Introduction to Bathing, Back Rubs & Assisting with a Clean Dressing.

Assisting a patient with regular bathing is important for patient health and for promoting self-esteem and healing. Patients who are recovering from an injury or illness, have a chronic condition, are permanently disabled, dying, or who are frail may require assistance with performing this essential task. This is an important part of the job of a Home Health Aide/Personal Care Aide. The Care Plan will direct the HHA/PCA as to the frequency and type of bath that should be performed. At minimum, a patient should have their face and genital areas cleansed daily in the morning. In the evening, HHAs/PCAs should offer to assist or provide the patient with evening care. This includes washing the face, brushing teeth, and any other area the patient wishes.

Providing for personal care gives Home Health Aides/Personal Care Aides an opportunity to assess a patient’s skin and to communicate with patients about their thoughts and feelings. The HHA/PCA should observe the patient’s skin for changes in color, temperature, swelling, new bruises, open areas, red areas, or sores. These should be documented and the supervisor informed.

Home Health Aides/Personal Care Aides should always encourage the patient to perform any personal hygiene task they are able and provide assistance as needed. Some patients may be able to bathe or shower independently, or with minimal assistance. Some patients will require complete (or total) care, meaning the HHA/PCA will have to provide their personal hygiene care completely. If a patient is immobile, weak, or frail, bed baths should be provided instead of risking a patient fall in a bath tub. Never allow a weak or frail patient to stand in a shower alone. In these types of situations, a tub or bed bath may be more appropriate. The HHA/PCA can also shampoo the patient’s hair in bed by using a shampoo tray.

Patients have a right to refuse any treatment, including bathing. The Home Health Aide/Personal Care Aide should provide education to the patient about the importance of bathing. Try to find out why the patient does not want a bath. Sometimes, the patient may not want a bath at that moment but would be willing to have one at a later time. Document the reason and patient refusal and inform the supervisor.

When providing or assisting with a bath, water temperature should be checked. The temperature should be no greater than 105 degrees Fahrenheit. Allow patients to test water temperature to determine if it is comfortable for them. It is very important when providing or assisting with a bath that the patient is provided with privacy. This includes closing doors, drawing curtains, and limiting access of the area to others while the patient is bathing. Towels or bath blankets can be used to cover the patient’s body, exposing only the body part being washed during bed baths.

Providing a back rub after a bath, before bed, or anytime a patient needs to relax is an important skill for the Home Health Aide/Personal Care Aide. This is an excellent way to teach a patient how to relax, assess their skin, and promote good circulation. This section explains the proper way to give a back rub.

Finally, instructions for how to assist with changing a clean dressing is provided. Home Health Aides may never perform sterile dressing changes. Personal Care Aides may not perform any type of dressing change.

Procedure – Tub or Shower Bath

1. Explain the procedure to the patient.
2. Wash and dry hands according to proper hand washing guidelines.
3. Assemble equipment needed (soap, shampoo/conditioner, wash cloths, towels).
4. Ensure that the bathroom is warm and comfortable. Take care it is not too cold or too hot.
5. Remove any fall risk hazards, such as loose rugs, from the floor.
6. Place any safety devices in the shower as needed (e.g. shower chair, rubber mats).
7. Ensure safety items such as handrails and grab bars are in good working order. Immediately inform a supervisor if they are not.
8. Turn on the water and test water temperature using a bath thermometer. Water temperature should be no higher than 105 degrees Fahrenheit. If providing a tub bath, fill the bath and test the temperature before putting the patient in the tub. Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.
9. Allow the patient to test the water temperature for their comfort. Adjust as needed.
10. Wash and dry hands. Put on gloves.
11. Assist the patient to the bathroom. If the patient is ambulatory, assist the patient as needed to undress and then transfer them into the tub or shower. Undress the patient immediately before getting them into the shower or tub. This prevents them from chilling.
12. If the patient is independent, give them privacy to bathe, if they prefer. If leaving a patient unattended, check on them every 5 minutes or more frequently as needed.
13. Ensure the patient knows how to use safety items such as shower chairs and grab bars.
14. If the patient is standing to shower, stay in the bathroom and monitor the patient’s need for assistance. If they are weak, always stay with them in the bathroom, providing privacy as able.
15. Never let a weak person stand to bathe or leave them in the bath alone. You can stay in the bathroom and draw the shower curtain to provide privacy.
16. Communicate with them frequently to let them know you are there to provide assistance.
17. Water should be turned off and the tub drained before assisting the patient to transfer out of the tub

