1

PERSONAL HYGIENE AND COMFORT

A. PERSONAL HYGIENE:

Hygiene is the practice of cleanliness that is conducive to the preservation

of health. Assisting the patient with hygienic and personal care activities is an
essential nursing function. Proper care of the skin, hair, teeth, and nails
promotes good health by protecting the body from infection and disease. In
turn, this promotes a sense of well- being for your patient. Personal hygiene
means measures of personal cleanliness and grooming that promotes physical
and psychological well-being and self esteem. These practices are influenced
by several factors such as:

a. Socio-cultural background – different cultures have different views

on hygiene practice.

b. Economic status – the availability of the materials for personal

hygiene may or may not be available

c. Knowledge Level – lack of knowledge may affect ones practice of

personal hygiene.

d. Ability to perform self care – The ability to perform self care may
be affected by the patient’s mental or physical condition, which
may be temporary because of illness or injury.

e. Personal preference- Refers to the choice and decision of the client

to bath at a specific time or day.

Types of bath include cleansing, therapeutic, complete and or partial. The

cleansing bath is generally provided either in a bed, tub, or shower. Bed
baths are given to patients who are unable to use a tub or shower.
Therapeutic baths includes baths that are used to reduce / control or
improve the health status of the individual. Examples of this bath includes hot
sitz bath and tepid sponge bath. The complete bed bath is provided to
dependent clients confined to bed. The nurse washes the entire body during
a complete bed bath. Partial baths includes variation of the complete bed
bath such as washing hands, face, oral, hair, feet, perineum and genitals.

Other types of hygienic care the nurse can provide to hospitalized patients
are: early morning care, morning or after breakfast care, afternoon care and
evening or hour-before-sleep care.

a. Early morning care or AM Care

 2

This care is performed with patients before they are served breakfast.
They are scheduled for early morning laboratory tests or surgery. it
includes offering a bedpan or urinal if patient is not ambulatory, washing
hands and face and assisting oral care.

b. Morning or after-breakfast care or complete morning care

This care is performed after the patient has eaten breakfast. It includes
offering a bedpan or urinal to patients who are confined to the bed;
providing a shower or bath, oral, foot, nail and hair care; giving a back
rub, changing patient’s gown or pajamas, changing bed linens and
straightening the bedside table and room.

c. Afternoon care

Afternoon hygiene includes washing the hands and face of the patient,
assisting with oral care, offering a bedpan or urinal and straightening bed
linen.

d. Evening or Hour-before- Sleep Care

Personal hygiene before bedtime helps the patient relax and promote
sleep. Afternoon care may include changing soiled bed linens; gowns or
pajamas; assisting the patient in washing the face and hands, providing
oral hygiene; giving back massage; and offering the bedpan or urinal to
patients who are not ambulatory.

1. Complete Bed Bath

Purposes:

1. To cleanse the skin

2. To stimulate circulation to all areas of the body
3. To promote comfort.
4. To remove waste products secreted through the skin
5. To assess the patient’s overall status, skin condition, and level of mobility.

Equipment:
Basin of warm water (45-46oC for adults/38-40oC for children)
Soap in a soap dish
Washcloth
Kidney basin
Bath blanket
Three sheets
Patient’s gown
Pillowcase
Bath towel
Perineal tray for female (gloves, forceps, pitcher of warm water, cotton
balls)
Shaving equipment for male patient
Personal equipment (deodorant, talcum powder, comb or brush,
protective pad, toothbrush and toothpaste)

