjoy immersing their hands
in the basin and washing themselves. Soaking
loosens dirt under the nails. Assist the client as
needed to wash, rinse, and dry the hands, paying
particular attention to the spaces between the fingers.
 Repeat for hand and arm nearest you. Exercise
caution if an IV infusion is present, and check its flow
after moving the arm. Avoid submersing the IV site if
the dressing site is not a clear, transparent dressing.
Rationale: A clear transparent dressing will keep
water from an IV site; however, a gauze dressing
becomes contaminated when it becomes wet with the
water.
9. Wash the chest and abdomen. (Omit the chest and
abdomen for a partial bath. However, the areas under a
woman’s breasts may require bathing if this area is irritated or
if the client has significant perspiration under the breast.)
 Place bath towel lengthwise over chest. Fold bath
blanket down to the client’s pubic area. Rationale:
Keeps the client warm while preventing unnecessary
exposure of the chest.
 Lift the bath towel off the chest, and bathe the chest
and abdomen with your mitted hand using long, firm
strokes.
 Give special attention to the skin under the breasts
and any other skinfolds, particularly if the client is
overweight. Rinse and dry well.
 Replace the bath blanket when the areas have been
dried.
10. Wash the legs and feet. (Omit legs and feet for a partial
bath.)
 Expose the leg farthest from you by folding the bath
blanket toward the other leg, being careful to keep the
perineum covered. Rationale: Covering the perineum
promotes privacy and maintains the client’s dignity.
 Lift leg and place the bath towel lengthwise under the
leg. Wash, rinse, and dry the leg using long, smooth,
firm strokes from the ankle to the knee to the thigh.
Rationale: Washing from the distal to proximal areas
promotes circulation by stimulating venous blood flow.
 Reverse the coverings and repeat for the other leg.
 Wash the feet by placing them in the basin of water.
 Dry each foot. Pay particular attention to the spaces
between the toes. If preferred, wash one foot after
that leg before washing the other leg.
 Obtain fresh, warm bathwater now or when
necessary.
Rationale: Water may become dirty or cold. Because
surface skin cells are removed with washing, the
bathwater from dark-skinned clients may be dark,
however, this does not mean the client is dirty.
 Lower the bed and raise the side rails when refilling
the basin. Rationale: This ensures the safety of the
client.
11. Wash the back and then the perineum.
 Assist the client into a prone or side-lying position
facing away from you. Place the bath towel
lengthwise alongside the back and buttocks while
keeping the client covered with the bath blanket as
much as possible.
 Rationale: This provides warmth and prevents undue
exposure.
 Wash and dry the client’s back, moving from the
shoulders to the buttocks, and upper thighs, paying
attention to the gluteal folds.
 Remove and discard gloves if used.
 Perform a back massage now or after completion of
bath.
 Assist the client to the supine position and determine
whether the client can wash the perineal area
independently. If the client cannot do so, drape the
client and wash the area.
12. Assist the client with grooming aids such as powder, lotion,
or deodorant.
 Use powder sparingly. Release as little as possible
into the atmosphere.
 Rationale: This will avoid irritation of the respiratory
tract by powder inhalation. Excessive powder can
cause caking, which leads to skin irritation.
 Help the client put on a clean gown or pajamas.
 Assist the client to care for hair, mouth, and nails.
Some people prefer or need mouth care prior to their
bath.
EVALUATION
 Note the client’s tolerance of the procedure (e.g.,
respiratory rate and effort, pulse rate, behaviors of
acceptance or resistance, statements regarding
comfort).
 Conduct appropriate follow-up, such as determining:
- Condition and integrity of skin (dryness, turgor,
redness, lesions, and so on).
- Client strength. Note range of motion and circulation,
movement, and sensation for all extremities.
 Percentage of bath done without assistance.
 Relate to prior assessment data, if available.
POSITIONING CLIENTS
 Positioning a client in good body alignment and
changing the position regularly (every 2 hours) and
systematically are essential aspects of nursing practice.
Clients who can move easily automatically reposition
themselves for comfort. Such people generally require
minimal positioning assistance from nurses, other than
guidance about ways to maintain body alignment and to
 exercise their joints. However, people who are weak, alignment intervention. Sometimes a client who
frail, in pain, paralyzed, or unconscious rely on nurses to appears well aligned may be experiencing real
provide or assist with position changes. For all clients, it discomfort. Both appearance, in relation to alignment
