4. Needs of the fragile, ill and physically disabled in the community setting with special training and staffing considerations. Part #1


  • Personal Care Services (General Principles).

    General Principles

            What is Personal Care?

            Personal care is caring for someone’s person or body. It includes shaving, shampooing, mouth care, bathing, grooming, dressing, toileting, and assistance with moving.

    Why do we perform personal care for clients?
    • Many injured, frail, elderly, and disabled clients are unable to care for themselves because of physical limitations.
    • Others cannot care for themselves because of diseases like Alzheimer’s, which hampers their thought process.
    • Assistance with personal care allows clients to remain at home when they would otherwise be in a nursing home. It also promotes and preserves the clients’ sense of well-being and dignity.
    • Assistance with bathing and grooming gives clients an opportunity to gently exercise muscles and stimulate circulation.
    • Some clients need assistance with personal care only on days when they are feeling weak and unsteady or are in need of a stand-by for “bad days”.
    Who does personal care?
    • Personal care workers/providers (PCW/P’s) are people trained to provide personal care to clients who have difficulty caring for themselves.
    • Agency training provides PCW/P’s with information and practice, which makes them capable and comfortable with providing personal care to clients.
    • Supervisors of PCW/P’s are available to answer questions and provide training.
    • PCW/P’s should always feel free to call with questions.
    When does personal care happen?

            Each client has individual needs and preferences. The supervisor establishes a Plan of Care for each client at the start of the service. The Plan of Care specifies the type and frequency of services to be provided. Some clients will need personal care only a few times a week; others will need services several times each day. The care plan dictates the types of services and frequency of visits that are to be provided to the client.

    Where does personal care happen?

            Some clients can manage most of their bathroom and bedroom personal care with minor assistance while weaker and/or sicker clients need personal care provided at their bedsides. PCW/P’s are taught to assist clients with needing minimal assistance. They also learn how to assist clients who cannot help themselves at all.

    How does one help another with personal care?

            Most adult clients prefer to be as independent as possible. If the Plan of Care is not clear about how much care a client needs, the PCW/P should question the client, and then encourage the client to do as much as he/she can. Whenever possible, the client should direct care. If the client is confused or unable to give directions, the PCW/P should take the initiative and guide the client through the personal care routine; while always being concerned for the client’s SAFETY, PRIVACY, and COMFORT.

    Examples of Safety, Privacy, and Comfort:

            Help the client with a sit-down tub bath if directed by the care plan – and only if the client needs the help.   Preserve the client’s independence                                                ·

    Sometimes a long warm soak will cause the person to relax anti become too weak to get out of the tub safely.
    SAFETY
    •       Verify that the shower or tub floor has a non-skid surface. Use a rubber mat if possible.
    •       Place a bath mat or towel on the floor for the client to step on when coming out of the shower or tub.
    •       Have the client use safety bars for assistance, if available.
    •       Never allow the client to hold onto towel bars to support their weight.
    •       Have the client use a tub bench, transfer bench, or shower chair, if they have one.
    •       Avoid exposing the client; provide drapes, use towels, a sheet, or a light blanket.
    PRIVACY

            Close the shower curtain and/or bathroom door to allow the person to complete as much of the shower as possible. The client may only need help with washing his/her back or other hard-to-reach places.

    COMFORT

            Test the water temperature.  It should be about 105 to 110 degrees, comfortable to the inside of the wrist. Change the water when it becomes cloudy, cool, or as necessary.

            Make sure the room is warm and draft-free.

            Proceed with confidence. Clients are more comfortable if they feel the aide is experienced.

    Be SYSTEMATIC in your approach.

            Throughout the personal care routine, think through what will be needed. Anticipate what the client will need.

    Organize Equipment and Supplies in Advance

            Organize supplies such as towels and soap. Place them where they will be easily accessible.

    Work from CLEANER to DIRTIER areas.

            Do mouth care before bathing. Wash the face and neck before armpits, feet, and bottom.

    Think about STANDARD PRECAUTIONS.

            Wear gloves whenever coming in contact with body fluids, such as in the mouth and genitals.

            Wash hands before and after doing personal care.

  • Personal Hygiene & Cultural Differences.

            Most cultures value personal hygiene, but personal hygiene means different things throughout the world. Americans may assume that bathrooms have towels and toilet paper, while other nationalities see travelers as being responsible for their own supplies. In many cultures, body odor is offensive, but some see it as natural. When interacting with different cultures, it is important to avoid assumptions. Rather, become informed about foreign expectations regarding cleanliness and etiquette.


    Personal Hygiene
    Introduction:

            Personal hygiene is one of the most effective ways to protect others and ourselves from illness. Hygiene doesn’t just keep a person clean – hygiene helps the skin fight infection, hygiene prevents injuries, hygiene removes substances from the skin that might promote the growth of bacteria and hygiene keep a person’s mouth and gums healthy. Good personal hygiene makes a person feel more comfortable and relaxed while boosting their spirits. A person who is clean and well-groomed is pleasant to be around.

    While older adults and people with mental illness or mental retardation are capable of taking care of their own personal hygiene needs, many need help. The type of help and the amount of help that is needed will be identified through an assessment. In providing assistance, from the beginning, it is important to communicate to clients two important things:

    • He/She is expected to do as much as they can do for him/herself and not be overly dependent on direct care staff persons. Keep in mind however that clients are in a personal care home because they need personal care services, and it is the job of the direct care staff person to help provide these services.
    • The client’s preferences for personal hygiene will be respected.
    • Maintaining personal hygiene enhances an individual’s physical and emotional well-being. Yet, when it comes to a person becoming dependent on you to keep their skin, nails, hair, and mouth clean, he/she can experience a deep loss of independence and self-esteem. With this in mind, remember that self-care is always the goal. Although it may take longer for a client to do a particular task, it is best for the client to do as much as they can for him/herself. For example, someone who is paralyzed from the waist down and still has a movement of their arms, can brush their teeth and wash their face. This keeps the client from becoming completely dependent and losing self-help abilities. It also helps the client to feel capable and it is good exercise.
    • The way in which you assist with personal care and hygiene ties to feelings of self-esteem and can reinforce the feeling of being valued. Does the client prefer to take a shower or bath at night or in the morning? Many adults have been doing personal care routines for many years and these rituals have become engrained in daily schedules. Also, keep in mind that personal hygiene habits can vary from culture to culture.  When you attempt to understand and respect cultural differences related to personal hygiene, you convey respect for the individual. This will help build a positive relationship between you and the client. Providing the option to continue with personal choices and routines will certainly help the client feel comfortable and in control.


