RGN; RSCN; BSc.; Certificate of Medical Education; PGCE; FAETC 7306;

ENB 870; D32/33/34 /A1/2/V1

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This book has been devised for those providing clinical care. It will provide in-depth advice on

aspects of basic care for the inexperienced, and serve as a salutary reminder of fundamental

care provision that should be inherent to clinical professionals of all grades and experience.

Acknowledgments

I have learnt so much from so many people that I cannot thank them all by name. To all those

trainers and colleagues who have been my mentors and friends – you know who you are –

“thank you”.

With reference to the production of this book, I need to thank the following people for their

invaluable support and encouragement over the past decade:

Alison Haines and Debra Chatterton ,Registered Nurse colleagues who

encouraged me to write this, have kept me focused and have provided

invaluable objectivity.

Barry Howarth, for giving me the freedom to develop as a trainer

ultimately writing this book

My brother Andy for his endless patience with the I.T. side of writing.

Valerie, Bea, Nicki and Jean for editing.

Our son and daughter, Chris and Jo Long for their support,

encouragement and feedback.

And above all, thanks to my wonderful husband Dave – for always

believing in me.

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Contents

1 WELCOME....................................................................................................................................5

2 WHAT HAS CHANGED IN NURSING? .......................................................................................6

3 NEW TO THE NURSING ROLE...................................................................................................8

3.1 Caring for a relative or loved one..........................................................................................9

3.1.1 Support for home carers............................................................................................. 10

3.2 What do they mean? .......................................................................................................... 11

3.3 Incompatible patients and carers ....................................................................................... 11

4 THE SIX FUNDAMENTAL PRINCIPLES OF NURSING CARE............................................... 13

4.1 Real communication........................................................................................................... 14

4.1.1 Barriers that can affect communication ..................................................................... 14

4.1.2 Hearing ....................................................................................................................... 15

4.1.3 Visual .......................................................................................................................... 16

4.1.4 Language barriers ...................................................................................................... 17

4.1.5 Words used................................................................................................................. 18

4.1.6 Patient unconscious ................................................................................................... 18

4.1.7 Disorientation.............................................................................................................. 19

4.1.8 Learning disability....................................................................................................... 20

4.1.9 Appearance and Body language................................................................................ 21

4.1.10 Patient in pain or frightened ....................................................................................... 21

4.2 Patient privacy .................................................................................................................... 22

4.3 Patient dignity ..................................................................................................................... 23

4.4 Infection control .................................................................................................................. 24

4.4.1 Reducing the risk of infection..................................................................................... 24

4.4.2 Hidden infections........................................................................................................ 25

4.4.3 Infection control by isolation....................................................................................... 26

4.4.4 Preventing infection via clinical waste ....................................................................... 26

4.5 Patient consent................................................................................................................... 27

4.5.1 Unable to give informed consent? ............................................................................. 28

4.6 Respecting the patient’s culture and religion..................................................................... 28

5 APPLYING THESE SIX PRINCIPLES ...................................................................................... 30

5.1 Providing appropriate personal care / hygiene .................................................................. 31

5.1.1 Equipment necessary for both full and assisted hygiene .......................................... 33

5.1.2 Principles applicable to all types of personal care delivery ....................................... 34

5.1.3 Assisted hygiene (partial self wash)........................................................................... 34

5.1.4 Full wash / blanket bath.............................................................................................. 36

5.1.5 Bath or shower ........................................................................................................... 38

5.1.6 After the patient has completed any type of personal hygiene ................................. 38

5.1.7 Passive movements ................................................................................................... 39

5.1.8 Oral care – mouth care............................................................................................... 40

5.1.9 Shaving....................................................................................................................... 43

5.1.10 Care of nails on hands and feet ................................................................................. 43

5.1.11 Care of the nose......................................................................................................... 44

5.1.12 Care of eyes ............................................................................................................... 44

5.1.13 Care of hair ................................................................................................................. 45

5.2 Managing nutritional needs – Feeding............................................................................... 46

5.2.1 Swallowing difficulties (Dysphagia)............................................................................ 49

5.2.2 Enteral Feeding .......................................................................................................... 50

5.2.3 Enteral feeding tubes ................................................................................................. 51

5.2.4 Testing for enteral tube misplacement....................................................................... 52

5.2.5 P.E.G. (percutaneous endoscopic gastrostomy) feeding tube.................................. 52

5.2.6 Care of the P.E.G. insertion site ................................................................................ 52

5.2.7 Feeding using enteral or PEG tubes.......................................................................... 53

5.2.8 Other enteral feeding notes........................................................................................ 54

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5.3 Managing Toileting - Elimination........................................................................................ 54

5.3.1 Screening urine samples............................................................................................ 56

5.3.2 MSU – mid stream urine specimen............................................................................ 57

5.3.3 CSU specimens.......................................................................................................... 58

5.3.4 Urinary incontinence................................................................................................... 59