is important to assess the skin and provide skin care criteria, and comfort are important in achieving
before and after a position change. effective alignment.
 Any position, correct or incorrect, can be detrimental if
maintained for a prolonged period. Frequent change of
position helps to prevent muscle discomfort, undue
pressure resulting in pressure ulcers, damage to
superficial nerves and blood vessels, and contractures.
Position changes also maintain muscle tone and
stimulate postural reflexes.
 When the client is not able to move independently or
assist with moving, the preferred method is for two or
more nurses to move or turn the client and use assistive
equipment. Appropriate assistance reduces the risk of
muscle strain and body injury to both the client and
nurse, and is likely to protect the dignity and comfort of
the client.
 When positioning clients in bed, the nurse can do a
number of things to ensure proper alignment and
promote client comfort and safety:
- Make sure the mattress is firm and level yet has
enough give to fill in and support natural body
curvatures. A sagging mattress, a mattress that is too
soft, or an under filled waterbed used over a
prolonged period can contribute to the development of Hot and Cold Application
hip flexion contractures and low back strain and pain. (CU)
Bed boards made of plywood and placed beneath a
sagging mattress are increasingly recommended for Brief Overview
clients who have back problems or are prone to them.
Some bed boards are hinged across the middle so In anatomy and physiology, it is taught that temperature
that they will bend as the head of the bed is raised. It receptors in the body adapt to temperature changes. Nurses
is particularly important in the home setting to inspect and clients need to understand this because a hot application
the mattress for support. can cause burn injuries while cold application can result to pain
- Ensure that the bed is clean and dry. Wrinkled or and severe circulation impairment.
damp sheets increase the risk of pressure ulcer
formation. Make sure extremities can move freely Physiologic Effects of Heat and Cold
whenever possible. For example, the top bed- clothes
HOT
need to be loose enough for clients to move their feet.
- Place support devices in specified areas according to
1. Vasodilation
the client’s position. Use only those support devices
needed to maintain alignment and to prevent stress 2. Sedative effect
on the client’s muscles and joints. If the client is
capable of movement, too many devices limit mobility 3. Increase capillary permeability
and increase the potential for muscle weakness and
atrophy. 4. Increase cellular metabolism
- Avoid placing one body part, particularly one with
bony prominences, directly on top of another body 5. Increase inflammation
part. Excessive pressure can damage veins and
COLD
predispose the client to thrombus formation. Pressure
against the popliteal space may damage nerves and
1. Vasoconstriction
blood vessels in this area. Pillows can provide needed
cushioning. 2. Local anesthetic effect
- Avoid friction and shearing. Friction is a force acting
parallel to the skin surface. For example, sheets 4. Decrease cellular metabolism
rubbing against skin create friction. Friction can
abrade the skin (i.e., remove the superficial layers), 5. Increase inflammation (slows bacterial growth)
making it more prone to breakdown. Shearing force is
a combination of friction and pressure. It occurs Therapeutic Application
commonly when a client assumes a sitting position in
bed. In this position, the body tends to slide Local application of heat and cold in the body can be
downward toward the foot of the bed. This down- beneficial. They can either be in moist or dry forms. But before
ward movement is transmitted to the sacral bone and using these therapies, the nurse must understand the HOW
the deep tissues. and WHEN of their usage.
- Plan a systematic 24-hour schedule for position
A. Heat Application
changes. Frequent position changes are essential to
prevent pressure ulcers in immobilized clients. Such Dry heat:
clients should be repositioned every 2 hours
throughout the day and night and more frequently  Hot water bottle/bag = mostly used, especially at
when there is a risk for skin breakdown. This home; accessible and economical
schedule is usually outlined on the client’s nursing  Aquathermia pad (K-pad) = pad is attached by a
care plan. tubing to an electrically powered control unit
- Always obtain information from the client to determine (waterproof); has a temperature gauge
which position is most comfortable and appropriate.  Disposable heat pack or electric heating pad =
Seeking information from the client about what feels provide constant, even heat; can be molded to the
best is a useful guide when aligning clients and is an body part (CAUTION! Can cause burns if the setting
essential aspect of evaluating the effectiveness of an is too high)
 Thermal Tolerance Considerations

