Chapter 9: Patient comfort and supporting personal hygiene
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Source: Adapted from NICE ([152]), Turns ([231]).
Evidence‐based approaches
Personal cleanliness is a fundamental value in society. Often, when an individual becomes unwell, they depend on others to assist them with meeting their personal hygiene needs. Within the healthcare setting, they will depend upon nursing and support staff. Although the provision of personal hygiene is a fundamental aspect of nursing care, the nursing workforce is changing and quite often the delivery of personal hygiene care is delegated to support staff team members. Personal hygiene is considered part of the essence of care and should never be treated as ritualistic. It is recommended that all professionals involved – nurses, student nurses, nursing associates, assistant practitioners and healthcare support workers – should be appropriately trained, so that they can question and evaluate care (HEE [81]). It is recommended that the personal hygiene care of patients be performed under the supervision of a qualified nurse to protect the best interests of the patient and maintain patient safety (NMC [163]b, RCN [194]).
Hygiene is a personal issue and everyone will have their own individual requirements and standards of cleanliness (Spencer [217]). It is important that the nurse or other professional delivering care observes and assesses the patient's needs on an individual basis. The nurse should not impose their own standards of cleanliness on the patient or even assume that theirs will match those of the patient.
Some patients may have a long‐term need for personal care support, such as those with dementia or a severe physical or learning disability. If a patient is unable to communicate their needs and preferences, then their family and carers may be able to advise on how best to provide such personal care.
When the patient has any degree of cognitive impairment, the approach taken to provide any personal care must consider how the patient is likely to experience that care. For example, a patient who has dementia may not retain the knowledge of who is delivering the care or what the person is doing, so they may need to be repeatedly orientated and talked through the process to prevent them from becoming distressed.
Within the patient assessment, religious and cultural beliefs that relate to and have an impact on personal care practices and the maintenance of personal hygiene should be taken into account and incorporated into care. For some religions such as Hinduism, Islam and Judaism, modesty is important (Fowler [67], [68], [69]) and can be challenging to manage in the hospital setting (Mujallad and Taylor [140]). In Western culture, privacy is of the utmost importance and considered to be a basic human right (Human Rights Act [90]). There are patients who may feel a great deal of embarrassment having to depend on another person to help them with an extremely private act. It is therefore surprising that so little reference is made to this in the literature. However, in the clinical situation, it is best to discuss this directly with the patient if possible, exploring with them how they want their hygiene needs to be met and identifying any specific requests they may have relating to their culture or religion (Mendes [128]).
Florence Nightingale ([161]) was the first to note the importance of good personal hygiene and the essential role nurses have in maintaining this in order to prevent infection and increase wellbeing (Boge et al. [23]). During the delivery of personal hygiene care, the nurse is able to demonstrate a wide range of skills such as assessment, communication and observation. Within the activity, opportunities may arise for the patient to discuss issues, concerns or fears regarding admission, treatment, discharge planning or prognosis (El‐Soussi and Asfour [59]). This can be the most significant social interaction of the day for the patient, as the nurse develops a deeper understanding of the patient's personality and needs, which serves to build a personal bond between the nurse and patient (Morrison and Korol [138]). This relationship offers the nurse opportunities to encourage the patient to reclaim autonomy and independence within the care need through participation, which can increase patients’ feelings of self‐worth and dignity.
Principles of care
Skin care is particularly important to prevent the colonization of gram‐positive and gram‐negative micro‐organisms on the skin, which lead to healthcare‐associated infections (Septimus and Schweizer [206]). By implementing simple personal hygiene measures such as regular bathing and changing of clothing and bed linen, the risk of infection can be reduced.
An initial assessment of the skin using observational skills is essential to ascertain the skin's general condition, colour, texture, smell and temperature (Voegeli [238]). Factors that may influence the appearance of the skin are outlined in Box 9.1 and specific considerations for the care of the skin are outlined in Table 9.1.