5.3.5 What is a Urinary Catheter and why are they used?................................................. 60

5.3.6 Care of the urinary catheter and catheter bag........................................................... 61

5.3.7 Emptying / changing the urinary catheter bag ........................................................... 62

5.3.8 Urinary catheter removal............................................................................................ 63

5.4 Bowel care .......................................................................................................................... 64

5.4.1 Risks associated with faecal incontinence................................................................. 65

5.4.2 Administering an enema or suppository .................................................................... 66

5.4.3 Administering suppositories ....................................................................................... 66

5.4.4 Administering an enema............................................................................................. 67

5.4.5 Colostomy / ileostomy ................................................................................................ 68

5.4.6 Cleaning a colostomy or ileostomy bag ..................................................................... 68

5.4.7 Emptying a “clipped” colostomy or ileostomy bag ..................................................... 69

5.4.8 Problems with colostomies and ileostomies .............................................................. 70

5.4.9 Post toileting needs .................................................................................................... 71

5.4.10 Pressure Ulcers .......................................................................................................... 71

5.4.11 How to prevent pressure ulcers developing............................................................... 73

5.5 Managing pain relief ........................................................................................................... 76

5.5.1 Delivering varied pain killers (analgesia) ................................................................... 77

5.5.2 Common side-effects of pain killers ........................................................................... 78

5.6 Making clinical observations .............................................................................................. 79

5.6.1 Observation of the patient .......................................................................................... 79

5.6.2 Responsive to communication ................................................................................... 79

5.6.3 Temperature, Pulse and Respiration (T.P.R.) ........................................................... 80

5.6.4 Temperature ............................................................................................................... 80

5.6.5 Measuring temperature orally .................................................................................... 81

5.6.6 Measuring temperature rectally.................................................................................. 81

5.6.7 Measuring temperature axially (under the arm)......................................................... 81

5.6.8 Measuring temperature aurally (in the ear)................................................................ 82

5.6.9 Measuring a pulse ...................................................................................................... 82

5.6.10 The pulse rate............................................................................................................. 82

5.6.11 The Rhythm ................................................................................................................ 83

5.6.12 Amplitude.................................................................................................................... 83

5.6.13 Taking a patient’s pulse.............................................................................................. 83

5.6.14 Assessing the radial pulse ......................................................................................... 84

5.6.15 Respirations................................................................................................................ 84

5.6.16 Assessing the patient’s respirations........................................................................... 85

5.6.17 Blood Pressure (B/P).................................................................................................. 85

5.6.18 Recording a patient’s blood pressure ........................................................................ 87

5.6.19 Recording a patient’s B/P using a manual sphygmomanometer .............................. 87

5.6.20 Recording a patient’s B/P electronically .................................................................... 89

5.6.21 Oxygen saturation levels – known as “Sats”.............................................................. 89

5.7 Care of the unconscious and / or dying patient ................................................................. 90

5.7.1 The anticipated (expected) death .............................................................................. 90

5.7.2 Communicating with the dying patient ....................................................................... 92

5.7.3 Sudden death ............................................................................................................. 92

5.7.4 Washing the deceased patient in hospital ................................................................. 92

5.7.5 Death in other institutions or at home ........................................................................ 94

6 USEFUL REFERENCE MATERIAL FOR THE NEW CARER.................................................. 95

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1 Welcome

I present this handbook from a position of experience, having completed more than 40 years

continuous nursing within the NHS. This is a guide to the fundamental principles of good

nursing care. For those already in the nursing or caring professions, it may serve as a useful

aide memoire. For those new to a caring role, it gives vital guidance to the fundamental

principles of nursing on which competence, confidence, and excellence can be built. It is also

hoped that those caring for a relative or loved one will find the guidance helpful. Anyone who

has cared for a sick child or relative has an idea of what it means to be a nurse and may find

this book useful.

The author fully acknowledges that there are many thousands of excellent nurses and carers

(both Registered and non registered) who deliver superb care all day every day and she does

not mean to insult them or appear patronising by re-emphasising the foundations of their

profession. Fellow professionals know that there is a problem with some staff in the care

sector. There have recently been reports1 in which the quality of nursing has been questioned

and there have also been many reports in the press suggesting that nurses don’t care and

that many Registered Nurses are “too posh to wash”.2

As usual, the media goes too far. There are some absolutely inspiring nurses and carers,

many of whom have not completed any formal training. The value of their experience and

commitment should never be underestimated. Conversely, the value of a qualification should

not be overestimated. Most qualified nurses and carers are excellent but some have been

able to qualify without showing any compassion or demonstrating / acquiring the caring skills

that should underpin everything they do. Those with a qualification are generally presumed to

have knowledge of the fundamental principles of nursing but, sadly, we know that this is not

always true. In some cases, the lack of compassion or caring skills can be explained by the

absence of any formal requirement to learn and practice them. This resource is intended to

go some way to filling that void. It could be considered as a valuable support to the

recommendations from the Cavendish Review published in 2013.