 To transfer the patient into the tube:

1. If the patient is in a wheelchair, face the patient and wheelchair toward tub, between the grab bars or safety rails. Lock the wheelchair brakes. Raise the wheelchair footrests. If using a gait belt, (a special belt placed on patients to assist with safe transfers), ensure it is secure and that the patient has a shirt or towel on, with the gait belt positioned over their clothing. This is to prevent skin irritation and breakdown. Instruct the patient or assist with placing their legs, one at a time, over edge of tub. Ensure feet are planted firmly onto tub floor before assisting them with transferring into the tub.
2. Instruct the patient to grab onto the bars or the side of the tub and assist them into a sitting position on the edge of the tub. Use a gait belt to assist the patient into position and to provide a safe transfer.
3. Bring patient to a sitting position at edge of tub. Lower the patient into the tub by holding around their waist or the gait belt. Instruct them to hold the edge of the tub or the grab bars for support and balance.If using a slide board, (a special board used to help a patient safely slide from one surface to another) position the slide board onto the shower chair and under the patient’s buttocks. Assist the patient to move across the slide board in small movements by lifting their bottom up and down, and moving slowly across the board until they are on the shower chair. Never drag a patient across a slide board.
4. Move the wheelchair away from the tub during bathing.
5. Place all supplies to be used during the shower/tub bath within your reach and the reach of the patient. This is to avoid unnecessary stretching to retrieve items. If assisting the patient during the bath, avoid bending over with your back. Position yourself to a safe working level at patient height. You may kneel on the floor using a cushioned mat to protect your knees.
6. Assist the patient to shampoo and condition hair, as necessary.
7. Assist the patient, as necessary, with washing their body. Start with the patient’s eyes and then face, using a clean washcloth. Do not apply soap to the patient’s eyes.
8. Assist the patient to clean their genital and anal areas. Use clean washcloths for these areas.
9. Wash the patient’s body from clean to dirty areas. This helps to avoid contaminating clean areas. Make sure all soap is rinsed off completely.
10. If the patient is ambulatory, assist them with the transfer out of the shower/tub.
11. Cover the patient with a towel or robe during transfer to prevent them from chilling.
12. To assist the patient out of the tub if using a wheelchair, assist them to the edge of the tub. Bring patients’ legs one at a time over the outer edge of tub. Assist them back into the wheelchair. Always ensure wheelchair locks are on during transfer.
13. Help or complete the drying of the patient. Take care to carefully dry areas where there are skin folds, underneath breasts, and in the genital and anal areas. Assist them with dressing.
14. Drain and clean tub/shower area. Discard used linens.
15. Remove gloves. Wash and dry hands.
16. Document completion of the task and record any changes in condition or behavior.

 Procedure – Bed Bath

Assisting a patient with regular bathing is important for patient health and for promoting self-esteem and healing. Patients who are recovering from an injury or illness, have a chronic condition, are permanently disabled, dying, or who are frail may require assistance with performing this essential task. This is an important part of the job of a Home Health Aide/Personal Care Aide. Providing for personal care gives Home Health Aides/Personal Care Aides an opportunity to assess a patient’s skin and to communicate with patients about their thoughts and feelings. Home Health Aides/Personal Care Aides should always encourage the patient to perform any personal hygiene task they are able and provide assistance as needed. Some patients will require complete (or total) care, meaning the HHA/PCA will have to provide their personal hygiene care completely. Providing a bed bath allows a patient to receive personal hygiene care with minimal movement on their part.