Table 9.1 Considerations for the care of the skin
| Skin condition | Special considerations |
|---|---|
| Frail and papery skin | Take extra gentle care in the bathing process, using soft cloths to wash the skin. Ensure that correct and/or preferred products and methods are used to cleanse and moisturize, thus not disrupting or impairing the skin barrier ( Voegeli [238]). This will maintain the integrity of the skin surface and prevent the skin integrity from being compromised. |
| Areas of red skin | If erythema or redness is noted, wound prevention measures need to be implemented to prevent sores and ulcers from developing. These include good pressure‐relieving positioning and repositioning and the use of barrier products in the form of creams, ointments and films (NICE [150], [151]). |
| Open wounds | When open wounds are present, such as pressure ulcers, abrasions or cuts, preventive measures such as pressure‐relieving mattresses and seat cushions should be used to prevent further breakdown (NICE [150], [151]). Appropriate cleaning solutions should be used to clear the area; soaps and perfumed creams should be avoided. Dressings should be used where appropriate to promote wound healing (NICE [150], [151]). |
| Medical devices and drains | Frequently, patients have medical devices and wound drains inserted as part of their therapy and these should be handled with care to prevent the introduction of infection or the pulling of the tubes and devices (Young [245]). |
Box 9.1
Factors that influence the appearance of the skin
Nutritional and hydration status
Imbalances will cause loss of elasticity and drying of the skin. Oedema will cause stretching and thinning of the skin (Everett and Sommers [60]).
Incontinence
The presence of urine and/or faeces on the skin increases the normal pH of 4.0–5.5 and makes the skin wet, which increases the risk of tissue breakdown and infection (Woo et al. [243]).
Age, health and mobility status
Reduced mobility in age, in ill health or with mobility problems can lead to the development of pressure ulcers (NICE [151]).
Treatment therapies
Many medications can adversely affect the skin. For example:
- Steroids may cause the skin to become papery and fragile.
- Treatments such as radiotherapy may cause the skin to become moist and cracked.
- Systemic anti‐cancer therapies can cause side‐effects relating to the hair and nails (e.g. alopecia or paronychia), on the skin barrier (e.g. skin rash or skin dryness) and on the mucosa. They can also cause a condition known as palmar‐plantar erythrodysaesthesia syndrome, which presents with cracking and epidermal sloughing of the palms and soles (Chirdharla and Kasi [36]).
Treatments that result in a low platelet count can lead to an increased risk of bruising, and a decrease in white blood cells can influence the rate of healing.
Methods of care
Perineal and perianal care
Meticulous care of the perineal and perianal areas is vital, especially for people who are prone to infection. Problems can also arise from treatment modalities that can cause fistulas, diarrhoea, constipation and urinary tract infections. Whenever possible, and if able, patients should be encouraged and assisted to perform this care themselves (Butcher et al. [32]). If a nurse is performing the care of this area, it is important that informed consent is sought, where possible, and privacy is maintained throughout. Nurse and patient should discuss this procedure together, ensuring that the patient agrees to care (NMC [163]a).
Ideally, perineal and perianal hygiene should be attended to at the end of the general bath or wash. If using a bowl of water and wipes, these should be changed after attending to this area due to the large colonies of bacteria that tend to live in and around it (Nicol et al. [160], Peate and Lane [177]). It is generally acknowledged that soap and lotions administered incorrectly to the perineum or perianal area can cause irritation and infection (Swamiappan [222]). Female patients should be washed from the front to the back (towards the anus), thus reducing the translocation of bacteria. Male uncircumcised patients should have the foreskin of the penis drawn back during washing and then returned to cover the glans of the penis (Lloyd Jones [111], Peate and Lane [177]).
Hair care
The way a person feels is often related to their appearance; hair condition and style are usually pertinent to this. Hair care can be complex and so it should be planned and carried out according to the patient's personal preferences (Peate [174]). Washing the hair of a bed‐bound patient can be challenging, but there are several ways to manage this, as follows:
The patient's condition must always be assessed before performing this task as it would not be appropriate for patients with head, neck or spinal injuries. Shampooing frequency depends on the patient's wellbeing and their hair condition. Referral to a hairdresser may be appropriate.