Procedure and Rationale:
PROCEDURE
1. Assemble equipment.
2. Bring all equipment to the patient’s To save time and energy.
unit.
3. Screen the patient if in the ward
and if in private room, close
windows and door.
4. Assess patient’s preferences
including cultural factors. Explain
unfamiliar methods or procedures
regarding bathing.
5. Offer bedpan to the patient.
6. Remove all but one pillow and
place the bed in a flat position.
7. Remove top linen from the bed.
Fold bedspread from top to bottom
in half and again in fourths. Fold
blanket in the same manner. If
they are to be reused, place in
back of the chair. If linen is dirty,
roll and place in hamper.
8. Fold the top sheet to the waist
line. Place the folded draping
blanket over the patient’s chest.
Secure one end under the
shoulder of the patient or have the
patient hold the top edge of the
blanket. Unfold to the foot of the
bed while fanfolding the top sheet.
Fold used top sheet and use it for
an adaptation linen draw sheet.
Drape over chair.
3
RATIONALE
Organization facilitates
performance of task.
Provide privacy; prevent draft. Air
currents increase loss of heat from
the body by convection.
Demonstrate respect for patient’s
preference and encourage
participation. Patient has the right
to receive information necessary
to give informed consent and
decrease fear of the unknown.
This will also give time to prepare
himself/herself.
The client will be more
comfortable after voiding, and
voiding before cleaning the
perineum is advisable.
Most patients are comfortable if
placed flat in bed with one pillow.
Putting the bed in flat/low
position is also convenient for the
nurse.
Removing the top linens will keep
it from getting wet. Folding the
linen in place as it is being
removed to avoid the stretching of
the arms, saves time and energy
when used in the bed later.
Provide privacy. Keep patient
warm. Save in cost and material.

9. Help patient to the side of the bed
closest to you. Let him lie flat on
his back.
10. Place a towel across the chest of
the patient and assist him with
oral hygiene as necessary.
11. Remove towel. Drape it over back
of the chair. Place the bath
blanket on the patient. Remove
patient’s hospital gown by slipping
it off under the bath blanket.
12. Make a bath mitt with the wash
cloth.
13. Wash the client’s eyes with water
only, and dry them well. Use a
separate corner of the washcloth
for each eye. Wipe from the inner
to the outer canthus.
14. Wash, rinse, and dry the patient’s
forehead, cheeks, nose, and area
around lips. Use soap with
patient’s permission. Wash, rinse
and dry areas behind and around
the patient’s ears. wash, rinse and
dry patient’s neck.
15. Remove towel and place it
obliquely under the patient’s arm
away from self.
16. Wash, rinse and dry the arm,
using long, firm strokes from distal
to proximal areas. Wash the axilla
well. Repeat for the other arm.
17. Wash patient’s hands by soaking
them in the basin. Rinse and then
dry.
18. Place the bath towel lengthwise
over the chest. Fold the bath
4
This facilitates access without
undue reaching and straining.
Oral hygiene is an important part
of helping to keep the mouth and
teeth clean, healthy and feeling
comfortable.
Provide privacy. Avoid
unnecessary exposure and chilling.
A bath mitt retains water and heat
better than a cloth loosely held
and it prevents the fingernails of
the nurse from hurting the client.
Soap is irritating to the eyes.
Using separate corners prevent
transmitting microorganisms from
one eye to the other. Cleaning
from the inner to the outer
canthus prevents secretions from
entering the nasolacrimal ducts.
Soap has a drying effect, and the
face, which is exposed to the air
more than the other body parts,
tends to be drier. Wash from the
cleanest to the most contaminated
area of the body. Patting dry is
less abrasive to the skin tissue.
Wash arm that is further from the
nurse to prevent accidental
dripping on the clean area as the
nurse reaches across.
Firm strokes from distal to
proximal areas increase venous
blood return. Bacteria collect in
the sweat gland areas, and extra
cleansing is needed to remove dirt
and body odor.
Allow for thorough washing of the
hands and the areas between the
fingers.
This keeps the client warm while
preventing unnecessary exposure

