BED BATH

Maintenance of personal hygiene is

necessary for an individual’s comfort,
safety, and sense of well being.
Bathing is an important intervention to promote
hygiene. Choice of the method depends on the
nurse’s judgment as well as the medical plan of care
in regard to the client’s activity level and mental and
physical capabilities to perform self-care. Several
types of bath can be used depending on the client’s
need. Baths may be used for cleansing or for
therapeutic measures related to some skin problems.
A bed bath cleans the skin and helps keep the
skin free of infection. It helps to relax the person
being bathed and help him feel better. Let the
person wash himself as much as possible. You
may only need to get the bath supplies ready
and wash the person’s back. Or you may need
to do most or all of the bath.
 PURPOSES
• To remove microbes, body secretions & dead skin cells.
• To promote circulation.
• To promote a sense of well being.
• To prevent or eliminate body odor.
• To induce sleep.
• To regulate body’s temperature.
• To prevent bed sores.
• To provide active and passive exercises.
 FACTORS AFFECTING PERSONAL
HYGIENE
• Cultural / Religious
• Developmental Stage
• Mobility
• Emotional
• Physical Illness
• Personal Preference
• North American culture places a high value on cleanliness bathing once or twice a day,
whereas other cultures bathe once a week.
• Body odors may be offensive in some cultures and accepted normal in other cultures.
• Some religious beliefs do not allow bathing for certain days and ceremonial washings
are practiced by some religions.
• Develop – the very young and elderly have needs for assistance
• Mobility – some patients have limited mobility due to weakness or a complete loss of
mobility . Determine if the patient can sit without support and stand.
• Emotional – stress and emotional disturbances can cause disruptions in ability to perform
self-care
• Physical – ill patient may not have motivation( not a hierarchy of need) or energy to
bath. Consider poor vision
• Personal preference – each pt. has individual desires and preferences when they want
to bath.
 TYPES OF BED BATH
1. Complete bed bath: Bath administered to totally
dependent patient in bed
2. Partial bed bath: Bed bath that consists of bathing only
body parts that would cause discomfort if left unbathed
such as the hands, face, axillae, and perineal area. Partial
bath may also include washing back and providing back
rub. Provide a partial bath to dependent patients in need
of partial hygiene or self-sufficient bedridden patients who
are unable to reach all body parts.
3. Sponge bath at the sink: Involves bathing from a bath
basin or sink with patient sitting in a chair. Patient is able
to perform part of the bath independently. Assistance is
needed for hard-to-reach areas.
4. Tub bath: Involves immersion in a tub of water that
allows more thorough washing and rinsing than a bed
bath. Commonly used in long-term care. A patient may
require the nurse's help. Some institutions have tubs
equipped with lifting devices that facilitate positioning
dependent patients in the tub.
5. Shower: Patient sits or stands under a
continuous stream of water. The shower
provides more thorough cleaning than a bed
bath but can cause fatigue.
6. Chlorhexidine gluconate (CHG) bath: This
antimicrobial bath wipe is used to decrease the
frequency of hospital-acquired infections on
skin, invasive lines, and catheters.
 NURSES’ ADVANTAGE
• Provides opportunity to develop a meaningful nurse-
patient relationship
• Provides opportunity for assessment of the patient
including condition of patient, psychosocial and
learning needs.
• Assessment: of the skin, hair, nails, feet
• Psychosocial data collection – where live, family
members, occupation, what is on their mind—some will
open up at this time
• Learning needs
 GUIDELINES
• Provide privacy. Close the door and/or pull room
curtains around the bathing area. While bathing a
patient, expose only the areas being bathed by
using proper draping.
• Maintain safety. Keep side rails up when away from
a patient's bedside when patients are dependent or
unconscious. Place the call light in the patient's
reach if leaving the bedside even temporarily.
• Identify patient using two identifiers (e.g., name and
birthday or name and medical record number, according
to agency policy)
• Assess for presence of equipment (e.g., intravenous [IV] line,
oxygen tubing, Foley catheter).
• Verify that bed is in locked position and raise bed to
comfortable working height. Lower side rail closest to you
and help patient into comfortable supine position,
maintaining body alignment. Bring patient toward side
closest to you.
• Maintain warmth. Keep the room warm because the patient is
partially uncovered and easily chilled. Wet skin causes an
excessive loss of heat through evaporation. Control drafts and
keep windows closed. Keep the patient covered. Expose only
the body part being washed during the bath.