    Bathing:

            There are several important reasons why one should bathe your loved one besides the obvious one of cleanliness. Bathing eliminates body odors, and it is cool, refreshing, and relaxing. It stimulates circulation and exercises parts of the body. It also allows the caregiver the opportunity to observe the care recipient’s body for any unusual changes such as rashes, decubitus ulcers (pressure sores), reddened areas, etc. Last, but not least, it provides the opportunity to talk with the care recipient.

            There are four types of bathing:

    1. Complete bed bath – usually used for the care recipient who is weak or unable to bathe themselves. You will usually receive little or no help from the care recipient.
    2. Partial bed bath – given when the care recipient can help themselves a little but needs help with areas unable to reach. Remember in the complete and partial bed baths to expose only that part of the body you are working on. The rest of the body should be covered with a large bath blanket for warmth and privacy.
    3. Tub bath – may need a doctor’s okay for a tub bath. The care recipient is assisted in and out of tub.
    4. Shower – may need a doctor’s okay for a shower. For the care recipient who is unsteady or weak, a chair can be used for them to sit on during the shower. The type of bath the care recipient receives will depend on the needs of the elder.

            Bathing can be an enjoyable and refreshing experience. A bath can be therapeutic by improving blood flow, easing discomfort and helping the resident to relax. Always listen, consider and try to accommodate the wants and wishes of the client’s bathing routine. The following is a list of ways in which you may assist a client with a shower or tub bath, depending on his/her level of independence in bathing:

    • Gather all needed supplies ahead of time, prior to getting the client into the bath or shower.
    • Make sure the bathroom is a comfortable temperature and the door is closed to give as much privacy as possible.
    • Make sure there is a non-slip safety mat (or another surface) on the bottom of the shower or tub to prevent falls.
    • Place a shower bench or seat in the shower so the client can sit down while he/she showers.
    • Place a nonskid bathmat (not a towel) on the floor in front of the shower or tub.
    • Be aware that an older person’s skin is thin and sensitive to high temperatures, irritation, and harsh soaps. Be aware of any health problems that may be affected by water temperature.
    • Check the water temperature (generally 105 F) and water pressure and make adjustments before the resident gets into the tub or shower. Never turn on hot water once the client is in the tub or shower.
    • Be aware that getting into and out of a tub may be difficult for the client and offer assistance if needed.

            If a client is unable to enter a tub or shower, but still wants to personally care for his/her hygiene, a good alternative is to provide a washbowl or assist them in using the sink. Providing this alternative allows the person to move at their own pace while giving them the independence of caring for him/herself. Offer the client the option of standing or sitting on a stool or chair.

  • Assisted Sponge Bath or Shower.

            Bathing assistance is provided to those clients who cannot be independent in self­ care due to either physical or mental limitations.

    Purposes of bathing:
    • To clean and deodorize the skin
    • To stimulate circulation
    • To produce a sense of well-being
    • To promote relaxation and comfort
    • To prevent and eliminate unpleasant body odors

            Clients require varying degrees of help with bathing. Typically, clients can wash with just a little assistance, like rinsing and wringing out the washcloth or washing their backs and feet. In those cases, the aide’s job includes:

    • Reading the care plan,
    • Organizing the equipment,
    • Anticipating what will be needed for this procedure,
    • Providing privacy and safety,
    • Offering a helping hand,
    • Observing the condition of the skin,
    • Doing the cleanup of the bathroom afterward.
    Reading the Care Plan:
    • Pay attention to the amount of help the client needs with the bath and make sure the care plan matches what the client needs.
    • If the care plan says the client needs only a stand-by assist into the shower, but you find that she
    • Cannot get into the shower at all due to her weakness, call the office and report this to the supervisor.
    • The supervisor needs to know about any changes in the client’s condition, which may change the plan of care.
    Organizing the equipment (wash hands first):
    • Washcloth 1 or 2 bath towels, soap and shampoo if is part of the shower routine.
    • Lotion, powder, and deodorant.
    • Clean clothing, slippers or shoes.
    • (Basin for soaking feet, if this is sponge bath)
    Anticipating what the client will need:

            Think about your own daily routine and the things you need in order to complete your own personal care. Proceed in an organized manner.