Several newly qualified Registered Nurse Practitioners have welcomed this resource in draft

form, saying that their academic training did not focus on these skills. They felt that it was

sometimes presumed that they would pick these skills up when working on the wards. They

had, but they were still grateful to see them clearly laid out for the first time.

While technically inaccurate, within this book I refer to “caring” and “nursing” as though they

are synonyms because, although nursing can be much more than caring, it should have

caring at its core. When I use the term “carer”, the context generally makes it clear whether I

mean a nonregistered care worker, a Registered Nurse Practitioner, an Allied Health

Professional3 or a Doctor: I often mean all of them because all of them should have these

basic caring skills.

1 I am thinking particularly of The Francis Report – February, 2013. The Cavendish Review July 20132http://nursingstandard.rcnpublishing.co.uk/students/clinical-placements/patientcentred-care/holistic-care/too-posh-to-

wash-nurses3

Allied Health Professional (AHP): a specifically trained non nurse or doctor Registered Practitioner working within the field

of health. Examples are:, social workers, physiotherapists, Occupational Therapists, Dieticians, Speech and Language

Therapists.

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2 What has changed in nursing / caring ?

If there is sometimes a temptation to think that carers of all grades from the inexperienced

support worker through to the experienced Doctor have forgotten what they were trained to

do, this is not generally so. The demands on carers has changed significantly over recent

years, as have the equipment and drugs in common use. During my career, nurse training

has changed as much as anything else.

I completed my general nurse training in the 1970s. It gave me the solid foundation of basic

nursing skills that has allowed me to have a varied and fulfilling nursing career. To qualify in

those days, we had to pass both practical and theoretical modules that many of us failed at

the first attempt. We had “dragons” for tutors – but they made us work and would not

compromise their standards for anyone. I remember having to resubmit an essay that had

achieved a pass mark because my tutor thought I was capable of a better mark. These days,

there seems to be an almost whimsical reverence for nursing as it used to be. While the

delivery of basic nursing care might have been better than today, the old days were far from

perfect. Patients were expected to be the passive recipients of all care delivered. Their total

compliance was expected – and usually received! Non compliant patients were labelled as

“awkward” and I cannot recall the words dignity or privacy ever arising – or indeed any

consideration of a patient’s religious beliefs or cultural background. Nurses were effectively

the doctors’ handmaidens and there was a hierarchical structure that was both complex and

terrifying. So I am not saying that the old ways were perfect and I am not advocating a return

to the old approach. I describe how it was merely to provide a contrast between my training

and the current “pass number” approach to training which sometimes appears to place

emphasis on passing the student regardless of their performance. This can only lower the

standard for everyone.

Today, the training as a Registered Nurse omits much of the hands-on ward experience I had

in favour of far more demanding academic requirements. This has a plus side because

Registered Nurses are now “Registered Nurse Practitioners”, able to routinely undertake roles

that were once the responsibility of medical staff4. This allows hard-pressed medical staff to

focus on other aspects of patient care. Registered Practitioners are vital to the effective

running of today’s high-tech, fast-lane, NHS. Significantly, the Registered Nurse is no longer

expected to unquestioningly “takes orders” from medical staff and is legally accountable for

any action or omission on their part. Recent reports have recognised sub optimal provision

of basic care within some areas. The Cavendish Review has recommended that a ‘Higher

Certificate of Fundamental Care” become available for Non Registered Staff to present

evidence of their recognition and delivery of standards of excellence in the delivery of basic

care

Some Registered Nurses with extensive practical experience undertake further academic

study to become “Specialist Nurses” in an area of expertise such as diabetes, cardiac

rehabilitation, tissue viability, infection control, Accident and Emergency, etc. Many of these

Specialist Nurses hold their own clinics, releasing medical staff to undertake their specialised

roles. And although these Specialist Nurses may no longer routinely deliver care at the

4 Within the NHS, the term “medical staff” is used to refer to Doctors, Junior Doctors, Consultants and Specialists in

discrete medical disciplines.

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patient’s bedside they still need to use the six fundamental principles of nursing care (see

Chapter 4) in everything they do.

The technology in hospitals has changed too. An example is the introduction of limited

intervention techniques such as “scoping”5 which reduce the need for a patient to stay in

hospital. These improved surgical techniques mean that large surgical wounds are rarely

required, so reducing the time that a patient needs to stay in hospital after an operation. One

unexpected consequence of improved intervention and surgical techniques is the fact that the

proportion of really sick patients in a ward has risen dramatically.

Not long ago, many beds were filled with post operative patients or those in hospital for

“investigations”. In consequence, there were only a few very sick patients in a ward at any

one time and there was time for the nursing staff to focus on the sick. Today, just about

everyone occupying a hospital needs active treatment but staffing levels and their skill mix do

not always seem to reflect these changes in demand.

Throughout the history of nursing, most caring has been carried out at home – often by a

patient’s relative. Usually the patient wants this, so it is a good thing. But many people find

themselves taking on a caring role without feeling adequately prepared for the responsibility

and without feeling confident about what the role entails. I hope that this book may be

especially useful to them.