• Promote independence. Encourage the patient to participate in
as much of the bathing activities as possible. Offer assistance
when needed.
• Anticipate needs. Bring a new set of clothing and hygiene
products to the bedside or bathroom.
• Conserve the energy of the client by avoiding unnecessary
exertions
• Remove the soap completely to avoid the drying effects of
soap residue left on the client’s skin
• Only small area of the body should be exposed and bathed
at a time
• Each stroke should be smooth and long rather than short
and jerky
• Support should be given to the joints in lifting the arms and
legs while washing and drying these areas
• Provide active and passive exercise whenever possible unless it is
contraindicated
• Wash the hands and feet by placing them in the basin because it promotes
thorough cleaning of the finger nails and toe nails
• Cut short the nails, if they are long
• A thorough inspection of the skin especially at the back should be done to
find out the early signs of bedsore. A redness in the skin, an excoriation of the
skin etc., should be reported immediately to prevent development of
bedsores
• All the skin surfaces should be included in the bathing process with special
care in cleaning and drying the creases and folds and the bony
prominences etc., since these parts are most likely to be excoriated by
moisture, pressure, friction and dirt.
• Special attention is given to axillae and groins to prevent disagreeable
body odors due to the decomposition of organic materials.
• Cleaning is done from the cleanest area to the less clean area, e.g.,
upper parts of the body would be bathed before the lower parts
• Avoid bathing a client immediately after a meal as it depletes the
blood supply to the digestive organs and interfere with the digestion
• Frequency and the time at which a cleaning bath is given should be
adjusted for the comfort of the clients and on the physician’s orders. A
critically ill client may tolerate only a partial bath
• Do not touch the body with hands. It is unpleasant to the clients.
 EQUIPMENT
• Washcloths and bath towels (disposable cloths optional)
• Bath blanket
• Soap and soap dish or liquid chlorhexidine gluconate
• Toiletry items (deodorant, powder, lotion, cologne)
• Toilet tissue or wipes
• Warm water
• Clean hospital gown or patient's own pajamas or gown
• Laundry bag
• Clean gloves (when risk for contacting body fluids)
• Washbasin (optional when using CHG cloths)
 BEFORE A BED BATH
• Explainwhat you are about to do, even if the patient is
unconscious.
• Clear the area of any obstacles so that you can move
around freely.
• Ensure the ward is warm.
• Have all the equipment to hand so that you do not
have to leave the patient during the procedure.
• The use of toiletries such as deodorants, cosmetics and
perfume should be determined by the patient
 PRELIMINARY ASSESSMENT
• Check the physician’s orders to see the specific precautions if
any, regarding the positioning and movement of the client.
• Assess the client’s need for bathing
• Assess the client’s ability for self care.
• Assess the cardio respiratory functioning. Check T.P.R. and B.P.
• Assess the client’s mental state to follow directions
• Check the client’s preference for soap, powder etc
• Check whether the client has taken the meal in the previous one
hour
 COMPLETE BED BATH STEPS
1. Wash your hands
Rationale: to prevent cross infection
2. Mix hot and cold water in the basin and check the temperature on the
back of the hand. Fill the basin half full.
Rationale: the skin on the bed of the hand is a sensitive area to assess the
temperature of the water
3. Place the towel under the chin. Wash, rinse and dry areas in the following
sequence – face, neck, farthest arm, near arm, chest, abdomen, back,
farthest leg, near leg and pubic region.
Rationale: protect the bed becoming wet. Cleaning is done from the cleanest
area to the least clean area. Upper part of the body first, before the lower
part of the body.
4. Take a wash cloth, wet it, squeeze the excessive water, make it
mitten, apply soap on it and clean the face, ears and neck. Put back
the wash cloth in the small bowl provided
Rationale: wash cloth used for the application of soap is kept
separately in order to keep the water in the basin as clean as possible.
5. Take the other wash cloth, rinse it in water, squeeze it, make a mitten
and clean the area where soap is applied. Repeat the procedure till
the area is cleaned thoroughly. Put back the wash cloth in the basin.
Rationale: the wash clothes are made into a mitten to avoid dragging
its cold wet ends over the skin of the client and make him
uncomfortable.
6. Dry the face with the face towel
STEPS FOR FOLDING WASHCLOTH
TO FORM A MITT.