blanket down to the client’s pubic
hair
19. 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 skin folds.
Rinse and dry well.
20. Place bath towel under the leg to
be washed and tuck under the hip.
Expose one leg at a time. Wash
thigh and leg farther from self first
with long firm strokes. Rinse and
dry.
21. Wash the foot. Place bath basin
on the towel. Support the ankle
and heel in your hand and the leg
on your arm and place the foot on
the wash basin. Rinse and dry
foot and the area between the
toes thoroughly.
22. Obtain fresh warm bath water.
23. Assist patient to a prone or side-
lying position away from you.
24. Place towel on the bed parallel to
the patient. Place the bath towel
lengthwise alongside the back and
the buttocks while keeping the
client covered with the bath
blanket as much as possible.
25. Wash and dry the client’s back,
moving from the shoulders to the
buttocks, and upper thighs, paying
attention to the gluteal folds.
Perform a back massage.
26. Place patient on her back (dorsal
recumbent). Place half of the bath
towel under the buttocks and do
perineal care. Obtain clean, warm
water.
5
of the chest.
Long firm strokes promotes
circulation.
Covering the perineum promotes
privacy and maintains the client’s
dignity. Long firm strokes from
distal to proximal areas promote
circulation by stimulating venous
blood flow.
Supporting the foot and leg helps
reduce strain and discomfort for
the patient. Placing the feet in a
basin of water is comfortable and
relaxing for the patient. It allows
for a thorough cleaning of the feet
and the area between the toes.
Water may become dirty and cold
because surface skin cells are
removed during bathing.
Restful position which permits
cleansing, massage, and
visualization of the back.
This provides warmth and
prevents undue exposure.
Doing a back massage relaxes the
patient by stimulating venous
blood flow thus promoting
circulation.
Provide easy access to genitalia.
Perineal care will provide comfort
and removes genital secretions. If
patient prefers to wash own
genitalia, the nurse may assist as
necessary.
 6

27. Apply lotion or powder as desired. To ensure comfort of the patient.

Put on the gown of the patient. Lotion lubricates skin. Powder
Brush or comb hair. Change linen. absorbs perspiration.

28. Put away articles used. Leave the unit clean and neat to
prevent accidents.

29. Wash hands. To prevent the spread of

microorganisms.

30. Document skin assessment, type Provides evidence of nursing care.

of bath given, and client outcomes
and responses.

2. Perineal Care

The area between the thighs is called the perineum. It extends from the anterior
pelvis to the anus. This area is dark, warm, and moist. It favors the growth of
bacteria. Perineal care consists of washing the perineum and external genitalia
to prevent bacterial growth. Perineal care is routinely performed when bathing
the client but may be required to prevent skin irritation or infection to clients
who are vulnerable. Vulnerable clients are clients with indwelling urinary
delivery. The nurse should maintain a professional and dignified attitude when
performing perineal care.

Purposes:
1. To promote or increase patient comfort.
2. To decrease bacterial growth.
3. To promote healing after perineal or anal surgery and vaginal
deliveries.
4. To remove excessive secretions. (e.g., Smegma – a thick, cheesy
substance found under the labia minora and around the clitoris in the
femalw and under the foreskin in the male client. When smegma is
allowed to collect, it irritates these areas and emits foul odor).

Equipment:
Bath blanket or sheet Disposable gloves
2 bath towels Forceps
Wash cloth Cotton balls
Protective pad Bedpan
Soap Cornocupia
Pitcher of warm water or prescribed solution (antifungal/antibacterial)

Procedure and Rationale:

PROCEDURE RATIONALE
1. Assess the presence of irritation, To determine extent of perineal
excoriation, inflammation, swelling, care required by client.
excessive discharge, odor, pain or
discomfort; urinary or fecal
incontinence; presence of
indwelling catheter; recent rectal
or perineal surgery.
 7

2. Determine self-care abilities or To determine level of assistance

whether the client is experiencing required from the nurse.
any discomfort in the perineal-
genital area.

3. Assemble equipment and supplies Organization facilitates

then bring to client’s unit. performance of procedure.

4. Explain to the client what you are Helps minimize client’s anxiety.
going to do, why it is necessary,
and how she can cooperate.

5. Wash hands and observe other Minimize transmission of

appropriate infection control microorganisms.
procedures.

6. Provide for privacy. Hygiene is a personal matter.

7. Fold the top bed linen to the foot The bath towel prevents the bed
of the bed and fold the gown up to from becoming soiled.
expose the genital area. Place a
bath towel under the client’s hips.

8. Position and drape the client and Prevents unnecessary exposure of

clean the upper inner thighs. the body part and maintains
For females: position client in a warmth and comfort of the client
back-lying position with knees during the procedure.
flexed and spread well apart.
Cover her body and legs with the
bath blanket.
For males: position client in a supine
position with knees slightly flexed
and hips slightly externally rotated.
Drape the legs by tucking the
bottom corners of the bath blanket
under the inner sides of the legs.
Bring the middle portion of the
base of the blanket up over the
pubic area.