    • Check out client preferences, like when to brush teeth – before or after a shower?
    • Remind the client, if necessary, to use the toilet or urinal before bathing.
    Providing Privacy and Taking Safety Precautions:
    • Assist the client as necessary with removing clothing.
    • As clothing is removed, offer a towel to drape the client.
      • Ladies may need 2 towels: one around the neck and down the front of the chest, another around hips – or one bath towel around her torso and underarms.
      • Men should be draped with one towel around the waist.
    • safety precautions should be taken to avoid wet surfaces and to offer stability during the step into the shower, etc.
    • Always make sure the floor of the tub or shower has a non-skid surface.
    • Have a small skid-resistant bath mat, rug, or dry towel for stepping out after showering.
    • Checking water temperature is a very important part of helping with bathing.
    • Test it as you would for your own shower or bath.
    • Have a stool or chair just outside the shower, in case the client becomes weak while bathing.
    • Have the client use the grab bars on the wall to assist sitting on the bath bench – if available.
    Offer a helping hand:
    • Some clients might need minor guidance in the shower.
    • Check the water temp. Help direct the shower spray or hand the shower extension to the client.
    • Remove the privacy drapes discreetly.
    • The client may need assistance rinsing and wringing out the washcloth.
    • Offer to wash the client’s back, lower legs, and feet, if necessary.
    • If steady and not confused, the client can be left alone for a few minutes to complete the bath.
    • Stay within earshot and announce your re-entry to the bathroom.
    • Offer towels again and help to drape the client if necessary.
    • Help to dry the skin in hard-to-reach areas (back, feet, lower legs).
    • Offer deodorant, lotion, powder, etc.
    • Help the client get dressed, but encourage independence as much as possible.
    • Provide hairbrush or comb, make-up, etc.
    Observing the condition of the skin:
    • During the bathing process, it is important to notice the condition of the skin.
    • Report anything unusual: rashes, wounds, redness, swelling, tenderness, or bruises to the supervisor.
    Bathroom cleanup:
    • After the shower, ease the client into a comfortable chair or bed.
    • Clean the tub or shower (or basin) with the client’s household or bathroom cleaner.
    • Hang towels to dry.
    • Put away all supplies.
    • Wash your hands.
    Giving a Partial Bath
    • Partial baths involve _bathing face, hands, underarms, genitals, back, and buttocks. These body parts develop odors or become uncomfortable if not clean.
    • Partial bed baths are given to clients who cannot bathe themselves independently and are given on days when a complete bath or shower is not given.
    • Partial baths can be given at the bathroom sink or at the bedside, depending on the client’s condition or preference.
    • Follow the general guidelines for the complete bed bath.
    Complete Bed Bath:
    • Are ordered for persons confined to bed for medical reasons like illness and paralysis.
    • Are ordered for bed-bound persons who can help with their bathing procedures and should be encouraged to participate.
    • Should be done at the bedside.
    The purposes of bathing, as stated previously, are:
    • To clean and deodorize the skin
    • To stimulate circulation
    • To promote a sense of well-being
    • To promote relaxation and comfort
    • To prevent and eliminate unpleasant body odors

    Steps in performing the Complete Bed Bath:

            Read the care plan. If you find the client’s condition requires a bed bath when he/she usually receives less assistance, report this to the supervisor because your care will not match the care plan established by the supervisor.

    The client may be going through significant changes, which the supervisor should know about.
    • Prepare the client and the surroundings.
    • Close windows and doors to eliminate drafts.
    • Provide privacy.
    • Assist the client to use the bedpan, urinal, or commode.
    • Wash hands after handling toilet equipment.
    • Offer oral care assistance at this time.
    • (This can be done when the bath is finished.)
    • Remove heavy blankets from the bed.
    • Help the client to undress.
    • A cover client with a light sheet, blanket, or towels. I 0. Privacy drape.
    • Bath towels can be warmed in the dryer to provide additional comfort.
    • If using the bedsheet as a cover, loosen the ends from the bottom of the bed.
    • If the client has a soiled incontinence pad, give peri-care and replace the pad before proceeding with the bath.
    • Make a bath “mitt” by folding the washcloth over your hand to form either a triangle or a rectangle. The mitt retains heat and moisture better than a washcloth that is loosely held.
     Face, Head, and Neck
    • Wash the client’s face. Use warm water – not soap – for eyes-only.
    • Use a separate corner of the washcloth for each eye.
    • Wash eyes from the inside corner toward the outside corner.
    • Do cleaner areas first to prevent infecting tear ducts with secretions from the eyes.
    • Ask whether the client wants soap used on the rest of the face.
    • Wash, rinse, and dry the client’s face, ears, and neck.
    Arms and Hands
    • Place the bath towel the long way under the client’s arm.
    • Wash, rinse, and dry the arm using long, firm strokes from the wrist to shoulder. This helps to stimulate circulation.
    • Move the towel under the hand.
    • Place the basin of water under the client’s hand.
    • Place the hand directly into the wam1water.
    • Assist client to wash, rinse, and dry the hand.
    • Repeat the above for the other arm and hand.
    Chest and Abdomen
    • Fold the cover sheet down to the lower abdominal area.
    • Cover the chest with the towel.
    • Wash, rinse, and dry the chest, and abdomen.
    • Pay special attention to any skin folds of the belly or breasts.
    • Replace the cover sheet when all areas have been dried.
    • Check water and change if cloudy or cool.
    Legs and Feet
    • Fold back the cover sheet to expose one leg and foot, keeping the client’s genitals covered.
    • Place the towel lengthwise under the leg.
    • Wash, rinse, and dry the leg from ankle to knee, then a knee to thigh, with long, firm strokes.
    • Work from the ankle upwards to help promote circulation.
    • Move basin and protective towel to the foot.
    • Place the foot in the warm water.
    • Wash between toes and check feet for breaks in the skin or reddened areas.
    • Dry the foot carefully.
    • Repeat the above for the other foot and leg.
    • Discard the water and start with fresh water. Use another dry towel if necessary.
    Back and Perineum
    • Assist the client to tum on her side, away from you.
    • Cover her back with the towel.
    • Wash and dry the back, buttocks, and back of thighs, using long, firm strokes.
    • Clean creases well.
    • Apply lotion and give the client a back rub at this time, if desired.
    • Keep the client covered as much as possible.
    • Pay close attention to the condition of the skin.

            Report to the supervisor areas that are reddened and remain reddened even after pressure is relieved.

  • Perineal Care and Incontinence.