1. Body part – foot and back of hand are NOT overly sensitive
to temperature

- Eyelids, neck, Inner aspect of arm, and perineal area

Moist heat:
 Hot compress = use of gauze pads or roll or towels
 Hot pack = commercially prepared; provides heat for
a designated time only; directions for use are found
on the package labels to initiate heating process;
applied to a wound or injury (water temperature =
40°C)
 Hot soak = requires immersing a body part in a
solution or wrapping in gauze dressings saturated
with a solution (observe sterile technique for open
wounds); use to soften or remove crusted/dead
tissues
 Hot sitz bath = also known as hip bath; soak perineal
or rectal area into a solution (e.g. Epsom salt, witch
hazel, lavender oils) while the client sits on a special
chair or tub (water temperature = 40-43°C)
B.Cold Application
Dry cold:
are extremely sensitive to temperature
- The larger the body size exposed to heat and cold,
the lower the tolerance
2. Length of exposure – tolerance increase after some time
3. Skin integrity – areas of the skin with injury/ trauma
(compromised skin integrity) are more sensitive to heat and
cold
Rebound Phenomenon – occurs at the time the maximum
therapeutic effect of a hot or cold application is achieved and
the opposite effect begin (Berman, Snyder, and Frandsen,
2020) Therefore, thermal applications must be halted before
this phenomenon begins.
SKILLS PROCEDURE
IMPORTANT! Ensure all your equipment and materials are at
hand before going to the client.
I. Application of Moist Heat: Moist Compress and Sitz
Bath/Soak (Based on Perry, Potter, and Ostendorf, 2018)

 Cold pack = same as hot pack but, it initiates cooling
process
 Ice bag, ice glove, ice collar = filled with ice chips or
alcohol-based solution; must be wrapped in a towel or
cover when being used
Moist cold:
 FIRST: Introduce self and identify the client by asking
for at least 2 identifiers (e.g. name, birthday, age, etc.)
Assessment:
1. Verify order for type of moist heat application, location and
duration, and desired temperature.

 Compress 2. Review client’s chart for medical history and

 Cooling sponge bath = to reduce fever of over 40°C contraindications that may prohibit the use of hot or warm
by heat loss through conduction and vaporization therapy.
accompanied by antipyretics (water temperature = 27-
37°C) 3. Assess client’s vital signs and mobility.

Table 1. Indications of Heat and Cold Application 4. Assess client’s skin around the area to be treated and
client’s temperature and pain sensitivity.
Indication Effect of Heat Effect of Cold
5. Inspect wound, if any, for size, color, odor, tenderness,
Muscle Relaxes and Relaxes and drainage.
Spasm Increases Decreases
contractility contractility 6. Assess client and family’s awareness, understanding of the
Inflammati Increases blood Vasoconstriction procedure, and related safety factors.
flow, softens exudates
on
Planning:
Pain Relief Decreases
1. Identify expected outcomes
Contractur Reduction -
es 2. Assemble and prepare the equipment and supplies needed.
Joint Reduction -
stiffness Implementation
Traumatic Decreases
- bleeding
injury and edema  Provide privacy at all times.