7. Place the bath towel lengthwise under the farthest arm.
Clean and dry the farthest arm as described above. Pay
special attention to axilla. Support the arm at the joints.
Rationale: axilla is moist with perspiration. If not properly
cleaned, the soap and dirt will remain in the axilla and harbor
microorganisms. Arms are supported to prevent fatigue.

8. Repeat the procedure on the near arm

9. Place the basin on the bath towel at the edge of the bed and let the
client place hands in the basin. Rinse and dry thoroughly, paying
particular attention to the skin between fingers and nails.
Rationale: hands are more contaminated area and soaked in water
enable the nurse to clean them thoroughly.
10. Place one corner of the bath towel over one shoulder and the
opposite corner folded back and placed on the other shoulder. Both
corners are fixed under the back of the client. Fold bath blanket down
to the level of the umbilicus
Rationale: draping the chest properly provides privacy and warmth
while keeping the bath blanket dry for later replacement over the
client.
11. With the left hand raise the towel and the right hand
mitted, cleanse the chest as before. Replace the towel over
the chest between wash, rinse and dry periods. Remember to
wash under the breasts.
Rationale: observe the chest and breasts for any
abnormalities. Note the respirations.
12. While the towel remaining on the chest, fold back the
bath blanket down to the pubic region, clean and dry the
abdomen. Give special attention t the cleanliness of the
umbilicus and creased folds of abdomen.
Rationale: observe the abdomen for abnormalities
13. Remove the towel and put back the bath blanket and cover the
client completely
Rationale: care is taken to prevent draughts

14. Change water. The waste water is discarded into the bucket
Rationale: to get clean water for back care. Changing water at
intervals, maintain a comfortable temperature

15. Turn the client to a prone or side lying position with the face away
from the nurse. Make sure that the client will not fail to the ground.
Rationale: allows the visualization of the back when the client is turned
away from you.
16. Fold back the bath blanket from the shoulder to the thighs and tuck the
edges securely around the thighs. Place the towel over the bed, close to the
back, lengthwise.
Rationale: the entire back is exposed from the shoulder to the buttocks for the
thorough cleaning of the back
17. Wash, rinse and dry the back from the shoulders to the buttocks with brisk
circular movements. After drying the back give a thorough back rub with
methylated spirit and powder. Pay particular attention to the pressure points.
Rationale: a thorough cleaning, a back rub and the application of spirit and
powder prevents bedsores. The spirits hardens the protein. Therefore, it
toughens the skin and make the skin more resistant to pressure. Powder
absorbs moisture and keeps the skin dry. It also protects the skin against
friction.
18. Put on the upper garments and cover him with the bath blanket

19. Change water

20. Expose the farthest leg. Place the bag towel lengthwise under the
leg. Flex the knee so that the sole of the foot is supporting on the
mattress. Place the basin on the towel and keep the foot in the basin.
Wash and rinse the thigh and leg with the wash clothes. Clean the foot
under the water paying particular attention to the toes and nails.
Rationale: placing the foot in the water and cleaning facilitates
thorough cleaning. The feet are considered to be the least clean
area. Observe the legs.
21. Remove the basin and dry the entire leg and repeat the
procedure on the near leg.

22. Wash the pubic area. It can be done by the client if he is

able. If he is not able to do it for himself the nurse does for him
making sure that the entire area is washed thoroughly and
dried.
Rationale: the cleanliness of the pubic area is often
neglected by the clients and by the nurses.
 PERINEAL CARE
• If patient is able to maneuver and handle washcloth,
allow him or her to clean perineum on own.
• Apply pair of clean gloves. Lower side rail. Help patient
into dorsal recumbent position. Note restrictions or
limitations in patient's positioning. Place waterproof pad
under patient's buttocks. Drape patient with bath
blanket placed in shape of a diamond. Lift lower edge
of bath blanket to expose perineum
• Female patients: Wash labia majora. Use nondominant hand to gently
retract labia from thigh: with dominant hand wash carefully in
skinfolds. Wipe in direction from perineum to rectum. Repeat on
opposite side with separate section of washcloth. Rinse and dry area
thoroughly
• Gently separate labia with nondominant hand to expose urethral
meatus and vaginal orifice. With dominant hand, wash downward
from pubic area toward rectum in one smooth stroke (see illustration).