    Peri-Care

            Determine whether the client can wash his/her own private areas. If they can’t, follow the procedure for “peri-care”:

    • Put on disposable gloves.
    • Help the client to back-lying or side-lying position with knees apart and legs bent.
    • Expose only the client’s genital area.
    • Provide drapes.
    • Place towel under hips.
    Females:
    • Wash perineal area.   Start with the upper, inner thighs.
    • Wash genitals on the outside – front to back.
    • Spread labia gently to wash inside, front to back, using separate corners of the washcloth for each stroke.
    • Wash the rectal area. Rinse and dry in the same fashion.
    • Apply moisture barrier cream to the genital/rectal area, if requested on the care plan.
    Males:
    • Wash and dry the penis, using firm strokes. (Handling the penis firmly may prevent an erection.) Gently push back the foreskin on uncircumcised males and clean behind the glans.
    • Rinse and pat dry. Replace foreskin.
    • Wash and dry the scrotum and around the rectum. Rinse and dry.
    • Apply moisture barrier cream, if necessary, around the rectal/perinea) area.
    • Note and report any chapped areas: redness, swelling, discharge, or discomfort.
    • Remove and discard gloves.
    • Wash hands. (Lotion can be warmed in the basin of hot water for additional comfort.)
    • Offer or apply deodorant, lotion, or powder.
    • Assist the client to dress.
    • Assist with hair care; nail care, and oral care.
    • (For some, mouth care may have occurred before the bath – a personal preference.)
    • Position the client comfortably and re-make the bed.
    • Clean up the area and put away supplies.
    • Wash your hands.
    Complete your note for the visit.
    • Specify the type of bath you gave.
    • Call the supervisor with any new information or if the care plans need changing.
    Perineal Care and Incontinence
    •       Perineal care (also known as “peri-care” or genital care) is an important part of personal hygiene.
    •        Some clients are unable to control the flow of urine or the movement of their bowels and need varying degrees of help with managing this problem.
    •        Many patients just need a helping hand with gathering supplies to change pads and clean their skin.
    •        Some patients need direct care – from start to finish – including cleaning the skin and putting on clean pads.
    Encourage as much independence as possible:
    •       Patients with incontinence problems are often embarrassed about their conditions. Every effort should be made to provide privacy and to protect the dignity of these patients.
    •       Some patients wear absorbent pads or underclothes and change their pads while on the toilet.
    •       More confused or infirmed patients need help changing their pads.
    •       PCW/P’ s should be knowledgeable about different products and know-how to how to use them in case a client needs more than supervision.
    •       Incontinence supplies with elastic side straps and buttons seem to be easier for clients to use because they can be worn like underwear and slide over the feet.
    Changing Incontinence Pads and Peri-Care
    1. Gather Supplies:

                   a)       Disposable gloves;

                   b)      Roll of toilet tissue;

                   c)       Basin or sink with warm water;

                   d)      Soap or other skin cleanser OR disposable wipes;

                   e)       Towel;

                   f)       Special powders or skin protectors, and moisture barrier cream, if ordered;

                   g)      Plastic trash bag or trash can with plastic liner;

                   h)      Dry replacement pad;

                   i)        Possibly, a change of clothing

    1. Explain what you will be doing or how you will help.
    2. Wash hands and put on gloves.
    3. Assist the client in a comfortable position – sitting on the toilet, standing, or lying down.
    4. Drape for privacy, as possible. If lying in bed, have the client roll to the side or lift hips.
    5. Place a waterproof pad under hips.
    6. Remove the soiled pad and fold, soiled side inward.
    7. Place in the trash receptacle.
    8. If the pad is soiled, not just wet, the client will need to be carefully cleaned.
    9. Wrap toilet tissue around the gloved hand. Wipe from urinary area to anal area in one swipe.
    10. Discard tissue and repeat this process until clean.
    11. Assist client to clean or wash the genital area with warm soapy water or the disposable wipe.
      1. Females should be washed from front to back, a cleaner area first, more soiled area last. Take care to clean in the creases and folds.
      2. Males should be cleaned around the penis first and then the scrotum. Uncircumcised males will need to have the foreskin gently pushed back to allow for complete cleaning.
      3. Rinse the genital area in the same, thorough fashion. There is no need to rinse if using disposable wipes.
    1. Apply moisture barrier cream, if ordered.
    2. Apply a dry pad, plastic side out. Have client bend knees, lift hips off the bed, or roll onto their side.
    3. Assist the client to re-dress as necessary.
    4. Remove and discard gloves.
    5. Close the trash bag and discard it.
    6. Wash hands thoroughly.
  • Haircare: Shampooing, shaving.

    Haircare:

            Hair that looks and feels good can influence your loved one’s appearance and psychological well-being. Clean hair prevents scalp and hair breakdown and improves circulation to the scalp. In general, you will only need to help your care recipient with combing hair. Remember to protect the pillow and shoulders with towels, remove any eyewear, and brush or comb the hair from the scalp to the hair ends. If the hair is tangled, start at the ends of the hair and work up to the scalp to remove the tangles. On some occasions, you may have to shampoo the care recipient’s hair. This can be done either at the sink or in bed. There are several devices you can buy that can make shampooing hair easier—especially if the care recipient is in bed. Follow the care recipient’s personal preferences when styling the hair or when buying shampoo and conditioner.

    The following general rules always apply:

    • Wash the care recipient’s hair as outlined in the outlined procedure below.
    • Keep the care recipient out of drafty areas.
    • Never cut or color the hair.
    • Never give a permanent.
    • Never use a hot comb or curling iron.
    • Dry and style hair as quickly as possible.

            Washing, drying and styling a resident’s hair can take 30-60 minutes. Consider scheduling a shampoo on a non-bath day to conserve the client’s energy.

            Hair should be combed or brushed every day to stimulate scalp circulation and distribute natural oils to the ends of the hair shafts. Daily washing is not necessary, but hair should be washed on a regular basis, at least once a week, with a mild, non-irritating shampoo. Include the client in the planning of this routine. Be sure to check the individual’s hair and scalp before each shampooing to determine if any changes are needed in things like the type of shampoo.

            The client’s sense of dignity and well being are affected by the appearance of their hair. Some are not able to groom their own hair due to disability or illness. If hair care is part of the care plan; the following guidelines may be helpful.

            Brushing and combing are part of daily personal care. Vigorous brushing on a regular basis stimulates the circulation of the scalp. However, each person has a preference for the styling, combing, and brushing of their hair. They should be encouraged to do as much as possible for themselves.

    Shampooing

            Most people wash their hair at least once a week; some prefer shampoos 2-3 times weekly, or even daily. There are several ways to assist with a shampoo. The method used depends on the client’s condition, safety factors, and personal preference. Always be sure the client’s hair has been brushed and all tangles have been removed.

    Shampooing during the bath or shower:

            Clients who can shower will probably be able to shampoo at the same time.