9. Put on gloves, and wash and dry Infection control procedure.

the upper inner thighs.

10. Inspect the perineal area. Note To determine the extent of

particular areas of inflammation, perineal care needed.
excoriation, or swelling, especially
between the labia in females or the
scrotal folds in males. Also note
excessive discharge or secretions
from the orifices, and the presence
of odors.

11. Wash and dry the perineal-genital

 8

area:
For females: clean the labia majora.
Then spread the labia to wash the
folds between the labia majora and
labia minora. Use separate
quarters of the washcloth for each
stroke, and wipe from the pubis to
the rectum. For menstruating
women and clients with indwelling
catheter, use clean wipes, cotton
balls or gauze. Take a clean ball
for each stroke. Rinse and dry the
area well.
For males: wash and dry the penis,
using firm strokes. If client is
uncircumcised, retract the prepuce
to expose the glans penis for
cleaning. Replace the foreskin
after cleaning. Wash and dry the
scrotum.
Secretions that tend to collect
around the labia minora facilitate
bacterial growth.
Using separate quarters of the
wash cloth or new cotton balls or
gauzes prevents the transmission
of microorganisms from one area
to the other. Wipe from the least
contamination (pubis) to the
greatest (rectum).
Moisture supports the growth of
many microorganisms.
Handling the penis firmly may
prevent an erection.
Retracting the foreskin is
necessary to remove the smegma
that collects under the foreskin
and facilitates bacterial growth.
Replacing the foreskin prevents
constriction of the penis that may
cause edema.

12. Clean between the buttocks . Side-lying position provides access

Assist the client to turn onto the to anal area for cleansing.
side facing away from you. Pay
particular attention to the anal Fecal material contains
area and posterior folds of the microorganisms that can cause
scrotum in males. Clean the anus vaginal or urinary tract infection.
with toilet tissue before washing it,
if necessary. Dry the area well.

13. Ensure client comfort. Remove Client’s comfort minimizes

bath blanket. Ensure that the emotional stress on procedure.
client’s clothing is dry. Position to
a comfortable position and keep
patient warm with top sheet and
blanket in place.

14. Dispose soiled articles and/or clean Reduces transmission of infection.

equipment and return to supply
room. Perform hand washing.

15. Document pertinent data. For continuity of care.

3. Oral / Denture Care

Patients confined in bed should receive oral care on a regular basis as part of a
personal hygiene routine. Oral care should be offered before breakfast, after
meals and at bed time. It is especially important to give oral care to patients
receiving oxygen, patients with nasogastric tubes in place, those on NPO
(nothing per orem) and unconscious patients.
 9

A. Oral care
Includes gargling, tooth brushing and dental flossing.

Purposes:

1. To prevent oral disease and tooth destruction.

2. To promote a feeling of well-being.
3. To remove foul tasting secretions or sores. (Sores are accumulations of
dried secretions, microorganisms, food particles, and epithelial tissues in
the, mouth which may have developed from illness or certain therapies.)
4. To maintain an intact and well-hydrated mucosa.

Equipment:
Water in glass Face towel
Small toothbrush Dental floss
Toothpaste Antiseptic mouth wash
Emesis basin (optional)

Gargling

Procedure Rationale
1. Assess patient’s ability to rinse the If patient can perform own oral
mouth. care, provide the necessary
articles.

2. Assemble equipment needed and Comfort and ease of the patient.

bring to the patient’s unit.

3. Place towel under patient’s chin, Prevent soiling of gown; prevent

tucking it behind the shoulders. towel from slipping.

4. Let patient rinse mouth with water Gargling provides relief and
or antiseptic mouthwash and freshens the breath.
expectorate into the emesis basin.
Repeat as necessary.

5. Help patient to wipe mouth, remove Shows respect to the patient.

and clean emesis basin.

Tooth brushing (for conscious patient)

Procedure Rationale
1. Assess patient’s ability to brush If patient own oral care, provide
teeth. the necessary articles. The nurse
assists the patient as needed.

2. Assemble equipment and place on Save time and energy.

 10

over bed table.

3. Place patient in fowler’s position or Comfort of patient.

semi-fowler position.