Wash middle and both sides of perineum. Use separate section of
cloth for each stroke. Clean thoroughly around labia minora, clitoris,
and vaginal orifice. Avoid placing tension on indwelling catheter if
present and clean area around it thoroughly.
• Provide catheter care as needed.
• Rinse area thoroughly. May use bedpan and pour warm
water over perineal area. Dry thoroughly from front to back
• Male patients: Cover thighs with bath towels. Raise bath
blanket up to expose genitalia. Gently raise penis and
place bath towel underneath. Gently grasp shaft of penis. If
patient is uncircumcised, retract foreskin. If patient has an
erection, defer procedure until later.
• Wash tip of penis at urethral meatus first. Using circular
motion, clean from meatus outward. Discard washcloth and
repeat with clean cloth until penis is clean. Rinse and dry
gently.
• Use circular motion to cleanse tip of penis.
• Return foreskin to its natural position. This is extremely
important in patients with decreased sensation in their lower
extremities.
• Gently clean shaft of penis and scrotum by having patient
abduct legs. Pay special attention to underlying surface of
penis. Lift scrotum carefully and wash underlying skinfolds.
Rinse and dry thoroughly.
• Avoid placing tension on indwelling catheter if present and
clean area around it thoroughly. Provide catheter care
 CHG BATH
• A cleansing pack contains six
to eight premoistened towels
for cleaning. Warm package
contents in microwave
following package directions.
If you are bathing patient
using warm commercial or
CHG cloth, check
temperature of cloth before
use. Gloves diminish sense of
heat.
• Use all six CHG cloths in the following order
Cloth 1: Neck, shoulders, and chest
Cloth 2: Both arms, both hands, web spaces, and axilla
Cloth 3: Abdomen and then groin/perineum
Cloth 4: Right leg, right foot, and web spaces
Cloth 5: Left leg, left foot, and web spaces
Cloth 6: Back of neck, back, and buttocks
 TUB BATH OR SHOWER
• Consider patient's condition and review orders for
precautions concerning his or her movement or positioning.
• Schedule use of shower or tub.
• Check tub or shower for cleanliness. Use cleaning
techniques outlined in agency policy. Place rubber mat on
tub or shower bottom. Place disposable bath ma
• Collect all hygienic aids, toiletry items, and linens requested
by patient. Place within easy reach of tub or shower. t or
towel on floor in front of tub or shower.
• Help patient to bathroom if necessary. Have him or her
wear robe and slippers.
• Demonstrate how to use call signal for assistance.
• Place “occupied” sign on bathroom door.
• Fill bath tub halfway with warm water. Check temperature
of bath water, have patient test water, and adjust
temperature if water is too warm. Explain which faucet
controls hot water. If patient is taking shower, turn shower on
and adjust water temperature before he or she enters
shower stall. Use shower seat or tub chair if needed.
• Instruct patient to use safety bars when getting in and out of tub
or shower to pull cord to summon assistance (if available).
• Instruct patient not to remain in tub longer than 10 or 15 minutes.
Check on him or her every 5 minutes.
• Return to bathroom when patient signals and knock before
entering.
• For patient who is unsteady, drain tub of water before he or she
tries to get out. Place bath towel over patient's shoulders. Help
patient out of tub as needed and help with drying.
• Help patient as needed with getting dressed in clean gown
or pajamas, slippers, and robe.
• Help patient to room and comfortable position in bed or
chair.
• Clean tub or shower according to agency policy. Remove
soiled linen and place in dirty-linen bag. Discard disposable
equipment in proper receptacle. Place “unoccupied” sign
on bathroom door. Return supplies to storage area.
• Perform hand hygiene.
 AFTERCARE
1. Replace the client’s personal clothing
2. Straighten the bed linen
3. Remove the bath blanket and put it for washing
4. Change the bed linen if needed.
5. Cut short the finger nails and the toe nails. The nail cuttings
should be received in the kidney tray
6. Comb the hair and arrange the hair
7. Position the client for comfort and proper alignment
8. Take all articles and soiled linens to the utility room.
Disinfect the bath basin and the wash clothes.
9. Send the soiled linen to the laundry. Put back all
the articles in the proper places after cleaning.
Personal articles are replaced into the bedside table.
10. Wash hands. Record the procedure in the nurse’s
record with time and date and the type of bath.
Record any abnormalities observed.
11. Take the opportunity to reach the client or his
relatives about the personal hygiene.
 BED SHAMPOO
• It is the easing of the hair with the patient in
bed.