Grooming the hair provides an ideal opportunity to observe for dandruff, psoriasis, flaky skin and head lice. Head lice are extremely infectious so if they are present it is imperative to treat the hair with a medicated shampoo as soon as possible. Hospital policy should be followed regarding the disposal of infected linen. Towel drying of hair should occur and hairdryers can be used with the consent of the patient (Peate [174]). However, use of a hairdryer may not be appropriate if the patient has had recent alopecia (loss of hair). Hairdryers should be checked for safety in accordance with local policy.
Care of the beard and moustache is also important. Excess food can often become lodged here so regular grooming is essential for hygiene and comfort purposes. Shaving or beard trimmers can be used as appropriate.
Care of the nails and feet
The feet and nails require special care in order to avoid pain and infection. Poor toenail condition can affect mobility, compromise independence and increase the risk of localized infection (King and Callaghan [99], Stockert [221]). Fingernails and toenails should be kept short and neat; nail clippers are recommended for the trimming of nails and emery boards for filing to prevent jagged edges (Soliman and Brogan [216]). Patients with visual impairment or dexterity problems and those with learning disabilities may require assistance with the trimming and filing of nails.
Some conditions (such as peripheral vascular disease, toe infections and diabetes) carry an increased risk of peripheral complications (such as neuropathy, ischaemia and foot ulcers). Such patients must therefore be assessed by a chiropodist and/or podiatrist (Soliman and Brogan [216]).
Special attention should be paid to cleaning the feet and in between the toes to avoid any fungal infection (Forbes and Watt [64]). Fungal infections of the skin can be subdivided into two distinct categories: dermatophytes (moulds) and Candida (yeasts). A fungal infection occurs where moulds or yeasts begin to live on the keratin of the host individual. This can include the keratin of the nail plate, leading to onychomycosis (fungal nail infection). The term ‘athlete's foot’ – which describes a condition caused by poor foot hygiene and is associated with excess sweating, infrequent changes of shoes and ineffective washing – is a common misnomer for a fungal foot infection. However, it is a precursor to infection as it provides the ideal environment for dermatophytes and yeasts. In general, fungal infections present as red, itchy, dry and flaky areas of skin and, depending on location, there may also be associated maceration and fissuring. Onychomycosis presents as thickened, discoloured nails that are also crumbly, elevated from the nailbed and malodorous (NICE [156], Watkins [239]). Topical drugs are available for the treatment of infections and odour management (Ameen et al. [5], Watkins [239]).
Diabetic footcare
Chronic diseases such as diabetes and the long‐term use of steroids can result in problems such as pressure ulcers, breakdown of skin integrity and delays in healing. A patient's whole body is affected by diabetes but, in particular, this chronic disease can cause foot complications. Damage to the nerves and blood supply to the feet causes lack of sensation and ischaemia. These problems can lead to diabetic foot ulceration, which, if left untreated, can result in amputation or even death (Bowling et al. [24]).
The Diabetes UK ([50]) campaign ‘Putting Feet First’ highlighted the increasing number of amputations caused by diabetes and called for better awareness and improved standards of care for people with the disease. The organization suggests that all healthcare professionals should know how to carry out foot checks, make people aware of the risks and know how to refer patients to specialist advice appropriately. The importance of nurses recognizing and acting on a diabetic foot ulcer cannot be overestimated (Corl et al. [41], Powers et al. [190]).
Guidelines published by the National Institute for Health and Care Excellence (NICE [152]) recommend that all people with diabetes have an annual foot examination. It is important to remove patients’ shoes, socks, bandages and dressings so as to be able to examine both feet for evidence of risk factors (outlined in Table 9.2). Based on the findings of the foot examination, the person can then be classified as low risk, increased risk or high risk of developing a foot ulcer (Table 9.2). By having this information, patients can be given the appropriate education, care and screening to avoid any acute diabetic foot episodes (Bus et al. [31]).