4. Place towel under the patient’s chin, Prevent soiling of patient’s gown,
tucking it behind the shoulders. anchors towel.
5. Wash hands and put on clean Prevent spread of microorganisms,
gloves. for infection control.

6. Moisten toothbrush with water and Toothpaste acts a cleaning agent.

spread a small amount of If no toothpaste is available, plain
toothpaste on it. water may be used. Baking soda is
a substitute that also freshens the
breath.

7. Hold brush at 45 angle and brush Procedure allows thorough

using small, vibrating, circular cleaning of the teeth, gums, and
motion with the bristles at the tongue.
junction of the teeth and gums. Use
a back-and forth brushing motion
over the biting surfaces of the
teeth. Brush the tongue last.

8. Allow patient to rinse mouth with Provide comfort to the patient.

water or mouthwash (if desired)
and expectorate into the emesis
basin. Wipe the patient’s mouth.

9. Rinse equipment and return to its Maintain cleanliness and

proper place. Dispose used orderliness in the ward.
materials.

10. Return bed to its low position. Comfort of the patient.

Dental Flossing

Flossing is carried out between the teeth and between the gums and each
individual tooth to remove plague. (plaque are microorganisms trapped in a
mucous base which if not removed causes tooth and gum disease). It
involves inserting wax or unwaxed dental floss between all tooth surfaces and
pulling the flos in see saw motion taking care not to injure the delicate
mucous membrane. After flossing, allow the patient to rinse mouth the
remove debris. It is recommended that flossing should be done once daily
after brushing.

Oral care for unconscious or debilitated patients

Additional equipment:

Anti-infective solution (e.g. hydrogen peroxide diluted in equal parts of

water)
Padded tongue blade
 11

Paper towels
Petroleum jelly
Disposable gloves
Tongue blade wrapped in single layer of gauze
Portable suction machine (optional) with suction catheter

Unconscious patients are susceptible to drying of mucosa-thickened salivary

secretions because they are unable to eat or drink, frequently breathe
through the mouth, and often receive oxygen therapy. The unconscious
patient also cannot swallow salivary secretions that accumulate in the mouth.
These secretions often get into the lungs. Therefore the nurse must protect
the patient from choking and aspirating.

Procedure and Rationale:

PROCEDURE RATIONALE
1. Assess for presence of gag reflex. Reveals patient’s risk for
Position patient in Sim’s or aspiration. Allows secretion to
sidelying position with head drain from mouth instead of
turned well toward dependent collecting in back of pharynx and
side. prevents aspiration.

2. Explain procedure to patient. Unconscious patient may retain

ability to hear.

3. Wash hands and apply disposal Reduces transfer of

gloves. microorganisms.

4. Place paper towels on over bed Prevent soiling of table top.

table and arrange equipment. Equipment prepared in advance
Turn on suction machine and ensures smooth, safe procedure.
connect tubing to suction
catheter.

5. Pull curtain around bed or close Provides privacy.

room door.

6. Raise bed to highest horizontal Use of good body mechanics with

level; lower side rail. bed in high position prevents
injury to you and patient.

7. Bring patient close to side of bed Proper positioning of head

and near you, be sure patient’s prevents aspiration.
head is turned toward mattress.

8. Place towel under patient’s face Prevents soiling of bed linen.

and emesis basin under chin.

9. Carefully retract patient’s upper Prevents patient from biting down

and lower teeth with padded on fingers and provides access to
tongue blade by inserting blade oral cavity.
quickly but gently between the
back molars. Insert when client is
relaxed if possible.
 12

10. Clean mouth using brush or Brushing action removes food

tongue blade moistened with particles between teeth and along
peroxide and water. Have second chewing surfaces. Swabbing helps
nurse suction as secretions remove secretions and
accumulate during cleansing. encrustations from mucosa and
Clean chewing and inner tooth moistens mucosa. Suction
surfaces first. Clean outer tooth removes secretions loose debris
surfaces. Swab roof mouth and and peroxide that can be irritating
inside cheeks. Gently swab or to mucosa.
brush tongue but avoid
stimulating gag reflex (if present).
Moisten clean swab or toothette
with water to rinse. Repeat rinse
several times. Suction any
remaining secretions.