            The aide should plan ahead and have the appropriate supplies for washing hair during the shower: shampoo, conditioner, a washcloth to shield the eyes, and an extra towel for the hair.

            Offer to help in whatever way the client may need. This may mean just handing supplies to the client or it may mean performing the entire procedure.

    Shampooing at the sink:

            If a client can sit comfortably in a chair, she can probably be shampooed at the sink.

    • The chair is placed so that the person faces away from the sink. A rolled towel is placed at the edge of the sink counter to protect the client’s neck.
    • The client’s head is tilted over the sink and water is poured from a pitcher or sprayed from a nozzle during the shampoo and rinse.
    • Some clients prefer to stand and lean forward over the sink.
    • There is also a shampoo tray that can be used at the sink.
    Shampooing the client in bed:

            Some form of the plastic trough or “shampoo ring” is needed to protect the bed linens from water. (Commercial products are available and recommended for the person who routinely needs to be shampooed in bed).

    • If using a makeshift trough, obtain a piece of plastic; a large trash bag will do. Wrap the edges of the plastic over a large rolled bath towel. This will make a raised boundary to prevent water from spilling onto the bed.
    • Place the raised edge of the plastic under the head of the client, draping it over the bed, and leading to a bucket positioned at the side of the bed.
    • A pitcher can be used to wet and rinse the hair. The bucket will collect discarded water as it runs off the bed.
    Shampooing

    Equipment/Supplies:

    1.       Shampoo
    2.       Conditioner
    3.       Brush and comb
    4.       1-2 towels
    5.       Washcloth to cover eyes
    6.       Electric hair dryer, if desired
    7.       Shampoo ring or trough, bucket, and a pitcher of warm water
    Procedure:
    •       Check the water temperature. It should be lukewarm when tested on the inside of your wrist.
    •       Ask the client to hold the washcloth over their eyes, if desired.
    •       Using a pitcher or the shower nozzle, apply water until the hair is completely wet.
    •       Apply a small amount of shampoo.
    •       Work up a lather with both hands. Start at the hairline and work toward the back.
    •       Massage the scalp with your fingertips.
    •       Rinse the hair thoroughly.
    •       Apply conditioner, if desired, according to directions on the bottle.
    •       Wrap the client’s head with a dry towel. Dry face and ears with the washcloth used to protect eyes.
    •       Rub the client’s scalp and hair with the towel.
    •       Comb the hair to remove tangles and snarls. A woman will probably prefer to have her hair curled in a preferred style.
    •       Dry the hair as quickly as possible.

            Both men and women often prefer to keep various parts of their body shaven. Most males feel much better when their face is clean-shaven. Some women may need to have their face shaved, as aging sometimes causes the growth of facial hair. When the care recipient cannot shave his or her own face, you may be asked to do it. Use only an electric or safety razor. Never use an electric razor when the care recipient is receiving oxygen. Do check with your care recipient to see how he wants a beard or mustache cared for. Women may want their legs and underarms shaved, also.

    Shaving the care recipient
    1. Assemble equipment
      1. Towels;
      2. Washcloth;
      3. Shaving cream;
      4. Shaver;
      5. Basin of warm water;
      6. Shaving lotion or aftershave.
      7. Wash your hands.
      8. Place basin of warm water by the bedside.
      9. Have the care recipient in a semi-sitting position or on the back.
      10. Cover the care recipient with a bath towel.
      11. Wash the face and apply a warm, damp washcloth for 3-5 minutes to soften skin.
      12. Spread shaving cream generously over the area to be shaved.
      13. Hold the skin taut and shave skin in the direction of hair growth. Begin at sideburns, work downwards over cheeks, and down over chin. Work upward on the neck under the chin. Use short, firm strokes.
      14. Rinse razor often during the procedure.
      15. Rinse off any leftover shaving cream.
      16. Apply shaving lotion, if desired.
      17. Make care recipient comfortable.
      18. Clean and replace equipment.
      19. Wash your hands.

            An individual’s appearance makes a statement about how they feel about him/herself. Encourage the client to care for his/her hair so that they can present a neat and attractive appearance.

  • Skincare.

            Skin changes with age. But the fundamentals of keeping aging skin clean and healthy aren’t very different from those of caring for young skin.

    Normal skin changes in aging include:
    • The outer layer of skin begins to thin making it more sensitive and easier to damage.
    • The normal fat layer under the skin begins to disappear. This makes it easier for an elderly person to develop pressure sores as well as feel colder more quickly.
    • Oil glands do not function as well and this makes the skin dryer. The skin begins to sag and wrinkle and it is easily bruised; bumps and scrapes tend to tear it. Dry skin is also more sensitive to chemical irritants, soap, infection and poor hygiene.
    • Liver or age spots appear on the face, arms and back of hands.
    • Sweat glands decrease in activity and this makes it harder for an elderly person to lower their body temperature in hot weather.
    • Blood flow to the skin decreases and this makes it harder to heal skin injuries.

            The skin is a major body system. Its most vital body function is to provide protection. Keeping the skin intact, with no open areas, is an important task. Decubitus ulcers, or pressure sores, are areas where the skin and tissues are broken down due to lack of blood flow. They are caused by the loss of circulation, caused in turn by pressure on a part of the body. Other factors that contribute to the decubitus ulcers are dry skin and irritation by urine and feces. Care recipients who are unable to move or to change positions are more likely to develop decubitus ulcers. Bony areas of the body are also called pressure points. These points bear the weight of the body. Decubitus ulcers usually occur over these bony areas. Common areas include ears, elbows, under breast, backbone, shoulder blades, knees, ankles, heels, and toes. In obese (overweight) elders, decubitus can develop where the skin is in contact with skin, such as between the legs and the folds of abdominal skin. The first sign of a decubitus ulcer is either sore skin or a reddened area. The care recipient may complain of tingling, burning, or pain in an area. If not treated, the skin may blister, open, and a deep sore may develop, increasing the risk of infection. To prevent decubitus, maintain good skincare and cleanliness. It is much easier to prevent pressure sores than it is to heal them. The following guidelines should be observed to prevent skin breakdown:

    • Change the care recipient’s position at least every two hours. The care recipient should be lifted or moved slowly to prevent burns from the sheets.
    • Be careful when using bedpans. They can cause pressure and friction. Avoid spilling urine on the skin.
    • Keep linens wrinkle-free and dry.
    • Remove any hard objects from the bed, such as hairpins, food crumbs, etc. ” Use powder where skin comes together to form creases.
    • Wash and dry care recipient’s skin with mild soap to remove urine or feces.
    • If the care recipient shows signs of a pressure sore, gently rub around the area with non-drying lotion every two hours. Do NOT rub directly on the reddened area as too much rubbing can cause further skin breakdown. Figure out why the area is reddened and try to correct the problem.
    • Always pat the skin dry (not rub) after bathing and apply lotion to dry areas.
    • Provide a back rub when the care recipient is repositioned. It stimulates the circulation of blood.
    • Use pillows, etc. to prevent skin from contact with skin.
    • Report any observations of skin breakdown or decubitus to the care recipient’s physician.
    Important facts to remember:
    • The skin is the body ‘s first defense against disease. It needs to be protected from injury and irritation.
    • Skin that is poorly nourished and dry has less ability to protect the body and is more vulnerable to injury.
    • Bathing may be limited for those whose skin is extremely dry.
    • Lotions or creams are often applied after personal care has been given.
    • Very elderly clients may have paper-thin, “parchment” like skin that tears easily. Be gentle.
    • Moisture in contact with the skin for a period of time can result in irritation and increased bacterial growth.
    • It is very important to pat the skin dry after bathing, paying particular attention to creases and skin folds. Cornstarch or talcum powder may be applied in certain areas to absorb moisture.
    • Incontinent clients need immediate cleaning to prevent irritation. During the bathing process, the skin should be washed with long, firm strokes, taking care to avoid harsh rubbing.
    • Extremities (arms and legs) are washed from the farthest point (feet, hands) toward the trunk. This stimulates blood flow back to the heart from the distant portions of the body.
    Infection Control Considerations with Skin Care

            Any time you contact body fluids during personal care or homemaking, when you discover open weeping areas, or when you help with cleaning a client after toileting, you need to wear disposable gloves. It is not necessary to wear gloves for general bathing, except for when cleaning the genitals. New areas of broken or reddened skin must be reported immediately to the supervisor.

            Always be sure that you protect your own skin from injury and irritation. If you have dry, cracked in on your hands, you should wear gloves. This protects you from picking up any infections and protects the client from your body fluids.

            Frequent hand washing during your workday can cause your skin to become dry and cracked. Use plenty of lotion after hand washing and at other times throughout the day. Well-lubricated skin provides a stronger defense for you, too.

    BackRub

            Back rubs are refreshing and relaxing for everyone. To the care recipient who is in bed and/or unable to get up and move around, a back rub is even more important as it stimulates circulation. Procedure: Back Rub

    1. Assemble equipment:

                 a)      Towels;

                 b)      Lotion;

                 c)      Basin of warm water

    1. Wash your hands.
    2. Explain to the care recipient what you are going to do.
    3. Warm the lotion by placing it in a basin of warm water.
    4. Ask the care recipient to turn on his/her side or abdomen. If unable to, you can assist the care recipient over to the side.
    5. Uncover the care recipient’s back and buttocks. Do not over-expose them.
    6. Put a small amount of lotion in the palm of your hand. Rub your hands together.
    7. Apply the lotion to the care recipient’s back, using long strokes. Remember to use proper body mechanics yourself.
    8. Use a circular motion on the bony areas of the back. Continue rubbing for one to three minutes.
    9. Dry the care recipient’s back and help to redress.
    10. Make the care recipient comfortable.
    11. Wash your hands and return equipment.
  • Hand and foot care.

    Hand care:

            The nails of an older adult tend to be ridged, grooved, thick and brittle. They grow at about half the rate than those of younger adults. Weekly attention to an older adult’s hands keeps nails attractive and in good condition. This should include:

    • Wash hands under running water and clean under the nails using the pointed end of an orangewood stick (a kind of wooden stick with a rough surface that is used in manicuring nails). After cleaning, be sure to rinse the orangewood stick off or dispose of it. The use of a metal instrument may roughen the nail and make it easier to collect dirt.
    • Massage the nails and cuticles with a lotion. Make sure to massage the sides of nails and the areas where the nail extends over the finger. This massage stimulates circulation, and this helps strengthen nails and prevent thickened nails. Lotion massaged on cuticles helps to prevent hangnails.
    • Soak the nails in warm, soapy water for 3-5 minutes. This will make the cuticles and nails softer and easier to manipulate.
    • Push cuticles back gently. Harsh rubbing or poking at the cuticles can cause them to split into hangnails and could cause infection.
    • Shape nails into an oval using the fine side of an emery board, making sure not to file too close to the sides of the fingers. Filing too close to the side of the finger could cause injury to the cuticle and skin around the nail. Cutting the nail tends to make them brittle. Move the emery board in one direction rather than using a sawing motion that can leave rough edges.

            The general health of the care recipient is often reflected in the nails’ appearance. Nails that are broken or brittle may be the result of an improper diet. However, they can also be the result of improper care. Improperly cared for nails can be a health hazard. Nails that are broken, brittle, or have cuticles that are torn can permit microorganisms to enter the body. Dirty nails also carry germs that can spread infection when handling food or scratching the skin. As people get older, their nails’ physical appearance and growth rate changes. Nails should be cared for daily by cleaning beneath them and pushing back the cuticle. The best time to do this is right after bathing. Soap and water will loosen dirt and soften the cuticle. Extreme caution must be taken when clipping and trimming nails to prevent any damage to surrounding tissues. If the care recipient has diabetes or circulation problems, do not cut the nails unless directed to do so.