1. Explain the procedure to the patient.
2. Wash and dry your hands. Put on gloves.
3. Gather equipment needed (e.g. soap, washcloths, 2 bath towels, 2 hand towels, bath blanket or clean sheet, shampoo/conditioner, basin for water, bath thermometer, lotion, patient clothing).
4. Raise the bed to a safe working height. Lock the bed brakes. Lower the railing only on the side you are working. Take care to remember to raise the railing before moving to the opposite side of the bed.
5. Provide for privacy. If in an area where others may come in, close doors and/or curtain off area as appropriate.
6. Protect bedding with towels and/or disposable pads. Place a towel under each area where you are working.
7. Remove glasses and jewelry from the patient.
8. Offer a bedpan or urinal to the patient before bathing.
9. Place a clean blanket, bath towel, or sheet over the patient to provide for privacy as you fold down bedding and remove the patient’s clothing underneath the clean blanket. Only remove blankets and clothing on areas where you are working that need to be exposed. This provides for some privacy and warmth.
10. Fill a basin with water. Test the temperature of the water. Take care to not exceed 105 degrees Fahrenheit. Have the patient test the water to see if it is comfortable for them. You may need to change the water during the bed bath to ensure it stays warm as well as when it is dirty. Always re-check the water temperature each time you change it or add water to it.
11. Always encourage the patient to assist as much as possible. This promotes independence and self-esteem.
12. To form a mitt with the washcloth: To form a mitt, open the washcloth on a flat surface. Place your palm facing up with four fingers on the washcloth, leaving your thumb out on the lower end of the washcloth. Fold washcloth into thirds lengthwise, around your palm. Your four fingers will be enclosed in the washcloth, with your thumb out. Straighten wrinkles. Fold the washcloth down. Tuck in the ends of the washcloth.
13. Wash and dry the patient from head to toe. Work on one part of the body at a time. Always move from cleanest area to least clean. Complete the front of the patient first before rolling them to their side to wash their backside.
14. Eyes, face, ears, neck: Wash the patient’s face with a wet washcloth without soap (unless patient requests). If the patient requests soap, take care that it does not get into the patient’s eyes. Start with the eyes and wash from the inner area of the eye (the corner closest to the nose) to the outer area (near the temple) with a corner of the washcloth. Using a different corner, clean the other eye. Ask if the patient would like soap to wash their face. Wash their face from the middle outward using gentle strokes. Wash behind the patient’s ears and their neck, from the chin downward. Rinse with a clean washcloth. Pat dry.
15. Arms and Axillae: Start with the arm furthest from you. Remove one arm from the blanket or towel. Support the patient’s wrist while washing the lower arm and hands. Support the person’s arm by holding their elbow when washing upper arms. They can rest their lower arm on your forearm. Using gentle but firm strokes, wash from the lower arm to the elbow area. Then wash from the elbow area to the upper arm and shoulder. Wash the axilla (underarm). Washing from the lower arm upwards helps to promote circulation of blood back to the patient’s heart. Rinse well and pat dry. Repeat for the other arm.
16. Hands: Soak hands in a basin, cleaning one hand at a time. Clean nails with a nail brush or as directed in the Care Plan. Dry thoroughly. Ensure between the patient’s fingers are well dried. Provide nail care as assigned.
17. Chest and Abdomen: Place a bath towel over the patient’s chest and lower the bed blankets down to the waist, taking care to keep the pubic area covered. This provides for warmth and privacy. Lift the bath towel slightly to wash the patient’s chest, keeping the patient partially covered. Wash the chest using long, firm strokes from the center out. For female patients, cleanse under each breast and dry well. Wash the abdomen using long, firm strokes from the center out. Take care to wash and dry well under abdominal folds. These moist areas can harbor bacteria and fungi. Apply powder to these areas as directed by the supervisor the Care Plan. Pull the blanket back up to the patient’s chin and remove the towel. Change the water.
18. Legs: Expose only one leg at a time. Place a towel under the leg lengthwise so the linens under the leg remain dry. Wash from ankle to knee with long, firm strokes upward. Then wash from the knee to the upper thigh. Rinse and pat dry. Remove towel and place underneath patient’s foot.
