Basis nursing care usually includes good nutrition and plenty of fluids, but this may not always be possible. Here are the rudiments of good skin care.
Keeping the Pressure off Boney Prominences
The main bony prominences are the heels, anklebones, tailbone, hips, shoulder blades and elbows. When the patient lies on these areas too long the cells beneath the surface of the skin become squeezed and die causing a pressure ulcer to develop. Such a condition does not take long to happen (one partly paralysed, local patient was on an airplane for four hours; the pressure sore he developed as a result of the flight took several months to heal). Not only is this very unpleasant for the patient but it also results in considerable expense for the medical system. To prevent such an occurrence, it’s crucial that the patient changes position or is helped to reposition at least every two hours.
Maintaining Clean and Dry Skin
The patient needs a bed bath every morning and evening. Particular attention must be paid to all folds and creases in the skin. These must be washed with mild, non-perfumed soap or no soap at all and then gently patted dry. If the person suffers from incontinence or is clammy from sweating further sponge baths are needed. The skin must not remain moist, as bacteria will grow on damp skin leading to break down. A barrier cream can be used to protect the skin. Powder is usually not recommended as it clogs and also encourages bacterial growth.
Providing Additional Protection
To provide extra care for the person a special mattress can be rented or purchased. A thick foam may also be worthwhile. A synthetic sheepskin or egg crate mattress can give comfort but will not relieve pressure enough to prevent cell death. Padding to keep the heels off the mattress, the anklebones and knees apart, and the patient comfortable are all a good idea. Sheets should not be too snug as this does not allow the patient to move and may increase pressure.
Moving the Patient Carefully and Preventing Shearing
Moving the patient carefully means not dragging the person up or across the bed. Two people are best or a lift unless the patient can help. There are techniques to moving a person that are easier on the patient and save the caregiver’s back.
Improving the Blood Supply to Bony Prominences
Gently massage in a circular fashion to those bony prominences using some kind of nonperfumed
lubricant. Rubbing too vigorously can damage the tissue.
Of all these basic elements of nursing care, the most important to stress is relief of pressure.
Prepared by Joanne Thomson, RN Feet.
We walk on them, squeeze them into shoes and then pamper them with a warm soak and lotions when they complain at the end of the day. Feet are important to our physical and emotional health. Healthy, pain free feet allow us to walk and move with good alignment so that our back and hips carry our weight evenly and with a minimum of effort. So, how can we keep our feet happy or return them to a happy state?
If you are healthy and free of diabetes or heart disease then regular washing, a light buffing with a pumice stone, regular nail clipping and some soothing lotion once in a while, and comfortable well ventilated shoes are probably all you need to do to keep your feet comfortable. However, if there are underlying diseases like diabetes or peripheral vascular disease (poor circulation of blood in the feet and hands) or pain and discomfort that a rest doesn’t relieve, call in a professional podiatrist. Do not struggle with a foot problem on your own. In British Columbia all individuals with MSP coverage can get up to $150.00 worth of podiatrist treatments a year without a doctor’s referral; this is about five visits a year. With a doctor’s referral there can be more visits allowed. There is a $10.00 user fee per visit however; most seniors and those on income assistance do not have to pay the user fee. The user fee can be claimed in most extended health plans. Many podiatrists make home visits.
Caring for Healthy Feet of Persons with Limited Mobility
Footbaths are very useful when the person is able to sit in a chair. Footbaths are available in cadillac versions with vibrating massage and heaters, and in dish basin versions. They all work. The object is to soak the feet in a warm water bath so they can be cleaned well, the dirt under the nails softened so it can be gently removed and the nails softened so they can be more easily clipped or filed. Clipping of nails should be done in good light with care not to clip the skin, which often grows up the nail on the underside. Clip or file toenails straight across even with the top of the toe (this reduces the risk of the nails becoming ingrown).
If a person is not able to get out of bed then the foot soaking can be done with them in bed. It is part of a total bed bath. Use a basin or footbath and soak one foot at a time. It is usually easiest to stand beside the person facing their foot so that you can support their knee between your body and you’re inside arm. It is virtually impossible to do a footbath in bed without some spilled water so plan for it with a plastic protection of some sort under the basin. Bend the person’s knee and support it between your body and your arm as you lift their foot into the basin. Continue to support the knee as you bathe the foot and then dry it. The water will cool quickly so change the water between feet. Often a light dusting of foot powder after drying will reduce the risk of fungal infections.
Common Problems and Treatments
Callus is a thickening of the skin caused by local friction or pressure. Soak in Epsom salts and warm water then gently rub with a pumice stone (emphasis here is on GENTLY as firm rubbing will encourage more callus growth). Application of a lotion can help reduce callus re-growth. The “Dermal Therapy” line of products is particularly good – ask your pharmacist for similar products. If calluses persist or become painful see your doctor or podiatrist.