Purposes:
• To maintain cleanliness
and provide comfort
• To refresh the client
• Special Considerations:
1. Be sure the procedure is ordered by the physician.
2. See to it that the client is in comfortable position.
3. Protect the client from chilling and falling.
4. Check the client’s temperature before the
shampoo.
5. See to it that the bed is adequately protected.
6. Observe principles of body mechanics.
• Equipment needed:
Underpads Pitcher of water
Basin Bath towel
Pail Face towel
Comb
Rubber protector
Cotton balls
• Procedure:
1. Explain the procedure to the patient.
2. Gather equipment at the bedside.
3. Close windows and the door, turn off air
conditioning or electric fan.
4. Screen the bed, if in a ward.
5. Position the bed to a comfortable working
height.
6. Prepare the water at desired temperature.
8. Loosen and fold the top sheet down to the
waistline or replace it with a bath blanket.
Rationale: This allows the easy change of
position.
9. Remove the pillow and bring the client’s
head close to the top edge of the bed.
Rationale: Working close to an object prevents
overstretching which causes muscle strain.
10. Place waterproof pad under patient's
shoulders, neck, and head. Position
patient supine. Place underpads under
patient's head and washbasin at the
patients’s head
Rationale: The underpad prevents soiling
of the pillow and mattress.
11. Place rolled towel under patient's neck and bath
towel over patient's shoulders
Rationale: To provide comfort.
12. Comb the client’s hair.
Rationale: To remove snarls
13. Cover the eyes with cotton balls/or instruct client
to close his eyes.
Rationale: Such precaution protects the eyes from
soap which may cause irritation and discomfort.
14. Plug the ears with cotton balls.
Rationale: This prevents water from entering the
ears which cause irritation and discomfort.
15. Mix warm and tap water into the basin.
Rationale: This ensure that the water is at the right
temperature.
16. Slowly pour water from water pitcher over hair
until it is completely wet. If hair contains matted
blood, put on gloves, apply peroxide to dissolve
clots, and rinse hair with saline. Apply small
amount of shampoo.
Rationale: Soap emulsifies hair oil and lower surface
tension of water, ensuring more effective
cleansing.
17. Work up lather with both hands. Start at
hairline and work toward back of neck. Lift
head slightly with one hand to wash back of
head. Shampoo sides of head. Massage scalp
by applying pressure with fingertips.
Rationale: Massage loosens accumulated dirt,
favoring better cleansing, as well as stimulates
circulation in the scalp necessary for a healthy
hair. Using the nails in massaging the scalp
hurts and irritates it.
18. Rinse, repeat process until the hair is
thoroughly cleansed, taking care to avoid
undue jagging or frequent turning of the head.
Rationale: Soap, if not completely rinsed off,
irritates the scalp as well as makes the hair
sticky. Undue jagging or frequent turning of the
head may cause dizziness and discomfort.
19. Use cold water, whenever required for the
final rinse.
Rationale: This provides a more refreshing
effect.
20. Squeeze off the excess water from the
hair.
Rationale: To facilitate the drying.
21. Remove the eye cover and ear plugs.
22. With one hand, raise the head while with
the other remove the basin and underpad.
Then wrap the hair with the bath towel under
the head and readjust the pillow.
Rationale: Prompt attention to details of
comfort enhance the client’s feeling of well
being and confidence.
23. Dry the hair well; then comb it.
Rationale: Wet hair may cause chilling
due to the cooling effect of evaporation.
24. Move back the client to the center of
the bed.
 ORAL CARE
It is the special care given to the mouth.
Purposes:
1. To cleanse the mouth and keep its mucous membrane
in good condition.
2. To prevent the formation of sores
3. To prevent dental caries
4. To prevent halitosis
5. To minimize bacterial flora,
in order to prevent infection
• Special Considerations:
1. If the client’s condition allows, encourage him to brush
his teeth.
2. Carry out oral hygiene measures as part of daily
routine care.
3. Observe special precautions when cleaning the
mouth of a very ill client.
4. Handle dentures with care to prevent loss or damage.
5. If antiseptic mouthwash is to be used, follow correct
dilution.