    Giving Finger Nail Care procedure:
    1. Assemble equipment

                 a)      Towel;

                 b)      Washbasin;

                 c)      Nail clipper;

                 d)      Orange stick;

                 e)      Nail file or emery board

    1. Wash your hands.
    2. Explain to the care recipient what you are going to do.
    3. Help the care recipient to a chair close to the table, if possible. If in bed, raise the bed to a comfortable working height.
    4. Place a towel under a half-full basin of water. The water temperature should be warm, but not too hot.
    5. Soak care recipient’s fingernails for 20 minutes.
    6. Clean under fingernails. Push cuticles back gently. Rinse and dry fingernails.
    7. Place hand on a towel. Shape into an oval or rounded shape with the nail file or emery board.
    8. Properly dispose of nail clippings by putting them in a sealed trash container.
    9. Clean and put away equipment.

    Wash your hands.

    NAIL AND FOOT CARE
    • Nails and feet need special attention to prevent infection ·injury and odor.
    • Many older clients cannot see well enough, or cannot reach their feet, to do thorough self-care.
    • Cleaning and filing nails are easier if nails are soft, like after soaking in water.
    • (Remember: PCW do  not cut or trim fingernails or  toenails).
    Procedure for Foot Soaks:
    1. Explain the procedure.
    2. Assist the client to remove shoes and stockings as necessary. Wash your hands.
    3. Gather equipment:

                  a)       Basin (large enough for feet);

                  b)      Towel;

                  c)       Washcloth;

                  d)      Emery board or nail file;

                  e)       Lotion;

                   f)       A bath mat or plastic cover (trash bag) to protect the floor from spilled water

    1. Cover the floor with a waterproof protector
    2. Fill the basin with warm – NOT HOT – water.
    3. Direct or help the client to place feet into a basin of water.
    4. Wash all surfaces of the feet and between the toes.
    5. Soak the feet for 15-20 minutes.
    6. Remove feet from water and dry thoroughly.
      1. Pay special attention to areas between the toes.
      2. Apply lotion to feet and legs as directed. (Avoid deep massage of the legs)
      3. Re-apply stockings and shoes.
      4. Clean up the area.
      5. Wash hands.
    Note:
    Report any of the following observations:
    • Swollen puffy feet;
    • Any breaks or cracks in the skin;
    • Reddened areas;
    • Pain.
  • Oral hygiene.

            A clean mouth and teeth prevent mouth disorders, infections, and the growth of bacteria plaques. Illness and disease may cause care recipients to have a bad taste in their mouths. In addition, some drugs have an effect on mouth odors. For these reasons, oral hygiene is important for the care recipient. It is important to the care recipient’s well-being and makes food taste better. A person’s food and fluid intake will be influenced by the condition of the mouth. Oral hygiene should be given every morning and after each meal. Some care recipients will require little help with oral hygiene. Others will need the family caregiver to perform the entire procedure.

    No matter how much assistance is needed, the following should be reported to the care recipient’s dentist or physician:

    • Dry, cracked, or blistered lips.
    • Redness, irritation, sores, or white patches in the mouth or on the tongue.
    • Bleeding, swelling, or extreme redness to the gums.

            Care recipients will have their own preference for toothpaste, mouthwash, and denture cleanser. Be sure to ask them what they prefer. Many microorganisms are found in the mouth. Gloves can prevent the spread of infections. In general, gloves should be worn when doing any mouth care and when handling dentures. Dentures need to be cleaned as often as natural teeth. When wet, dentures are slippery. They can easily break and chip. For these reasons, take special care when handling dentures. When they are not worn, they should be stored in a container filled with cool water. Dentures will dry out and warp if not stored in a liquid. Don’t ignore the care recipient’s mouth when you remove dentures for cleaning. The mouth needs to be cleaned with a soft toothbrush or to be rinsed with mouthwash.

            Good mouth care is valuable to the health and well-being of everyone, but it is especially important to the health and well-being of the elderly and persons with mental illness or mental retardation.

            As a person ages, soft tissues of the teeth tend to harden. Pain perception is reduced so it is more difficult to detect painful toothaches. Gum tissue recedes from around the teeth and oral membranes become pale and dry. Aside from dental problems, older adults are more prone to problems with the gums, salivary glands, lips, muscles, and jawbones. Tobacco smoke, food pigments, and saliva salts cause discoloration of teeth that cannot be removed by surface cleaning. Be aware that the amount of saliva (which cleans teeth) decreases with age, leaving the mouth more vulnerable to tooth decay and infection. Pair that with the inability to brush and floss, and the risk soars.

            Good oral hygiene prevents sores and bad breath and keeps mucous membranes from becoming dry and cracked. Poor oral hygiene can contribute to poor appetite, leading to weight loss and malnutrition. Poor oral hygiene is also associated with the development of pneumonia in older adults. It is extremely important that you encourage clients to brush their teeth daily, especially at bedtime.

            Regular brushing and flossing can prevent decay and mouth disease, improve blood flow and enhance appetite. Additionally, the individual will look and feel better. Dentures also need regular care to ensure a healthy mouth and should be checked regularly for proper fit. Dentures should be cleaned at least once a day to prevent staining, bad breath, and gum irritation. If you assist a client with oral hygiene, examine the mouth on a regular basis for signs of redness, swelling or bleeding. A dentist should check any red or white spots or sores that bleed and do not go away within two weeks. Regular teeth brushing will also prevent bad breath making it more pleasant for friends, family, and other people to be around the client.

    ORAL HYGIENE (mouth care) is an important part of personal care. Oral care is important   for several reasons:
    • The client looks and feels better with clean teeth.
    • Food tastes better and appetite improves.
    • Cavities and infections are avoided.
    • Bad breath is prevented.

    Check the care plan to see if the client needs help with oral care.

