Bed bath - The aim of this paper is to alert nurses in our local intensive care unit (ICU) to practice their work rationally and not on a ritualistic routine approach.
The I.C.U.
Bed Bath
Vincent Saliba
Introduction
In 1981, Armstrong Esther wrote "The daily bed bath, often described as a 'cat's lick' is not given on the basis of patient need or habit but as a part of ritualised care." Gooch (1989) admits that despite the documentation of the effects of soap and water on the skin, "the routine blanket bath remains one of the most frequently performed, and least often omitted, nursing task."
The aim of this paper is to alert nurses in our local intensive care unit (ICU) to practice their work rationally and not on a ritualistic routine approach. The aspects of bathing from different perspectives is going to be discussed, the primary aim being to demonstrate both its benefits and dangers to patients' health, focused mainly on critically ill patients. Such aspects include sleep-wake patterns, subjective opinions, skin integument, and physiological changes.
Many are the procedures that need to be carried out on patients requiring intensive care; some of them are invasive and inevitable, others include basic nursing care that, although important, could be co-ordinated and delayed according to the circumstances or priorities. One such basic procedure is bathing. Webster and Thompson (1988) describe how bathing has been, throughout history, associated with physical, emotional, and social well being; and how today, society seems to regard hygiene as a high priority. Henderson and Nite (1978) consider that cleanliness is essential to a normal physical and mental state and point out that many diseases inhibit physiological functions such as lacrimation, salivation, and sweating, that, in a sense, cleanse the body so that "cleansing processes inadequate in health may have to be modified in sickness." Nightingale (1859) considered that leaving a patient unwashed was interfering injuriously with the natural process of health just as effectively as if she were to give the patient poison.
During their time of study in nursing, the majority of nurses, if not all, have come across literature supporting the importance and necessity of bathing as indicated above. In the classroom, the student learnt the procedure both theoretically and practically. In the clinical setting the student was conditioned to bathe patients in the early morning. However the co-ordination of this procedure with others has hardly ever been emphasised. The result is that bathing became and still is a ritual in each and every corner of our hospital. The intensive care unit whom the author works in is no exception and since its inauguration, this procedure has been ritualised to the fullest. Nurses bathe patients between seven and eight in the morning irrespective of whether they (the patients) are still asleep, they had a 'rough' night, they do not feel like to, or their degree of sickness is so grave; such as in haemodynamic instability; that the minimum of procedures further compromise their condition. Moreover most of the nurses do not seem to perceive rest and sleep as an essential necessity.
"The patient has the right to have knowledge and information, and the right to be fully involved in planning care" (Walsh and Ford 1992). Unfortunately this does not often apply to patients receiving care in an intensive care unit whom the majority of them are either sedated or worse still, are muscle relaxed too. Their critical condition prohibits them from participating in their care therefore leaving the nurses in a position to plan the nursing care according to the patients' needs alone. Such planning demands careful attention for timed procedures, a broad knowledge base of intensive care nursing and common sense. Are nurses practising in this manner? Walsh and Ford (1992) argue how "common sense is highly preferable to ritualistic action" and admit that "traditional nursing is based on many unsubstantiated beliefs, but not so many facts".
Fabijan and Gosselin (1982) suggest that patients in ICUs show signs and symptoms of sleep deprivation within 48 hours of admission and although the majority of nurses are aware of the importance of sleep, they do not differentiate between essential and non-essential nursing tasks and often disturb patients unnecessarily (Morgan and White 1983). Hilton (1976) admits that due to the critical nature of the patient's illness in the ICU and the essential need for continuous monitoring and care, the normal sleep patterns and cycles are highly susceptible to interruptions and changes. From his study Hilton (1976) concludes that ...
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Fabijan and Gosselin (1982) suggest that patients in ICUs show signs and symptoms of sleep deprivation within 48 hours of admission and although the majority of nurses are aware of the importance of sleep, they do not differentiate between essential and non-essential nursing tasks and often disturb patients unnecessarily (Morgan and White 1983). Hilton (1976) admits that due to the critical nature of the patient's illness in the ICU and the essential need for continuous monitoring and care, the normal sleep patterns and cycles are highly susceptible to interruptions and changes. From his study Hilton (1976) concludes that personal care (which includes bathing amongst others) scored 18.5% when compared to other possible sleep disturbance factors. These results are considerably high and should be seriously considered so that awareness for the promotion of adequate sleep periods is ensured from all nursing professions.
Many studies have confirmed that there is a huge body of evidence which supports the hypothesis that sleep aids healing. Although not concrete, Torrance (1990) argues that there is evidence that many cycles, such as protein synthesis, cell proliferation, metabolism of plasma amino acids, and growth hormone secretion, are entrained to the sleep-wake cycle; and that wakefulness is marked by enhanced catabolism, while sleep appears to be the time of maximum anabolic activity. The findings suggest that disturbing patients' sleep interferes with anabolic body functions and thus increasing the time of recovery in critically ill patients.