5 5Passing a special instrument with a light attached into the patient’s body without needing to cut the skin. Biopsies can be

obtained simultaneously. These are routinely undertaken without the patient needing to stay in hospital overnight.

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3 New to the Nursing / Caring role

Today, nursing / caring roles can fall to a wide range of people. These may be specifically

trained and qualified people with a title such as Registered Nurse6 or may be Non Registered

Carers who are given a variety of titles such as Care Workers, Support Workers, Health Care

Assistants or as suggested within the Cavendish Review – Nursing Assistants. The term ‘non

registered carer’ within this book encompasses all of these titles. Evidence of sub optimal

delivery of basic care within some areas was identified within the Francis Report. Among the

recommendations of The Cavendish Review is a nationally recognised standard of basic care

– demonstration of which should culminate in the awarding the non registered carer with a

Certificate of Fundamental Care

Increasingly, entirely untrained people also find themselves in a nursing /caring role looking

after a loved one or relative at home. While qualifications and experience can give

confidence, a new carer does not need them to deliver excellent basic care.

Whatever a carer’s training background, they share a responsibility to deliver care of the

highest standard.

The above summary makes it clear that all paid professional carers have both a responsibility

for and accountability over their delivery of care.

The non registered carer has a responsibility to deliver high quality care and should have the

knowledge or skills required to conduct the tasks asked of them. When they do not, they must

make that fact known to those above them, seeking supervision or training as required. The

Cavenish Review calls for a rigorous quality assurance mechanism for training courses and

6 Also known as Registered Practitioners, and formerly known as Staff Nurses and Sisters.

Summary of Accountability and delegation for carers*

All patients should expect the same standard of care, whoever

delivers it.

When delegating any aspect of care, it must be determined that

delegation is in the best interest of the patient. The person who

delegates the task is accountable for the appropriateness of the

delegation.

If the delegation of a task to another person is appropriate, the

support worker is accountable for the standard of performance.

The level of supervision provided must be appropriate to the

situation and take into account the complexity of the task, the

competence of the support worker, the needs of the patient and the

setting in which the care is being given.

*From RCN 003 942 Accountability and delegation, Published October 2011

9

vocational qualifications that include a focus upon basic care of a high standard. The result of

this requires all employers to ensure these standards are met as of 2015

The Registered Practitioner is subject to the Registered Nurse Practitioner Code of conduct7

and has a responsibility to ensure non registered nurse competence as part of his or her

delegation of roles and for ensuring that accurate records are compiled and updated.

There is only one simple way to deliver care of the highest standard. The carer must both

consider and apply the six fundamental principles of nursing care to each aspect of their

work. This will require both application and self discipline until it becomes second nature. For

a true carer, the only acceptable excuse for failing to deliver the highest standard of care is

their own initial inexperience.

It does take time to learn how to apply the fundamental principles in situations that are

unfamiliar, although it takes no time for a careless8 person to ignore them. If the principles

within this book are followed, superb basic nursing care standards will develop and will

quickly become second nature.

Be thorough, think it through and do things properly. This generally takes only

seconds longer than taking a short cut. Short cuts create problems – remember if

they really were a better way of doing things they would not be short cuts.

3.1 Caring for a relative or loved one

Anyone caring for a relative or loved one should want to do so. Nursing used to be

considered a vocation and there are still many who would say that if you do not have the

vocation, no amount of training will compensate for that. Wanting to care is a good start but

their emotional involvement can make a caring role more difficult. Becoming a competent

carer always takes both time and practice – and the carer can become anxious and frustrated

when they are afraid of letting down a person they are caring for.

The new carer could use this book as a tool to teach themselves, and also as a guide to

assess the care provided by others. If any other caring support is provided, the new carer

should watch them work and help them with their care delivery. If an external carer does

something they do not understand or thinks inappropriate, they should mention it. The

professional carer may have a good explanation, or may need to be reminded about the

application of the principles.

If basic nursing care is new to you, give yourself time.

By referring to this book and by watching how it is done by those with more experience, the

new carer’s confidence should grow. There is no need to copy the way it is done by others

slavishly. The fundamental principles can be applied in many ways and each person’s care

will be subtly different.

You are human. Don’t forget, no one is perfect.

7 Nursing and Midwifery Code of Conduct 2015,8 It is not merely semantic to say that a truly ‘”careless” person cannot also be a true “carer”.

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It always takes time to become proficient at all new skills and this will be complicated when a

carer is emotionally involved with the person they are caring for. For example, expressing

emotion to the person being cared for may seem very appropriate but the delivery of care with

compassion based on the patient’s needs should always be the aim. When the expression of

emotion is the need of carer rather than the person being cared for, that is not ideal. The new

carer should strive to achieve objectivity because that can protect them as well help them to

deliver the best care to the person being nursed.

3.1.1 Support for home carers

Throughout the U.K. there will be some support networks for the home carer and the person

being cared for. Many things influence the level of support that may be available – from

politics and the economy to the rarity of the patient’s condition and their geographical location

– but the carer owes it to the person they are caring for to explore what support is available

and to make best use of it for the patient and for themselves.