    Wear gloves if you assist with mouth care (Body fluid protection)

    Equipment:
    • A cup of water and straw, if necessary
    • Toothbrush and toothpaste
    • Basin or bowl “spit basin”
    • Mouth, if desired
    • Towel
    • Disposable gloves
    Steps:
    • Gather equipment,
    • Wash hands and put on gloves.
    • Prepare the client: Talk about what you are doing. Have them sit up in a chair or at the bedside.
    • Put a towel across their chest.
    • Place all equipment within reach so the client can brush his or her own teeth.
    • If you brush the client’s teeth, use firm, up and down short strokes in the front. On the sides use in and out strokes.
    • Brush across the tops of the teeth.
    • Be sure to scrub all surfaces.
    • Allow the client to rinse with water or mouthwash, as preferred. Clean up the area and put away all equipment.
    • Discard used gloves.
    • Wash hands.
  • Denture Care.

    • Dentures and false teeth should be cleaned at least daily.
    • Mouth care should be provided at the same time.
    • Dentures are expensive and easily damaged. Handle them with care.
      • If dentures are not worn for long periods of time (more than a few hours) they should be stored in a container of cool water.
    Equipment:
    • Denture cup or small bowl
    • Small basin, bowl, or sink
    • Cool water
    • Denture brush or toothbrush
    • Denture cleaner or mouthwash
    • Denture soaking solution
    • Denture adhesive
    • Towel and washcloth
    • Disposable gloves
    Steps:

            Gather equipment, wash hands, put on gloves. Ask for the client’s guidance for this procedure, or proceed as follows:

    •       Ask the client to remove dentures and put them in the denture cup or small bowl or remove the client’s dentures for them.
    •       Expect dentures to be slippery. Wrap a small piece of fabric, a piece of gauze, or the comer of a paper towel around the dentures.
    •       Place your gloved index finger and thumb on either side of the upper denture’s front gum line and pull slightly downward until you feel the suction break.
    •       Carefully remove the uppers from the client’s mouth. Place them in the denture cup or small bowl. Repeat the process for the lowers, pulling upward to break the suction.
    •       Fill another bowl or the sink with warm water.
    •       Hold dentures firmly in one hand and clean them thoroughly with a toothbrush or denture cleaner. NEVER use bleach or abrasive cleaners such as toothpaste on dentures.
    •       Rinse dentures thoroughly in cool water. Set them in the denture cup or small bowl. (You might soak them in a special solution. Follow directions on the package.)
    •       Rinse dentures thoroughly again before giving them back to the client.
    •       Before inserting the dentures, the client’s mouth should be cleaned and rinsed well.
    •       Note any redness or sores in the mouth.
    •       Apply denture adhesive, if the client uses it. (Follow package instructions.)
    •       Hand the clean dentures back to the client OR:
    •       Replace the dentures for the client. Position the dentures right side up or down. (Remember; the uppers have a roof. The lowers are horseshoe-shaped).
    •       Gently guide them into the mouth, moving the tongue out of the way as necessary. The client can usually help to reposition them by moving his tongue and jaw.
    •       Clean up the area and put away equipment
    •       Discard gloves and wash hands.
  • Dressing.

            Dressing and undressing the care recipient occurs daily and, sometimes, more often. Some love ones will need little or no help, while others will totally depend upon the family caregiver to dress them. Allow the care recipient to choose his/her own clothes. Everyone has their own preferences. If the care recipient is in bed all day, bedclothes are preferred. However, if they spend most of the day out of bed, encourage them to wear street clothes.

            Certain rules should be followed when dressing or undressing the care recipient:

    • Remember to always provide privacy. Never expose your care recipient. Keep them covered as much as possible.
    • Always encourage the care recipient to do as much for self as possible.
    • Always place clothing on the “weak” side of the care recipient first. If both sides have equal strength, then dress far arm and leg first.
    • Always remove clothing from the “strong” side of the care recipient first. If both sides have equal strength, undress near arm and leg first.
    Dressing the care recipient
    • Assemble clean clothes the care recipient has chosen.
    • Wash your hands.
    • Explain to the care recipient the procedure.
    • Assist the care recipient to the edge of the bed.
    • Put on underwear and pants. Pull up to the waist by having care recipient stand or, if possible, by having them lift up buttocks as they are lying on their back.
    • To put on an over-the-head type of shirt (pullover), place the weak arm (or far arm) in the armhole first. Then, slip the shirt over the head. Lastly, put the strong arm (or near arm) into the shirt.
    • Help the care recipient put on socks or stockings. Make sure they are not too tight to interfere with circulation.
    • Put on shoes or slippers.
    • Make the care recipient comfortable.
    • Wash your hands.
    Dressing and Undressing dependent Client

            Unless bedbound, a client should be encouraged to be dressed in street clothes instead of bedclothes.  Some clients need assistance getting dressed due to an injury, pain, or paralysis.

    Guidelines for dressing and undressing:
    • Wash your hands.
    • Provide for privacy and comfort.
    • Encourage the client to do as much as possible.
    • Remove clothing from the strong side first. – Put clothing on the weak side first.
    • Protect client fingers and toes by covering them with your hand. Roll up, then pull sleeves or pant legs over client’s hand or foot.
    • Anticipate the client’s needs for help with buttons, zippers, and snaps.
    • Notice the condition of the skin during this procedure.
    • Report any bruised skin, breakdown, rashes, or reddened areas.
    • Wash your hands.
    What are Ted Hose and Jobst Stockings?

            Ted Hose and Jobst Stockings are elastic stockings that are usually worn by elders who have circulation problems. The stockings help the blood to circulate through the legs and back to the heart by squeezing slightly in the veins of the legs. They are also referred to as anti-embolism stocking or hose. The care recipient will often need assistance with applying and removing these stockings. Elastic stockings are difficult to put on initially, but, with practice, you will master the technique.

            Tips and Techniques for stockings:

    • It is easiest to put the stockings on when the care recipient is lying down.
    • The stockings should be removed and reapplied at least every 8 hours, and the circulation and skin condition checked.
    • Apply the stockings according to the manufacturer’s instructions. They should fit fairly snuggly. That’s how they are able to apply the pressure needed to help the circulation.
    • The stockings are usually elder specific in that they are measured to fit one person. Don’t share the stockings or use someone else’s.
    • The stockings need to be laundered routinely just like regular stockings. Usually, hand washing is best. If the care recipient wears the stockings all the time, get another pair so one can be laundered while the other one is being worn.