11. Apply thin layer of petroleum jelly Lubricates lips to prevent drying
to lips. and cracking.

12. Explain that procedure is Provides meaningful stimulation

completed. to unconscious or less responsive
patient.

13. Remove gloves and dispose in Prevents transmission of

proper receptacle. microorganisms.

14. Reposition patient comfortably, Maintains patient’s comfort and

raise side rail, and return bed to safety.
original position.

15. Clean equipment and return to its Proper disposal of soiled

proper place. Place soiled linen in equipment prevents spread of
proper receptacle. infection.

16. Wash hands. Reduces transmission of

microorganisms.

17. Inspect oral cavity. Determines efficacy of cleansing.

After thick secretions are
removed, underlying inflammation
or lesions may be revealed.

18. Record procedure, including Determines response of patient to

pertinent observation (e.g.
bleeding gums, dry mucosa,
ulcerations, or crusts on tongue)
and report any unusual findings to
nurse in charge or physician.
nursing therapy. Bleeding may
indicate more serious systematic
problems. Lesions of oral cavity
can be cancerous.

4. Shampooing Hair in Bed


Purposes:
1. To remove oil and dirt.
2. To increase circulation to the scalp.
3. To improve appearance and morale.
Equipment:
Kelly pad
Rubber sheet
Pail
Safety pins
Shampoo
Hair conditioner (optional)
Wash basin
Procedure and Rationale:
PROCEDURE
1. Assess activity tolerance of the
client. Check for existence of any
scalp problem.
2. Determine whether a physician’s
order is needed before a shampoo
can be given.
3. Assemble equipment and supplies
then bring to client’s unit.
4. Explain to the client what you are
going to do, why it is necessary
and how she can cooperate.
5. Provide for client privacy.
6. Assist client to the side of the bed
from which you will work.
7. Arrange the equipment:
a. Put the plastic sheet on the bed
under the head and cover it
with draw sheet or bath towel.
b. Place Kelly pad over the bath
towel and let its end extend to
the receptacle or pail. If Kelly
pad is not available improvise a
trough.
c. Place newspaper on the floor
under the pail. All other
articles are placed on bedside
table.
13
cotton balls
bath blanket
2 face towel or washcloth
2 pitchers of warm and cold water
newspapers
cornocopia or paper bag
RATIONALE
Certain medical conditions may
place client at risk for injury.
Some agencies require an order.
Save time and energy.
Client may be anxious about
positioning or risk of water
entering the ears or eyes.
Hygiene is a personal matter.
Minimizes back strain of health
provider.
The plastic keeps the bedding
dry.
Allow drainage of water from the
pad that is directed into the
receptacle.
Protect the floor from getting
wet. Placing the other articles
within reach minimizes strain.
 14

8. Put folded wash cloth or towel Protect the gown of the patient.
where the client’s neck rests on
the Kelly pad. Tuck another bath
towel over the chest and around
the client’s shoulder.

9. Fanfold the top bedding down to The folded bedding will stay dry,
the waist, and cover the upper part and the bath blanket, which can
of the client with the bath blanket. be discarded after the shampoo,
will keep the client warm.

10. Protect the client’s eyes and ears:

a. Place a wash cloth over the The washcloth protects the eyes
client’s eyes. from soapy water.
b. Place cotton balls in the These keep water from collecting
client’s ears. in the ear canals.

11. Shampoo the hair:

a. Gently comb hair well,
observing scalp and hair for
color, texture, distribution,
scaling, infestation or infection.
b. Wet the hair thoroughly with
warm water directing water
away from eyes and ears.
c. Place a small amount of
shampoo into your hands,
working it into a lather and
massage it into the scalp and
hair. Apply conditioner if
preferred by patient.
d. Rinse the hair thoroughly.
Squeeze as much water as
possible out of the hair with
your hands.
Removing tangles results in in
more thorough cleansing.
Water aids in distribution of
shampoo over hair.
Massaging stimulates the blood
circulation in the scalp.
Conditioner prevents excess
drying.
Shampoo remaining in the hair
may dry and irritate the hair and
scalp.