The patient’s General Practitioner (G.P.) and the local hospital should be able to let the carer

know what is available. The patient’s G.P. has a responsibility to help the carer identify

potential support streams (networks). The Royal College of General Practitioners (RCGP) has

recently acknowledged the tremendous work undertaken by family carers, often to the

detriment of their own health. The RCGP has suggested that health screening mechanisms

be introduced for all such carers.

If the person being cared for has a definite diagnosis the carer could telephone the local

hospital and ask whether they have a “Specialist Nurse” covering the condition. If they do, the

nurse should be able to advise about all aspects of care and provide contact information for

any support networks in the area.

Social workers may be a source of support. The local Council should be able to give the carer

contact information for social workers in the area. Social workers are also care workers and

have in-depth knowledge that can be of great help to the home carer. Some specialise in the

needs of “children” others “adults with learning difficulties”, others with “dementia” and others

with simply “adults”. The carer may need to ask for their help, after which the social worker

should call and examine the support that the patient is entitled to. This entitlement might

include transport to day centres, meetings, etc.

The home carer may be sharing their role with a variety of carers who call at specific times of

day. Local councils franchise (pay) external (non NHS) agencies to provide some personal

care (washing, feeding, help getting out of bed etc.) to patients in their own homes. Many of

the carers who deliver these services are non registered nurses. Some may have a

qualification like an NVQ, while some do not. These carers are very rarely Registered Nurse

Practitioners (they could earn far more in other caring work) but these non registered carers

still have a duty to consider and apply the Six fundamental principles of excellence in nursing

care. The home carer may learn from them, and may need this book to give them the

confidence to question the quality of the services being delivered.

Home carers often feel isolated and should be aware that “soldiering on alone” is probably

not in the best interests of the patient, or of themselves. They should find out about available

informal support networks. A search of the internet can often be useful, providing contact

details for support groups for specific ailments or conditions. Local Libraries can also be a rich

11

source of information about support groups and their contact details. Meeting with others who

are dealing with the same condition can be of great help to both the patient and the carer.

The help can be “emotional” but also lead to the sharing of skills and strategies that improve

the care for the patient. It may also lead to offers of carer respite, where responsibilities can

be shared and the carer be given “time off”.

3.2 What do they mean?

When a carer has managed to access NHS support networks they may have a problem

understanding the advice and support that is being offered. NHS staff often speak in a

specialist language of technical terms and acronyms that are meaningless to those who do

not share their background. Of course this should not happen because all staff should take

responsibility for ensuring that the communicate clearly, but it does. The carer should not feel

out of their depth, belittled or ignorant. They should insist on being spoken to in terms that

they understand clearly.

When a carer does not understand, that is the failing of the person advising

them, not of the carer.

The NHS has its own language (NHS speak) which all staff use to speed up communication.

This makes sense internally but it is usually inappropriate to use with anxious patients or

relatives. Every patient or relative is nervous and or frightened and this often impairs

concentration. Compound fear impaired concentration with the fact that the staff are speaking

an NHS language and the result is often appallingly ineffective communication.

The use of NHS speak to patients and relatives may be arrogant, elitist or simply

inconsiderate – but mostly it occurs because the work level of the staff is so high that they

simply do not think about it. Whatever the reason, the new carer and the patient should not

accept it. When they don’t understand, they must ask. All carers, relatives and patients should

remember that they are speaking to people for whom part of their paid role is to communicate

clearly. If the carer or patient asks for clarification, any nurse, doctor or carer should

recognise that they were not clear in their explanation and make every effort to explain in a

way that is understood.

3.3 Incompatible patients and carers

This may never be a problem but it can be and must be recognised when it does occur. New

carers can be particularly vulnerable to feeling an incompatibility simply because their

relationship with the patient is not “perfect”. For professional carers, that is just part of the job

and must be overcome without taking any friction personally, and without ever being the

cause of friction themselves.

In my 41 years with the NHS I experienced two patients who, for reasons I never understood,

took an instant dislike to me. This was before the time of “acknowledge and discuss” so I had

to ignore the patients’ obvious dissatisfaction with everything I did for them. This was not a

major problem because I worked in the acute sector where patient stay was of limited

duration but if you are caring for someone long term you must acknowledge this kind of

problem and resolve it, however that might be.

12

Any carer can find themselves caring for someone who instinctively neither like or trusts

them. Equally, a carer can find themselves caring for a patient who they have problems

relating to. Whichever way the problem goes, it is an incompatibility that must be

acknowledged and overcome. All those employed in the “care sector” must report an

apparent incompatibility to their supervisor, record it in writing and ensure their managers are

aware of the difficulty. It may be that a patient has a problem relating to every available carer,

in which case the carer may not be able to minimise their contact with the patient. While it is

part of carer’s responsibility to acknowledge the problem it cannot be used as an excuse for

them to choose “easier” patients. But if it is a problem and it affects the quality of care that

can be delivered, the carer must find a way around it either by negotiating with their

managers to avoid contact with that patient, or by resolving the conflict.