a. Applying moist sterile compress:

Neurosensory impairment – they are unable to perceive hot
and cold temperatures that can lead to burns or tissue injuries
Impaired mental status – they have altered level of
consciousness and need monitoring during applications to
ensure safety
Impaired circulation – those with diabetes mellitus or
congestive heart failure lack the usual ability to dissipate heat
via blood circulation making them at risk for tissue damage
Materials needed: Moist compress (e.g. commercially prepared
aquathermia pad, etc.); Sterile gauze pads or roll (size and
number depends on the body part of client to be treated);
Heating equipment (to warm the water to the needed
temperature), Water proof pad or clean dry towel, Water
container/ basin), Gloves (1 pair clean and 2 pairs sterile)
1) Explain the procedure and purpose to the client, sensations
the client would feel and precautions to prevent burning.

Post-surgery – heat increases bleeding and swelling
Open wounds – cold can decrease blood flow to the wound
and impair the healing process
2) Heat water to the desired temperature for moist compress.
(For aquathermia pad use, prepare and set the desired
temperature.)
3) Perform hand hygiene and put on a pair of clean gloves

4) Keep client’s body part in proper alignment, drape client as

need, exposing only the body part to be treated.
5) Place a waterproof pad under the client’s body part, if
appropriate
6) Remove any wound dressing present, inspect condition of
wound and surrounding skin.
7) Dispose gloves and dressing into a biohazard bag. Then
perform hand hygiene.
8) Prepare the compress:
A.Pour the warm solution into a container
***Follow instructions for warming using commercially
prepared compress.
B.Wear sterile gloves
C.Using the sterile technique, open the gauze
D. Immerse gauze into the container of water
9) Pick up one layer of gauze, wring out excess water and
apply onto the wound and its surrounding skin
10) Lift gauze to initially assess for redness due to the moist
heat applied
11) Pack the moist gauze snugly if client tolerates the
compress covering all wound surfaces.
12) Cover moist compress with dry sterile gauze and clean
bath towel. Secure as appropriate; use pin, tie, etc. (Apply
aquathermia or water-proof heating pad if available)
13) Dispose gloves properly and perform hand hygiene.
14) Check back with client after 15 minutes and assess.
Change moist compress using sterile technique if heat pad is
not used.
15) After 30 minutes, or as ordered, remove the moist
compress using clean gloves.
16) Reassess wound and surrounding skin condition. (Replace
with dry sterile dressing, if ordered or as necessary, using
sterile technique, i.e. use sterile gloves and sterile gauze)
17) Help client to preferred comfortable position.
18) Dispose all soiled material and equipment appropriately
and perform hand hygiene.
B. Applying sitz bath or warm soak to sutured wound:
Materials: Sitz bath/tub equipment; Heating equipment (to
warm the water to the needed temperature), Clean and dry
blanket or bath towel, 3 pairs clean gloves
1) Heat water to the desired temperature in a separate
container.
2) Perform hand hygiene and wear clean gloves.
3) Remove any existing dressing over the client’s wound and
inspect the condition of the wound and skin, especially the
suture line.
4) Dispose of the soiled dressing and gloves appropriately and
perform hand hygiene.
5) Apply clean gloves again and clean the suture and
surrounding skin
6) In the client’s bathroom, fill the sitz bath container with the
warmed water. Check its temperature.
7) Assist client to the bathroom or to the bedside commode
and immerse body part into the bath and cover patient with
blanket or towel as needed. Remove and dispose gloves.
8) Assess client’s heart rate and ensure that client is not
lightheaded. Place the call button/ call light switch is within
reach.
9) After 20minutes, or as ordered, wear clean gloves, remove
client from the soak. Dry client, as necessary, and assist client
back to bed on position of comfort.
10) Drain the used sitz water and clean the equipment
properly. Place in the appropriate storage area. Dispose of
soiled blanket or towel and gloves and perform hand hygiene.
STOP the application immediately if any untoward incident
or problem(s) occur.
Evaluation
1. Inspect the body part or wound condition for evidence of
effectiveness of therapy and sensitivity to touch.
2. Ask client to describe level of comfort and burning sensation
following the treatment.
3. Obtain vital signs and compare with baseline.
4. Identify any unexpected outcome.
Recording and Reporting: Record, document, and report all
pertinent information of the procedure performed.
II. Application of Cold (Based on Perry, Potter, and
Ostendorf, 2018)
 FIRST: Introduce self and identify the client by asking
for at least 2 identifiers (e.g. name, birthday, age, etc.)
Assessment:
1. Verify order for type of moist heat application, location and
duration, and desired temperature.
2. Review client’s medical history and contraindications that
may prohibit the use of cold therapy
3. Assess client’s vital signs and mobility.
4. Assess client’s skin around the area to be treated and
client’s temperature and pain sensitivity.
5. Inspect wound, if any, for size, color, odor, tenderness,
drainage.
6. Assess client and family’s awareness, understanding of the
procedure, and related safety factors.
Planning:
1. Identify expected outcomes
2. Assemble and prepare the equipment and supplies needed.
Implementation
 Provide privacy at all times.
a) Applying a cold compress:
Materials needed: Cold compress may be commercially
prepared, a towel, or gauze pads or roll (size and number
depend on the body part of client to be treated); Ice,
Container/basin, Waterproof pad or clean dry towel, 1 pair
clean gloves
1) Explain the procedure and purpose to the client, sensations
the client would feel and precautions to prevent complications.
2) Perform hand hygiene and put on a pair of clean gloves
3) Keep client’s body part in proper alignment, drape client as
need, exposing only the body part to be treated.
4) Place a waterproof pad or towel under the client’s body part,
if appropriate.
5) Place ice water into a basin and check the temperature.
6) Submerge gauze pad or towel into the water and wring out
excess moisture.