Table 9.2 Risk factors and the level of risk for developing foot ulcers (NICE [152])
| Risk factors | Risk level |
|---|---|
| No risk factors present except callus alone |
Low risk |
|
Deformity
Neuropathy
Non‐critical limb ischaemia |
Moderate risk |
|
Previous ulceration, previous amputation, on renal replacement therapy, neuropathy and non‐critical limb ischaemia together, neuropathy in combination with callus and/or deformity, non‐critical limb ischaemia in combination with callus and/or deformity |
High risk |
| Ulceration, spreading infection, critical limb ischaemia, gangrene, suspicion of an acute Charcot arthropathy, or an unexplained hot, red, swollen foot with or without pain |
Active diabetic foot problem |
When a patient with diabetes has a foot with complications, such as sensory neuropathy or poor blood supply, it can be damaged easily. It would be prudent for them not to walk barefooted, and use open sandals or shoes with caution, as even a small graze or bruise can lead to the development of a foot ulcer. Some potential causes of foot ulceration are:
- animal hair and scratches
- corn/verruca treatment containing salicylic acid
- footwear – friction caused by creases, seams and stitching in or on the shoe
- foreign body in shoe
- hot water bottle used in bed
- ill‐fitting hosiery, for example due to pressure from sock seams
- elastic on stockings
- resting feet on or near a heater or radiator
- scald from bath water (Moakes [134]).
The formation of a foot ulcer is multifactorial. The underlying features of diabetes predispose the person to ulceration. Any altered sensation in the foot may impair recognition of injury to the skin, particularly in individuals who are unable to cut their toenails adequately. A mycotic nail may damage the nailbed or the skin of an adjacent toe, leading to subungual ulceration. Older people with diabetes may suffer from age‐related changes to vision, which makes nail care more difficult; bending down to carry out self‐checks of the foot may be hampered by reduced mobility, being overweight and/or loss of dexterity (Crews at al. [43], Turns [231]).
Daily foot care checks should be undertaken either by the person or by a relative or carer, reviewing the whole of the foot and footwear. If the person with diabetes requires help reviewing the underside of the foot independently, then a mirror can be placed either on the floor or propped in a position to assist with viewing the sole of the foot. Daily checks should include the following:
- Check top of foot, bottom of foot, tips of toes, in between toes and back of heels. Feel the foot to assess its temperature and assess sensation, ideally using a 10 g monofilament.
- Be aware of fragile skin, especially in those who are very old, and of pressure areas if the person is spending a lot of time in one position, for example in bed or seated.
- Check for pain, but remember that absence of pain in those with neuropathy does not mean that all is well.
- Check for changes in the skin's colour and look for ulcers, sores and areas of hard skin and any signs of inflammation or infection.
- Check footwear for any foreign bodies and evidence of any blood, which could indicate injury to the foot.
- Apply emollient all over the feet but not in between the toes because this may predispose the person to fungal infection as this is already a moist and warm area.
- Refer for specialist help if needed (Moakes [134], NICE [152]).
When the person is in a healthcare setting, these checks can be undertaken by a competent healthcare professional. By performing these checks and by touching the feet when applying emollient, problems are likely to be detected and treated promptly.
Methods of care of the ears and nose
Lack of attention to cleaning the ears and nose can lead to impairment of the senses of smell and hearing. Usually these small organs require minimal care, but observation for a build‐up of wax in the ears and deposits in the nose is essential to ensure patency. The outer ear can be cleaned with cotton wool or gauze and warm water. Cotton buds must be avoided; they can damage the ear canal and eardrum, and push the wax further down into the ear (NICE [157], Poulton et al. [189]).
Patients with a nasogastric tube in situ and/or oxygen therapy should have regular nasal care to avoid excessive drying, excoriation of the delicate air passages, pressure damage and skin breakdown (Asti et al. [11], Young [245]). Gentle cleaning of the nasal mucosa with cotton wool or gauze and water is recommended. Coating the area with a thin water‐based lubricant to prevent discomfort can be beneficial, but petroleum jelly is not recommended when oxygen therapy is in progress, as it is highly flammable. These interventions will remove debris and maintain a moist environment (Bauters et al. [17]).
Patients who have piercings to the ears or nose will require cleaning of the holes to avoid the risk of infection. Gently cleaning around the pierced area with cotton wool or gauze and warm water and then towel drying is recommended. Observe for inflammation or oozing; if this occurs, inform the patient and doctor and seek permission from the patient to remove the device (Smith [215]).