13

4 The Six Fundamental Principles of Nursing Care

So what are the Six fundamental principles that must be behind all caring activities before the

care delivery can be considered “excellent”?

They are:

1. Enabling real communication

2. Preserving patient privacy

3. Promoting patient dignity

4. Controlling the risk of infection

5. Asking for patient consent

6. Respecting the patient’s Culture and Religion

Often abbreviated to the titles Communication, Privacy, Dignity, Infection Control, Consent

and Culture & Religion, these are fundamental requirements that should underpin all care

delivered at every level from unqualified carers to senior medical consultant.

These requirements may appear “obvious” because they are. But when you examine patient

care in hospitals and other institutions today you will find evidence that these Six are not

known or are being ignored by some. Others may nod at them without having fully

understood what they mean.

People new to caring will need to keep reminding themselves of the application of each

fundamental principle to each newly acquired competence of nursing care. This might be

hard for a carer who is looking after someone they love. It should be rather easier for a

professional who is able to keep an emotional distance.

Whatever competence is being acquired, the trainer must ensure that the trainees consider

the activities in relation to the six fundamental principles of nursing care. I have found it useful

to ask trainees to roll a dice and explain how the principle that comes up applies to the matter

under discussion. The principles lend themselves to this by being the same number as the

sides of a dice. An ordinary dice can be used with the numbers having a meaning assigned

as below – or a special dice can be prepared.

1. Communication

2. Privacy

3. Dignity

4. Infection Control

5. Consent

6. Culture and Religion.

Using a dice introduces an element of chance into the learning experience and ensures that

the more challenging principles are also discussed.

It could be suggested that I am omitting a vital principle – compassion. There are many

slightly different definitions of “compassion”. Some stress “caring”, “understanding” or

“empathy” but it is tremendously significant that they all include the desire to resolve whatever

is the problem. Every carer of any grade should exercise compassion throughout every

contact or task they are delivering. They should care and want to help resolve problems for

the patient. Compassion is not something that can be taught. If it is not “felt” this raises the

question of whether the person is suitable for a caring role.

14

As a natural progression from this desire to resolve any patient problems it is incumbent upon

every carer to write down (record) the care they have delivered and any problems they have

been unable to resolve.

4.1 Real communication

Communication is an essential part of daily life. It enables us to affect changes to the world

around us, to socialise, to inform about events and so on. Communication takes a variety of

forms:

Verbal – face to face, telephone, involving speech, sound, listening

Non verbal – body language, gestures, facial expressions

Electronic – email, intranet/internet, computer records, social networking

Written – patient notes, nursing records, leaflets, letters, symbols.

In its simplest form communication is about one person sending a message to a second

person and that second person understanding it accurately. It is not real communication

unless the second person understands it accurately.

Communication is at the heart of everything we do. All patients and

relatives have a basic right to affect, through communication, the conditions

of their existence.

In every communication with a patient or their relatives the carer should try to “Listen

Actively”, giving their full attention to:

The verbal message;

The tone of voice;

The person’s posture; and

The person’s gestures.

When the carer also knows some of the patient’s background, that also allows them to put

things into context and see things from their point of view.

A good carer should never answer a question from a patient with the dismissive “sorry, you’ll

have to ask someone else” or words to that effect. It is the carer’s responsibility to find out the

answer and ensure that it is delivered whenever possible.

Even when the words cannot be understood, the tone and demeanour

can. The carer should try to be reassuring and comforting even when

they cannot be sure that full communication is taking place.

4.1.1 Barriers that can affect communication

The most common barriers to effective communication are introduced here. There may very

often be more than one barrier in place but I introduce them separately to try to communicate

them clearly.

In reality, when you add physical problems, language problems and the anxiety of a patient

together, there is often a complex and serious communication difficulty that the carer must

overcome in order to work effectively. When care staff of any grade ignore this, they can

cause entirely unnecessary distress to both patients and relatives.

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Each act of communication must be relevant to the individual, and must avoid appearing

patronising. It may sometimes be appropriate to avoid telling a patient or relative something,

but the carer should generally avoid lying. In most health cases the entire truth is not known

anyway, so saying the parts that will avoid distress can be both caring and appropriate.

4.1.2 Hearing

A problem hearing may be more than simply not hearing. It can also be mishearing or

interpreting an unfamiliar word or phrase as if it were a familiar one. Deafness is rarely as

simple as being deaf or not. Diminished hearing of some pitches and within certain ranges is

common and increases with age. The carer should be alert for signs of hearing trouble

whenever meeting a patient or relative for the first time. The patient may not tell the carer

because they may not have recognised that they have a problem, or may presume that

because it is obvious to them, it will also be obvious to everyone else.