7) Apply compress to affected area, molded over the site.

8) Remove, remoisten, and reapply to maintain the cold

temperature as needed.

9) Check skin condition at appropriate and regular intervals.

10) After Remove gloves, dispose of properly, and perform

hand hygiene.

11) Help client to a comfortable position.

12) Remove, clean, dry, and store or dispose of supplies and

equipment accordingly.

b) Applying an ice pack or bag

Materials needed: Ice bag or commercially prepared ice gel

pack; Ice, Container/basin, Waterproof pad or clean dry towel,
1 pair clean gloves

1) Explain the procedure and purpose to the client, sensations

the client would feel, and precautions to prevent complications.

2) Perform hand hygiene and put on a pair of clean gloves

3) Keep client’s body part in proper alignment, drape client as

need, exposing only the body part to be treated.

4) Place a waterproof pad or towel under the client’s body part,

if appropriate

5) Fill bag with water (approximately 2/3 full) and ice.

6) Express excess air from bag, secure cap, and wipe the bag
dry.

7) Apply over injury, mold and ensure it is secure in place.

*For commercially prepared ice gel pack, squeeze and knead

then wrap with towel.

8) Check skin condition at appropriate and regular intervals.

8) After 30 minutes, or as ordered, remove gloves, dispose of

properly, and perform hand hygiene.

9) Help client to a comfortable position.

10) Remove, clean, dry, and store or dispose of supplies and

equipment accordingly.

STOP the application immediately if any untoward incident

or problem(s) occur.

Evaluation

1. Inspect the body part or wound condition for evidence of

effectiveness of therapy and sensitivity to touch.

2. Ask client to describe level of comfort and burning sensation

following the treatment.

3. Obtain vital signs and compare with baseline.

4. Identify any unexpected outcome(s).

Recording and Reporting: Record, document, and report all

pertinent information of the procedure performed.