12. Pat dry hair with bath towel and Prevents dripping from wet hair.
wrap turban style. Remove Kelly
pad, rubber sheet and position
client comfortably in bed.

13. Remove cotton balls from ears and For comfort of the client.
discard properly. Dry ears,
forehead and neck.

14. Continue rubbing hair and scalp Drying prevents chilling.

gently until dry. Comb and
arrange hair using a clean brush or
comb.

15. Ensure client comfort. Remove For comfort of client.

bath blanket, ensure that client’s
clothing is dry, position to a
comfortable position and keep
 15

patient warm with top sheet and

blanket in place.

16. Dispose or clean equipment and Decreases the spread of

return to supply room. Perform
handwashing.
17. Document pertinent data.
microorganisms.
Document patient’s response to
therapy and conditions of hair
and scalp should further
treatment be neces.sary

5. Sponge Bath

A sponge bath is an alternative to bathing in a tub or showering. A sponge

bath is also common for young babies since concern exists about them
slipping in large tubs. When water is in short supply, a sponge bath may also
be an effective means for cleaning the body.

Hospitals employ the sponge bath, particularly for clients who have mobility
issues and can’t stand in a shower or safely bathe in a tub. Regular bathing
of the body is particularly important especially those who have inability to
turn in beds, and excess of dirt or oil on the body can cause bedsores to
form, which easily can become infected.

Purposes:
1. To give bath to a client who is not fit to have a standing bath.
2. Used for hygiene purposes, especially for confused or agitated
clients.
3. Used when a full bath is not necessary.
4. To assist in lowering body temperature.
5. To promote relaxation.

Equipment:
Basin of tepid water Clinical thermometer
Washcloth (4 pieces) Client’s gown
Bath towel Waterproof pad
Bath blanket Light weight linen

Procedure and Rationale:

PROCEDURE RATIONALE
1. Take the patient’s TPR and record. Provides baseline data for
evaluating response of patient to
therapy. Sudden circulatory
changes may alter pulse.

2. Close the doors and windows. To prevent drafts and provide

Screen the patient. privacy. Drafts may cause the
patient to chill or shiver. Shivering
is a heat-producing mechanism
and will act against the purpose of
the bath.
 16

3. Explain procedure to the patient. Explaining the purpose may

reduce anxiety.

4. Bring the needed articles to the Saves time and energy.

bedside.

5. Place the client in a comfortable To prevent strain on the client and

position. Client should be close to the nurse doing the procedure.
the side near you.

6. Replace the top covers with the Removing the top linens will keep
bath blanket. it from getting wet.

7. Remove the client’s gown. Place
the bath towel lengthwise on top
of the patient’s chest 2/3 under
the bath blanket and 1/3 turned
over the blanket.
Removing the client’s gown will
keep it from getting wet and
provides access to all skin
surfaces.

8. Dip the washcloth in tepid water. To prevent linen from getting wet.
Wring out excess water.

9. Make a bath mitten. This facilitates easier sponging

and preserves temperature of wet
wash cloth.

10. Sponge starting from the face and Patting the skin dry prevents
neck, moving towards the chest chilling and rubbing will produce
and abdomen. Avoid friction. Pat warmth by increasing cell
excess water lightly from the metabolism.
patient’s skin using the bath towel.

11. Place the towel under the patient’s Prevents sudden temperature fall
arm farthest from you. Sponge and minimizes risk of developing
the arm moving upward for 3 chills.
minutes; consider areas where
heat is confined, such as the axilla.
Do the same with the other arm.
Expose only the area you are
sponging.
12. Expose and put the towel under Prevents sudden temperature fall
the leg further from you. Sponge and minimizes risk of developing
using upward strokes; consider chills.
areas where heat is confined, such
as the groin. Do the same with
the other leg. Expose only the
area you are sponging.

13. Turn client to side. Place the
towel lengthwise on the back of
the patient. Sponge the patient’s
back using long strokes from the
nape down to the end of the
spine. Pat and dry.
Turning client to side provides
access to the back for sponging.
Patting and drying prevents
sudden temperature fall and
minimizes risk of developing chills.
 17

14. Put on the patient’s clothing or For client’s comfort and warmth.
gown. Replace the patient’s top
covers. Do not allow shivering to
occur. Stop the treatment or
modify it to prevent shivering.
15. Check the client’s TPR 30 minutes To evaluate effect of bath on the
after the procedure and record. client.