Look out for hearing aids but don’t presume that their presence means that the wearer can

hear with them. On the contrary, their presence should alert you to the fact that there may be

a problem. When there are hearing aids, ensure that they are turned on, have functional

batteries, and are adjusted appropriately for the wearer. As the carer, it may be part of your

role to ensure that the patient has spare batteries, so asking them if they have spare batteries

and know where to get more can be a useful way of checking whether they can hear you

properly and respond appropriately.

Remember that most people with hearing problems do not wear hearing aids. Many hearing

problems are relatively minor and the person has found ways to live with them. So the

absence of a hearing aid does not mean that a person has perfect hearing.

With a hearing aid in place or not, many people with problem hearing compensate by lip

reading. Most will not have been taught to do so and may even be unaware that they are

doing it, but they watch the speaker’s lip movements and visually “read” some information

about the speaker’s words. The carer should position themselves so that the patient or

relative can see them, and then speak clearly, avoiding jokes or slang until communication

has been established.

Hearing loss is not always balanced and many people hear better in one ear than another.

The carer should find this out quickly and ensure that they never speak from the inappropriate

side.

Some people will not be able to easily turn to face the carer, so the carer must position

themselves so that the potential for lip reading and hearing is maximised.

Even when people have good hearing, background noise can introduce confusion. This is

especially true when the background noise is “new”, such as may occur when a patient

arrives in a busy hospital environment. The carer may be familiar with the background noise

and able to filter it out but the new arrival may find that impossible. Whenever possible, the

carer should always find a quiet place to talk.

When there is a hearing problem, the carer should notice which words and intonations seem

to work and try to use them as often as possible. Some words have distinctive lip patterns

while others can be mumbled too easily. The carer should use body language to help the

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communication, nodding vigorously and smiling for “yes” is almost too obvious to mention, but

often forgotten.

Profound deafness usually means being entirely deaf within the range of sounds used in

human speech. A profoundly deaf person may not wear hearing aids, although many do.

When meeting a profoundly deaf person, the carer should find out as much as possible about

the deafness. If it is recent, the person may need help to access appropriate treatment and

support. If the person has been profoundly deaf for a length of time, they may know how to

communicate using a sign language such as Makaton. If they do, one of their relatives or

another carer may know how to use it and be able to act as temporary “interpreter”. When a

carer is responsible for a person who uses a sign language, it is the carer’s responsibility to

communicate. The carer must find a way to do this, either by enlisting help from those who

know the sign language or by learning it themselves. When a carer has a “boss”, they should

discuss the need with them, report the need in writing and ensure that the need is met.

Failure to do this would be a form of neglect.

The main carer of a profoundly deaf patient who uses sign language should be able to get

support to learn signing themselves. Their managers, the patient’s G.P., local college or a

nearby hospital audiology (hearing) department should be able to advise.

4.1.3 Visual

Just as deafness is rarely as simple as being deaf or not, blindness is rarely as simple as

being able to see or not.

Understanding and supporting people in the everyday management of their visual problems is

fundamental to helping them cope with their additional needs. All too often, essential

information is provided in writing, presuming that the person can read it. The carer should

always ensure that they can read and when they cannot, must provide all the assistance

required.

The carer might consider the following:

Does the patient have spectacles, and if so – are they clean?

If the patient can read the information with difficulty, can they understand it? Some

functionally literate people can read, but they are concentrating on reading while they

do so and not thinking about what is being read.

Would the patient like to have the information read aloud to them?

Would the patient cope better with larger print?

Would the patient like access to audio books? If so, how can they be accessed?

(While many libraries do offer this service there is often a charge.)

The carer should try to understand their patient’s restricted vision and the impact it might

have on their everyday life.

We were extremely fortunate in my last hospital because Nina from our local association for

those with visual difficulties regularly visited new care staff and provided a basic explanation

of the more common visual ailments. She also brought along several pairs of special glasses

that provided the wearer with the experience of several common eye conditions – glaucoma,

cataract, tunnel vision etc. She then encouraged the carer to undertake some routine tasks

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while wearing the spectacles, so experiencing just how the condition was affecting the

patient’s vision.

This experience was literally an eye opener for all staff. Carers wanting a similar experience

might find that the local yellow pages or an internet search yeild contact details for any local

associations for those with visual difficulties who could share their knowledge in a similar way.

Carers should not have difficulty accessing audio tapes or CDs for their patients, but if they

do, they should seek to find a way around the problem. It might be appropriate to start a local

library resource for the area. Local charity shops often have copies of either cassette or CD

audio books. They are easy to clean between patients by wiping with a damp cloth and the

appropriate cleaning solution for the area where the patient is.

Many patients have experienced a gradual reduction in sight over a long period and will have

developed their own coping strategies at home. If the patient is no longer within their home

they will require very specific support in order to create an environment that they feel

comfortable and confident within. This should include provision for independent personal care

and going to the toilet whenever possible. If a patient is acutely ill this might not be possible

initially but this requirement should be accommodated as part of their subsequent care. This

can be particularly difficult within the current NHS where there sometimes seems to be a

competition to see how often a patient can be moved, both within the ward or around the

hospital, but the carer must try. Simple things such as discussing with the patient where they

would like things to be left and then confirming that this has been done will maximise patient

independence even when they are often moved.