Corns are thickened skin, usually cone shaped, round and raised. If allowed to grow they can become painful causing a person to walk with poor alignment and leading to problems with the hips and back. Corns may need to be surgically removed. Consult your doctor for treatment options.
Plantar warts are caused by a virus and usually are on the sole of the foot. See your doctor for treatment options.
Athlete’s foot is a fungal infection of the skin and usually presents as peeling or cracking skin and small blisters under the skin. It can be spread to other areas of the body. Treatment includes a cream or powder anti-fungal, washing the feet regularly, changing socks or stockings daily, and drying the feet well after bathing. Consult your pharmacist or doctor.
Ingrown nails – the nail grows in a curve that causes it to grow into the tissue surrounding the nail. This can cause pain and increases the risk of infection. Treatment may involve removal of part of the nail by a podiatrist. Consult your doctor or podiatrist.
Prepared by Renee Bradley RN
Most people have some pleasant memories of bathing. These memories are best accessed by recreating the environment that made them possible. When assisting a loved one with bathing it is important to learn what they define as safety, warmth, caring and adequate time.
The bathroom is the most dangerous room in the house. The dangers can be reduced by installing railings, setting the temperature on the hot water tank to prevent scalding, using a nonslip tub mat, and converting the bath into a shower with a transfer bench and a shower hose. A bath lift is expensive but gives bathtub enthusiasts tremendous pleasure when they cannot safely get in and out of the tub with assistance.
Safety also involves feelings of security. Modesty must be protected by providing privacy and allowing time for the person to be comfortable with the one assisting with the bathing. If it is safe to do so allow them privacy by leaving the room or if it is not safe turn around to “tidy the counter top” or pull the shower curtain and sit on the closed toilet seat for a few minutes. Sometimes hair washing in the tub or shower is a source of fear. Consider a weekly trip to the hairdresser for a wash and set or to the barber for a wash and trim if washing the hair in the bath or shower is uncomfortable.
What does the individual define as warm? Ask a few questions. Then adapt to their preferences. If they like the bath hot and the heat lamp on you may need to wear a short sleeved t-shirt and shorts so you don’t get too warm and appear impatient.
What does the person define as caring behaviour? Allow the person to direct the bath as much as is
reasonable but always take into consideration your own comfort level and safety.
How long does a good bath take? Fifteen, thirty, sixty minutes? Be sure to communicate the amount of time you have available before starting the bath. If the person considers this amount of time much too short leave the bath for another day and help them with a quick sponge bath.
A sponge bath is the term used when the person uses water from the bathroom sink to bathe. It is important to have a non-slip bath mat on the floor and have a chair (or walker with a seat) for the person to sit on to reduce the risk of falls. Change the water frequently and have several washcloths and small towels available. Assist with washing the back and feet. Many elderly people maintain good hygiene with daily sponge baths and weekly trips to the hairdresser or barber.
A successful bed bath requires careful planning and a mattress protected from water spills. A bed bath is simply a sponge bath in bed. The sheets will get damp and need to be changed. It is very important to dry the skin well. Sometimes powder is used to take the last feeling of dampness away. It is always easiest for both the care receiver and the caregiver if the person being bathed can get up to a chair while the bed linens are changed.
If it is not possible for the person to get out of bed remove the top sheets and damp towels and cover the person with a warm blanket then put a dry towel under the person by having them roll from side to side. Release the bottom sheet and fold it toward the centre of the bed tucking it as far as possible under the dry towel. Then put the clean sheet on the bed and tuck it under the towel as well. Assist the person to roll over the tucked sheets and onto the clean sheet then go to the other side of the bed to remove the damp sheet and straighten out the clean sheet. Remove the dry towel and put on the top covers.
Incontinence: Managing it at Home
Prepared by Renee Bradley RN and Joanne Thomson, RN
AaaCHoo….OOPS! Sound familiar? Stress incontinence is the most common form of incontinence. Most people who experience some type of incontinence want the problem to be invisible to the casual visitor. In this article we will be giving you some tips for how this can be accomplished.
There are five main types of incontinence:
- Enuresis (night time bed-wetting).
- Stress incontinence (dribbling when coughing, laughing, or sneezing).
- Urgency (inability to hold back the stream of urine when you have the urge to void).
- Paradoxical or overflow incontinence (retention of large volumes of urine with the involuntary passing of small amounts or urine).
- Continuous incontinence (no conscious control of urination).
Enuresis is a type of incontinence often associated with the very young but it occurs in adulthood as well. Some medications have the side effect of enuresis and there are others that are designed to treat it. If your loved one develops enuresis discuss it as soon as possible with their family doctor and provide a list of all the medications your loved one is on (including prescription, non-prescription and herbal medications).