• Equipment:
Glass of water Mouthwash
Toothbrush Toothpaste
Drinking tube Rubber sheet
Bath or face towel
Kidney basin
Mineral oil
• Procedure:
1. Wash your hands and dry.
2. Gather equipment needed.
3. Explain the procedure to the client.
4. Screen the bed if the client is in a ward.
5. Place the client in a semi-sitting position
6. Spread the towel across the client’s chest.
Rationale: The towel serves not only as a protector but will
also prevent wetting of the client’s bedclothes.
7. Put some toothpaste on the toothbrush wet it
with water or mouthwash and hand it to the
client.
Rationale: Toothpaste helps clean the mouth by
mechanical and chemical action on bacteria.
8. Hold the kidney basin close to the chin.
Rationale: For ease in spitting out mouth rinsings.
9. Offer the glass of water and allow the client to wet his
mouth.
Rationale: Wetting the mouth will promote foaming of the
dentrifice thereby resulting in better cleansing action.
10. If the client can, allow him to do the brushing. Assist
him if it is necessary.
Rationale: This gives the client a feeling of achievement
and a sense of well-being.
11. Offer the glass of water and allow the client
to rinse his mouth.
Rationale: To remove the dirt, bacteria, and the
dentifrice.
12. Offer the glass of mouthwash and allow
client to gargle.
Rationale: Mouthwashes clean and refreshes
the mouth.
13. Dry the lips with towel. Apply mineral oil if
necessary.
Rationale: Lips become dry and cracked
especially if fever is present.
14. Clean all used articles and return them to
proper places.
Rationale: To prevent the spread of
microorganisms.
15. Discard mouth rinsings direct to the drain or
toilet bowl.
 ORAL CARE OF AN
UNCONSCIOUS CLIENT
Equipment:
Mouthwash in medicine glass
Cotton-tipped applicators
Several wooden tongue depressors wrapped with
gauze and secured by adhesive tape
Kidney basin
Rubber sheet
Face towel
Suction Brush
• Procedure:
1. Wash your hands and dry
2. Assemble equipment needed
3. Inform the relatives about the necessity of the
procedure
4. Screen the bed if the client is in a general ward
5. Protect the pillow with a rubber sheet or towel.
6. Turn the client’s head to the side, with the face slightly downward.
Rationale: This position allows fluid in the mouth to gravitate towards
the lips – thereby preventing aspiration.
7. Drape the towel across the chest.
Rationale: To protect the client’s pillow and gown from getting wet.
8. Dip the gauze-wrapped tongue depressor in the mouthwash
solution.
Rationale: To provide better mechanical cleansing effect.
9. Insert a gauze-wrapped tongue depressor to keep the
mouth open.
Rationale: To keep the mouth open and facilitate
cleansing
10. Using the wet tongue depressor, clean the buccal
cavity starting from the inner cheeks; then the teeth, the
tongue and towards the lips.
Rationale: Accumulated dirt in the mouth favors bacterial
growth causing halitosis, local and systemic infection.
11. Suction excess solution
Rationale: To prevent choking and aspiration
12. Apply mineral oil to the lips and mucous membrane of
the mouth using the cotton-tipped applicator.
Rationale: To prevent dryness, crusting and cracking of
lips.
13. Discard used applicators and wooden tongue
depressors. Clean other equipment used.
Rationale: To prevent spread of microorganism.
 NAIL AND FOOT CARE
The feet and nails require special attention to prevent
infection, odors, and an injury to tissue. People are
unaware of foot or nail problems until pain or
discomfort occurs. Problems may result from poor
care of the feet and nails such as biting nails or
trimming them improperly, exposure to chemicals and
wearing poorly fitted shoes.
Patients with diabetes mellitus or peripheral vascular
disease should be observed for adequate circulation
of the feet. Because of poor vision and decreased
mobility, the elderly are at risk for foot disorders. Care
of hands and feet can be administered during the
morning bath or at another convenient time.
1. Identify patient using two identifiers according to agency policy. Ensures
correct patient.
Rationale: Complies with The Joint Commission standards and improves
patient safety
2. Perform hand hygiene. Apply clean gloves if drainage present. Inspect all
surfaces of fingers, toes, feet, and nails. Pay particular attention to areas of
dryness, inflammation, or cracking. Also inspect areas between toes, heels,
and soles of feet.
Rationale: Integrity of feet and nails determines frequency and level of
hygiene required. Heels, soles, and sides of feet are prone to irritation from ill-
fitting shoes
3. Assess color and temperature of toes, feet, and fingers. Assess
capillary refill of nails. Palpate radial and ulnar pulse of each hand
and dorsalis pedis pulse of foot; note character of pulses
Rationale: Assesses adequacy of blood flow to extremities.