16. Do after care of equipment used. Controls transmission of

Wash hands. microorganisms.

17. Record time procedure started and Recording communicates care

terminated, changes in vital signs provided.
and response to therapy.

6. Foot Care

Purposes:
1. To provide a clean feet, odor free and hydrated skin.
2. To provide comfort.
3. To assess skin integrity and abnormalities of the feet.

Equipment needed
Gloves Nail clippers
Bath towels (2) Talcum powder
Wash basin Foot cream
Washcloth Cotton tip applicators
Soap Water
Nail brush Pillow

Procedure and Rationale:

PROCEDURE RATIONALE
1. Explain to client planned Client must be willing to place
procedure and confirm that client feet in basin and explaining the
has no allergies. procedure would allay the
client’s anxiety.

2. Assemble equipment. Assembling all equipment

provides for smooth performance
procedure.

3. Seat client in stable, comfortable Sitting in chair facilitates

chair if able. If the client is immersing feet in basin.
bedridden, pull bedding out of
the foot of the bed and fold
upward to expose feet and lower
legs.

4. Place towel under client’s feet. The towel will protect the feet
from exposure to soil or debris.

5. Wash your hands. Apply gloves
as necessary.
6. Fill basin halfway with warm
water. Test temperature and
place basin on top of the towel.
Water should not exceed 40
degrees centigrade.
7. Assist/ place client’s foot into the
basin. Immerse. If bedridden,
have client bend knees to
immerse foot in the water. Place
a pillow under the knees PRN.
And cushion the basin rim with
the edge of the towel.
8. Soak foot 2 – 10 minutes,
depending on client’s health and
tolerance.
9. Wash foot with scant amount of
a mild antibacterial soap. Cetaphil layers. Lotion lubricates dry
lotion may be used in place of
soap. Use a towel or stone
pumice on any thickened, dry
skin areas usually heels and
medial side of large toe. Brush
nails.
10. Rinse well to be sure all soap is
removed.
11. Remove foot from the basin and
place directly onto clean towel.
12. Pat and then gently rub dry,
paying close attention to
between and under the toes.
Trim nails according to client
taste.
13. Put in your hand or on a towel
small amount of powder. Lightly
powder between and under toes.
14. Concurrent assess skin and
function. Observe color, shape,
texture. Note dryness, redness,
cracks, blisters, discoloration,
trauma, pain, numbness, tingling,
swelling, muscle wasting,
18
Reduces transmission of
infection.
Warm water softens nails and
thickened epidermal cells,
reduces inflammation of skin,
and promotes local circulation.
Proper water temperature
prevents burns and injury.
Clients with muscular weakness
or tremors may have difficulty
positioning feet. Client’s safety
is maintained.
Softening of corns, calluses, and
cuticles ensures easy removal of
dead cells and easy manipulation
of cuticle.
Friction removes dead skin
skin.
To protect the client’s feet from
exposure to soil or debris.
Removal of debris and excess
moisture reduces chances of
infection.
Powder will help keep between
and under toes dry.
Assesses adequacy of blood flow
to extremities. Circulatory
alterations may change integrity
of nails and increase client’s
chance of localized infection
when break in skin integrity
 19

decreased sensation, hair growth occurs.

or pulse.

15. Check pulses, turgor and capillary Assesses circulatory conditions

refill. of the lower extremities.

16. Empty basin and refill. Repeat

procedure with other foot.

17. Lightly apply cream not lotion, Lubricates dry skin and helps
massaging into the foot. Pay retain moisture.
special attention to dry areas.
Avoid between and under toes.

18. Wipe with a dry towel any excess Excess moisture reduces chances
cream. Perform ROM exercises of infection. ROM exercises
improves circulation.

19. Put on clean dry socks after foot

care. Rub your hand around the
interior of shoes or slippers. Put
on shoes, if desired.

20. Remove, clean and replace Reduces transmission of

equipment/ supplies used. infection.

21. Dispose of gloves and wash Reduces transmission of

hands. microorganisms.