These findings urged the author to ask, is bathing an essential or a non-essential task in an ICU environment? A study conducted by Webster et al (1988) on patients' and nurses' opinions about bathing shows how patients and nurses have different views on the importance of this task when compared to others. Patients perceive bathing as a non-essential task (86%), while nurses think that it is essential (90%). In this same study Webster et al (1988) observed that most bathing was carried out in the morning and that two thirds of the nurses in the study disagreed that such a practice is best for patients. The researchers conclude by admitting that such practices appear to continue as a result of ward tradition and routine. Although this study was done on a small scale (22 nurses and 22 patients) it seems to represent the true picture of the current situation concerning bathing in many hospitals. It also shows that patients and nurses often have rather opposite views of what is important. However the study has shown too that both nurses and patients disagree that it is essential for all patients to have a daily bath while in hospital. Walsh and Ford (1992) suggest that a good starting point, in the context of bathing, would be to consider whether the patient needs or wants a bed bath and argue that "like all aspects of care, this should be individualised to meet the patient's needs." They also recommend the evaluation of various routine tasks and ask if they really are necessary.
The literature demonstrates different views of bathing tasks and studies have been performed to show the effects of bathing both from a quantitative and a qualitative perspective. Weissman et al (1984) performed a study on the effects of routine intensive care interactions on metabolic rate in a group of 23 mechanically ventilated critically ill patients and demonstrates how the various routine daily activities can significantly alter metabolic rate. The comparison of percent change of oxygen consumption, carbon dioxide production, heart rate, and systolic blood pressure between rest and bathing in the above study show that:
. There are significant increases (about 20%) in both oxygen consumption and carbon dioxide production above the resting levels.
2. There are significant increases (about 10%) in both heart rate and systolic blood pressure above the resting levels.
These empirical findings indicate the extent of both the metabolic and haemodynamic stress that is associated with the various routine daily activities on ICU patients. Such findings should be taken into consideration, especially when patients are haemodynamically unstable and septic, so that the minimum of disturbances are inflicted on them thus minimising their catabolic state during wakefulness while indirectly improving their rate of recovery. Weissman et al (1984) however admit that the measurement of resting energy expenditure is a complex and exacting task which is difficult to achieve. Another weakness in the study is evident in a way that it was impossible for the authors to measure energy expenditure which is traditionally performed in the 'basal' state. This is defined as "the minimal energy expenditure of a subject lying down and resting in a thermoneutral environment having fasted for the previous 12 hours." The authors admit that such conditions are extremely rare in the critically ill patient since such a patient is receiving some form of continuous nutrition, whether it is 5 percent dextrose, or enteral or parenteral nutrition.
Contrary to the data presented above, other studies are more in favour of the therapeutic benefits of bathing. Bersevick and Llewellyn (1982) compared the effects of the towel bath and the conventional bed bath on patient anxiety. Anxiety was measured by three methods namely, State-Trait Anxiety Inventory, the Palmar Sweat Index, and the Behavioural Cues Index on 53 patients with unrelieved pain and 52 patients who would be having invasive procedures. Although results show that there are differences between the two procedures to the levels of anxiety, in general both methods of bathing have anxiety reducing effects. From this study Bersevick and Llewellyn (1982) suggest that bathing should be indicated among the methods used to increase patient comfort. However further studies are needed to determine generalizability of these findings to other patient populations which, in the context of critically ill patients nursed in ICUs, is still lacking.
Heilman (1974) studied bathing from a qualitative perspective and, from the data collected, finalised a hypothesis which says that patients would experience greater relief of stress following the conventional bed bath because of more direct skin-to-skin contact. She also concludes that bathing patients was a desirable nursing action which provides them (nurses) an ideal opportunity to talk with the patients and getting to know them better. Referring back to the study conducted by Webster et al (1988) on patients' and nurses' opinions about bathing, the majority of nurses and patients agree to the fact that bathing provides this opportunity of acquaintance between the two parties.
When it comes to the actual procedure of bathing, where the first aim is to clean the skin, literature shows that patients are more often exposed to harm rather than the benefit that many nurses think they are doing while bathing a patient. In the author's working environment, nurses use communal basins which are moist and stacked one inside the other. Common soap (supplied by the health authorities) is usually used. A face cloth or washing flannel is usually found hanging to dry from the previous bath, and throughout the procedure the same water is usually used. According to Gooch (1989) any piece of equipment that cannot be dried, such as washing flannels and soap, will be contaminated with gram negative organisms. If water and flannel are unchanged throughout a blanket bath, according to Gooch (1989) the water becomes "a soup of soap and bacteria by the end of the procedure." Gooch (1989) also argues that when washing bowls are left moist and stacked one inside the other they will be heavily contaminated. A study conducted by Greaves (1985) shows that microbiologically patients could be dirtier after a bed bath than before it if face cloths are used for washing.