19. Feet: Place one foot at a time into the basin. Ensure the water in the basin is warm. Wash the foot and between toes with a washcloth. Rinse well and dry thoroughly, paying special attention that the area between the toes is well dried. Moistness between the toes promotes bacterial and fungal growth. Provide nail care as assigned in the Care Plan. Change the water.
20. Perineal area: Place a towel underneath the patient’s buttocks and upper thighs. Ask the patient if they are able to wash their own perineal area. If so, provide them with clean, warm, soapy water and a washcloth. Leave the room if the patient requests. If cleaning the patient’s perineum area, use a clean washcloth and warm, soapy water. Only expose the perineal area, leaving the rest of the patient’s body covered. Replace soiled washcloths with clean ones as needed.
21. For female patients: Wash the perineum area from front to back with single strokes. Use a clean area of the washcloth for each stroke. Wipe one side, then the other of the labia majora. Spread the labia apart and, using a clean part of the washcloth, wipe from front to back on each side, using a clean part of the washcloth for each stroke. Wipe from top to bottom down the middle to the opening of the vagina. Clean the area between the vagina and anus last, washing from front to back. Never move from back to front. This puts the patient at risk for a urinary tract infection due to exposure to bacteria from the anal area into the cleaner vaginal area. Rinse thoroughly. Dry well with a blotting motion.
22. For male patients: In uncircumcised males, gently pull back the foreskin toward the base of the penis. Hold the penis by the shaft and using a circular motion, wash from tip to base. Use a clean area of the washcloth for each stroke. Rinse the penis and pat dry. Be sure to replace the foreskin in uncircumcised males by gently pushing it back into its normal position. If you forget to replace the foreskin, you risk causing injury to the patient as the skin will cut off circulation to the penis, causing pain and swelling. Wash the scrotum, taking care to be gentle. Lift the scrotum up with one hand while gently washing the area underneath as well as the entire surface of the scrotum. Rinse and dry very well, using patting motions. Do not use the same water that has been used to clean the anal and genital areas on other parts of the body.
23. Back: Assist or position patient onto their side or stomach so that their back is facing you and they are in the center of the bed. Ensure side rails are up on the side they are facing toward. Place a towel so that it is slightly tucked under the patient’s back to prevent bed linens from getting wet. Fold the blanket back only enough to expose the back. Wash the back of the patient’s neck and back with long, firm strokes. Rinse and pat dry.
24. Buttocks: While the patient is on their side, wash their buttocks. Buttocks should be washed last, after you have washed the patient’s back. Never move from buttocks to back. Always work from clean to dirty areas. Replace soiled washcloths with clean ones as needed. Discard washcloths used to clean buttocks before moving on to new areas. Change the water.
25. Remember to change the water in the basin, as needed, when it becomes too cool or dirty.
26. Ensure that all body parts are thoroughly dried.
27. Apply lotion as needed, as requested, and as ordered.
28. Applying Incontinence Products: Some patients who are incontinent may wear disposable briefs to help keep them dry. If the patient is able, they may bend their knees and lift their hips. Place the brief under the patient’s buttocks. If unable, roll the patient to their side. Fanfold one side of the brief and tuck it under the patient. Check for correct placement of the brief. It should cover their buttocks and groin area. The top part of the brief will be about 1-3 inches above their buttocks. Roll the patient to the other side. Let them know they will feel a “bump” from the brief as they roll over it. Ensure the bed rails are up. Move to the other side of the bed. Pull the other half of the brief from under the patient. Assist the patient back to the supine position (patient is lying on their back with their face up). Pull the brief up between their legs. Peel tape from tabs and fold each side inward toward the front. Secure tape to the front of the brief.
29. Give a back rub if time permits and the patient requests.
30. Assist the patient with dressing.
31. Lower the bed to its lowest height. Ensure side rails are up for patient safety.
32. Clean area and put away equipment and supplies.
33. Remove your gloves. Wash and dry your hands.
34. Document completion of task and record any changes in condition or behavior. Document and report any skin issues, such as red or white areas, skin breakdown, open areas, rashes, or new bruises.