Circulatory alterations often change integrity of nails and increase
patient's chance of localized infection when break in skin integrity
occurs.
4. Ask female patients whether they use nail polish and polish
remover frequently. Rationale: Chemicals in these products cause
excessive dryness.
5. Assess type of footwear worn by patient: Does patient
wear socks? Are shoes tight or ill fitting? Does patient wear
garters or knee high nylons? Is footwear clean? Types of
shoes and footwear predispose patient to foot and nail
problems (e.g., infection, areas of friction, ulcerations).
Rationale: These conditions decrease mobility and increase
risk for amputation in patient with diabetes.
6. Identify patient's risk for foot or nail problems:
Rationale: Certain conditions increase likelihood of foot or
nail problems
7. Assess patient's ability to care for nails or feet: visual
alterations, fatigue, and musculoskeletal weakness.
Rationale: Determines patient's ability to perform self-care
and degree of assistance required from nurse.
8. Assess patient's knowledge of foot and nail care practices.
Rationale: Determines patient's need for health teaching
9. Help ambulatory patient sit in bedside chair. Help bed-bound patient
to supine position with head of bed elevated. Place disposable bath
mat or towel on floor under patient's feet or place towel on bed.
Rationale: Sitting in chair facilitates immersing feet in basin. Bath mat or
towel protects feet from exposure to soil or microorganisms on floor;
towel lessens chance of splashing water on floor or bed.
10. Fill wash basin with warm water. Test water temperature.
Rationale: Warm water softens nails and thickened epidermal cells,
reduces inflammation of skin, and promotes local circulation. Proper
water temperature prevents burns.
11. Place basin on bath mat or towel and help patient place feet in basin.
Place call light within patient's reach.
Rationale: Patients with muscular weakness or tremors often have difficulty
positioning feet. Maintains patient's safety
12. Adjust over-bed table to low position and place it over patient's lap.
(Patient sits in chair or lies in bed.)
Rationale: Easy access prevents accidental spills.
13. Fill emesis basin with warm water and place basin on paper towels on
over-bed table.
Rationale: Warm water softens nails and thickened epidermal cells.
14. Instruct patient to place fingers in emesis basin and arms
in comfortable position. Rationale: Prolonged positioning
causes discomfort unless normal anatomical alignment is
maintained.
15. Allow patient's feet and fingernails to soak for 10 to 20
minutes. Rewarm water after 10 minutes.
Rationale: Softening corns, calluses, and cuticles ensures easy
removal of dead cells and easy manipulation of cuticle. Do
not soak if patient has diabetes.
16.. Clean gently under fingernails with plastic stick while fingers are immersed
with water in basin; then dry fingers thoroughly
Rationale: Plastic stick removes debris under nails that harbors microorganisms.
Do not use wood, which could cause splintering. Thorough drying impedes
fungal growth and prevents maceration of tissues.
17. Using nail clippers, clip fingernails straight across and even with tops of
fingers; Using a file, shape nails straight across. If patient has circulatory
problems, do not cut nail; file nail only.
Rationale: Cutting straight across prevents splitting of nail margins and
formation of sharp nail spikes that irritate lateral nail margins. Filing prevents
cutting nail too close to nail bed.
18. Use soft cuticle brush or nail brush around cuticles. Do not
push cuticles back roughly or cut them.
Rationale: Reduces incidence of inflamed cuticles.
19. Move over-bed table away from patient.
Rationale: Provides easier access to feet.
20. Put on clean gloves and scrub callused areas of feet with
washcloth.
Rationale: Gloves prevent transmission of fungal infection.
Friction removes dead skin layers
21. Clean gently under nails with plastic orange stick. Remove
feet from basin and dry thoroughly.
Rationale: Nails harbor debris and dirt and are a source of
potential infection from poor care habits .
22. Clean and trim toenails using procedures same in
fingernails. Do not file corners of toenails.
Rationale: Shaping corners of toenails damages tissues.
23. Apply lotion to feet and hands and help patient back to
bed and into comfortable position.
Rationale: Lotion lubricates dry skin by helping to retain
moisture.
24. Remove clean gloves and place in receptacle. Clean
and return equipment and supplies to proper place. Dispose
of soiled linen in hamper. Perform hand hygiene. Rationale:
Reduces transmission of infection