For persistent problems, management of the bed-wetting includes use of pads to protect the mattress and skin care to prevent skin break down. Skin care includes bathing the skin and replacing wet pads with dry ones. Disposable briefs can be used for short periods but are not recommended for overnight use.
Stress incontinence frequently affects women who have experienced childbirth and men who have had prostate surgery. Sneezing, coughing, and laughing can relax the sphincter muscles surrounding the urethra and allow urine to leak from the bladder. The person affected is usually very aware that the leakage has occurred.
Treatments can include reparative surgery and exercises of the pelvic floor. Kegel exercises are designed to improve the tone of the muscles of the pelvic floor and when practiced regularly can often decrease stress incontinence in women. “Management” of the problem is used when there is no treatment. Management usually includes regular bathroom breaks (toileting) so that the bladder never gets too full and the use of protective pads worn inside the underwear.
Urgency is the inability to hold back the stream of urine once the urge to void is communicated from the bladder to the brain. Some degree of urgency is common in old age as the urge to void occurs later and later as we age, often occurring just before the bladder is completely full. However, urgency can also occur as a result of urinary tract infections.
Treatment includes regular toileting to prevent overfilling of the bladder and medication if there is an infection. If urgency occurs at night, a commode chair at the bedside that can be discreetly removed to the bathroom in the day is often the answer.
Paradoxical or overflow incontinence involves the retention of large volumes of urine with the involuntary passing of small amounts of urine. This usually occurs when there is some nerve damage to the bladder. Treatment can include daily catheterization(s) to remove the urine that remains in the bladder after the overflow incontinence (the residual urine) or it may be the use of an indwelling catheter with a drainage bag.
If the cause of the overflow and residual are physical (i.e. enlarged prostate) then surgical intervention is considered. The overflow incontinence is often managed with incontinence pads and briefs.
Continuous incontinence is when there is no conscious control of urination. The individual cannot control the flow of urine and cannot predict its flow. This usually occurs when there is nerve damage caused by a spinal fracture or stroke. Treatment can be with incontinent pads and briefs if the person is quite mobile. However, often it is treated with a combination of catheterization and condom drainage in men and catheterization in women because the risks of skin breakdown and urinary tract infection are very high in individuals with continuous incontinence.
TIP: Your nose should not be able to tell if a person is incontinent. If there is an odour of urine around the person then something is wrong. Check the cleanliness of clothing and person. If the person’s private parts are clean and skin is dry and healthy looking the problem is likely due to a urinary tract infection, which changes the smell of the urine or dehydration causing the production of very strong smelling urine. Urine should never smell “foul”. The urine of healthy individuals is clear pale amber, like a very mild beer, and has a mild odour. If it is darker, or cloudy, or there are flecks of white or red in the urine check with your family doctor. Take a sample of the urine with you in a clean glass jar. Some medications can stain the urine and are not a concern. Some foods can stain the urine too.
Medication Management in the Home
Prepared by Renee Bradley, RN
Care in the community often involves the aspect of medication administration. We all know that taking a couple of Tylenol is not a problem, taking multiple medications three times a day sometimes is a daunting task. Complicated medication setups may require professional help and your doctor may refer you to Community Nursing.
Here are some suggestions for those people that are able to manage their medications at home.
Establish a routine. Have your doctor prescribe the largest proportion of your medications at breakfast. Program the TV to turn on in the morning for the day, date and time. Tick off the days with a wall calendar. An egg carton with felt pen markings makes a useful pill container and can be set up each day.
A pillbox or dossette is a great organizer. Most dossettes have the day and the time printed on them
and can be set up with all pill form medications for a week.
Bubble packs are cards with clear plastic pop out bubbles that are filled by the pharmacy according to the direction of your doctor. Bubble packs have the time and day printed on them and they are great for those people who don’t require frequent changes to their medications.
Small syringes without the needle and with a cap are very useful for liquid medications such as cough medicine. Syringes can be pre-measured and left in the fridge for as long as they are needed and you can wash and re-use them. Pharmacies will pre-measure medication syringes according to doctors orders.
Insulin is administered in small doses and sometimes the doses and syringe measurements are difficult to see. Insulin can be pre-measured and left in the fridge. Take out the insulin about half an hour before injecting to let it warm a little. This helps to reduce discomfort. Mixed insulin often separates when standing and needs a gently rolling action before administering. Remember to roll pre-measured syringes gently between your fingers to mix the dose.
The Arthritis Society is a good resource for people unable to open pillboxes. Both the CNIB and Diabetes Society have aides for people with visual difficulties. Pharmacies try to accommodate their clients by supplying visual aides such as large printing and labeling. Pharmacies and mobility companies have dossettes and medication reminders. Talking clocks, wristwatch alarms and pillbox alarms are available in the community.
Some over-the-counter drugs interfere with prescription drugs. Consult your doctor or pharmacist
before taking antacids, cold medications or herbal remedies.