Another aspect to be taken into consideration is skin integument. Armstrong Esther (1981) states that in elderly people, the dermis and epidermis are thinner, nail and hair growth is slowed, and sweat and sebaceous secretions are diminished. The slower renewal rate of the stratum corneum renders the skin more liable to excessive drying after washing. Skin also becomes more permeable to irritants with age. Penbroke (1983) argues that subjecting elderly patients to soap and water several times a day in hospital, when they are only used to wash down once or twice a week at home can cause them to develop asteatotic eczema with its dryness, cracking, and occasional excoriation. Considering that a large proportion of patients admitted to the ICU are elderly people, these facts should not be overlooked and nurses should update their knowledge frequently.
Other facts that Armstrong Esther (1981) brings into attention, which may be surprising to most nurses, is that the use of detergents, soaps, bubble baths, or sodium bicarbonate in baths will aggravate skin dryness, as will water that is too hot. Soap remaining on the skin due to inadequate rinsing (a common habit during bed bathing) intensifies dryness; and the use of soap is not very effective in removing dried faeces. The use of emollients, such as aqueous cream and mineral oils during bathing help in reducing scaliness and make the skin more pliable and may be sufficient enough for cleansing (Armstrong Esther 1981).
Conclusion
The arguments brought forward in this paper highlight facts that should urge nurses to stop and think about their practice concerning bathing. The phenomena of 'let's get the work done' without enough reasoning echoes in our unit not just on bathing, but for each and every nursing task. Stereotyping is still dominant over individualised care with possible detriment to the same patients.
To change nursing habits that have anchored for a long time demands risk taking and besides a positive approachable attitude, requires time, patience, and perseverance. According to Plant (1987) change is a five stage process which requires:
1. Recognising the need for change.
2. Mobilising commitment of the critical mass.
3. Building a shared vision.
4. Diagnosing current reality.
5. Getting there.
Plant (1987) argues that unless behaviour changes nothing changes. However Walsh and Ford (1992) rightfully state that "while there may be a place for intuition in the art of nursing, there is no place in the science of nursing for rituals and mythology."
References
Armstrong Esther C. (1981) Skin introduction. Nursing 1st series, 1115. In Gooch J. (1989) Skin Hygiene. The Professional Nurse Oct. pp. 13-18.
Bersevick A. and Llewellyn J. (1982) A comparison of the anxiety-reducing potential of two techniques of bathing. Nursing Research Vol. 31 No.1 pp. 22-27.
Fabijan L. and Gosselin M. (1982) How to recognise sleep deprivation in your ICU patient and what to do about it. The Canadian Nurse 78:4, 20-23. In Closs J. (1988) Patients' sleep-wake rhythms in hospital. (Occasional Paper) Part 2. Nursing Times Vol 84 No.2 pp 54-55.
Gooch J. (1989) Skin Hygiene. The Professional Nurse Oct. pp. 13-18.
Greaves A. (1985) We'll just freshen you up, dear... Nursing Times Vol. 81 No.10 Supplement 3-8. In Webster R., Thompson D., Bowman G., Sutton T. (1988) Patients' and Nurses' opinions about bathing. (Occasional Paper) Nursing Times Vol 84. No.37. pp 54-57.
Hailman M. (1974) The importance of touch in bathing bedfast adults. Tucson, University of Arizona (unpublished masters thesis). In Bersevick A. and Llewellyn J (1982) A comparison of the anxiety-reducing potential of two techniques of bathing. Nursing Research Vol. 31 No.1 pp. 22-27.
Henderson V. and Nite G. (1978) Principles and Practice of Nursing. London. Macmillan.
Hilton B. (1976) Quantity and Quality of patients' sleep and sleep-disturbing factors in a respiratory intensive care unit. Journal of Advanced Nursing. Vol 1 pp 453-468.
Morgan H. and White B. (1983) Sleep deprivation. Nursing Mirror 157:14, S8-S11. In Closs J. (1988) Patients' sleep-wake rhythms in hospital. (Occasional Paper) Part 2. Nursing Times Vol 84 No.2 pp 54-55.
Nightingale F. (1859) Notes on Nursing. London. Harrison and Sons.
Penbroke A. (1983) Preventing skin problems. Geriatric Medicine Vol.13 pp.797-781. In Gooch J. (1989) Skin Hygiene. The Professional Nurse Oct. pp. 13-18.
Plant R. (1987) Managing Change and Making it Stick. Fontana Collins.
Torrance C. (1990) Sleep and wound healing. Surgical Nurse 3:2 pp 16-20.
Walsh M. and Ford P. (1992) Nursing Rituals: Research and Rational Actions. London Butterworth and Heineman Ltd.
Webster R., Thompson D., Bowman G., Sutton T. (1988) Patients' and Nurses' opinions about bathing. (Occasional Paper) Nursing Times Vol 84. No.37. pp 54-57.
Weissman C., Kemper M., Damask M., Askanazi J., Hyman A., and Kinney J. (1984) Effect of routine nursing care interactions on metabolic rate. Chest Vol.86 No.6 pp.815-8.
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