A partially sighted patient usually prefers to undertake as much as possible themselves – this

should be accommodated even though it may take slightly longer. One of the problems with

the ”timed” personal care delivery that is increasingly found within both hospitals and the

community is the fact that it does not encourage independence by giving the patient time to

undertake tasks themselves. It is undoubtedly quicker for the carer to undertake many tasks

for the patient but this should only be done when it is in the patient’s best interest to do so.

Often it is not, but it may be in the interests of the carer or their employer. When a patient has

relinquished their care to impatient carers they often lack the confidence to develop it again at

a later date.

4.1.4 Language barriers

The patient may be able to hear perfectly but that will be of little help to communication if they

do not understand the language you are speaking. In a professional environment, the carer

should have access to interpreters but these can take time to arrange and the cost generally

means that they are only available for a short time. The carer should make the need for an

interpreter known, in writing, and press those responsible to meet the need. In the meantime,

the carer must solve the immediate problem. The carer should prioritise this and follow it up

because without adequate communication, the patient will be confused and may be fearful,

distressed or even angry.

Often a relative or friend of the patient may be able to act as temporary interpreter allowing

limited communication to be established.

Some basic communication can be achieved without language, using an appropriate tone of

voice, reassuring smile and simple body language mime, for example. But this is a temporary

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fix that does not allow the true communication that must be in place between a carer and the

person they are caring for.

An interpreter does not have to cost a lot of money. When necessary, the carer should

identify the key words needed for communication about the patient’s needs and get a

competent linguist to write these clearly in both English and the appropriate language on

durable sheets of card. Several potential responses should also be written down for the

patient to point to. Some obvious phrases are:

Are you hungry?

Would you like a drink?

Are you in pain?

Point to the pain.

Do you need to go to the toilet?

Each patient is unique so the appropriate questions will not all be generic. At least some of

the questions should be patient specific.

Some communication can be established using pictures – and there are basic picture boards

available – but a patient specific series can be devised at little cost.

Picture boards and translation sheets should be laminated to allow them to be cleaned and to

give them a useful life.

When neither the patient nor their relatives can read or speak English and the use of picture

boards or translation sheets has not improved communication, communication will have to be

verbal and an interpreter must be provided.

4.1.5 Words used

Carers should avoid speaking to patients or their relatives in terms that are specific to the

caring profession. They should also avoid using acronyms unless they know they are talking

to someone who will understand them. UTI, for example, often (but not exclusively) stands for

a ‘Urinary Tract Infection’. UTI is not usually a major problem but patients and relatives may

think the acronym stands for something really serious. Using the acronym may save the carer

a second but that second may cause the patient and relatives hours of unnecessary anxiety.

A good carer will speak in ordinary English and never hide behind professional jargon.

4.1.6 Patient unconscious

Unconsciousness is usefully defined as the condition in which a patient is unresponsive to

touch or talk, and appears to be unaware of the environment and in a state of sleep. The

carer should never presume that an unconscious or semi-conscious person cannot hear.

There have been many reports of unconscious people hearing everything that was said

around them and recalling it in great detail when consciousness returns.

In some situations the patient’s level of response is assessed in order to gauge the depth of

their unconsciousness and their progress towards resuming consciousness. These formal

assessments use the Glasgow Coma scale.

There is another shorter assessment tool that carer’s may use - known as AVPU scale. On

this simple scale a patient’s response is assessed as being either A, V, P or U:

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(A) - Alert and fully responsive

(V) - responds to Voice or verbal stimulus

(P) - responds to Pain or discomfort

(U) - Unresponsive to any of these: Unconscious.

Unconsciousness is common and might be caused by an illness / condition or its treatment.

Common causes include hyperglycaemia (diabetic) keto-acidosis, stroke, head injury,

overdose, trauma, alcohol, post ictal (after a fit) and the patient becoming unconscious as

they approach death. The most common cause of unconsciousness related to treatment is

unconsciousness caused by an anaesthetic.

All unconscious patients are at risk of suffering an obstructed airway by choking on their

tongue. When a patient is unconscious, the smooth muscles in their body relax. The tongue is

a large smooth muscle and it can become so relaxed that it drops backwards to occlude

(block) the throat. This can be such an effective obstruction that it causes suffocation.

The easiest way of reducing this risk is to tilt the patient’s head slightly back while

simultaneously holding the patient’s chin to prevent the tongue from dropping back. This is

not practical for any length of time. Placing the patient in the recovery position with their head

tilted back will ensure that their airway remains open. This is not always possible, especially

when patients have suffered physical injuries or have spinal conditions. A device called a

Geudel or oro-pharangeal airway, can be used to keep the patient’s tongue forward but can

only be used by Registered Practitioners and must only be used on deeply unconscious

patients. If the patient is not unconscious but there is reason to think his / her airway is at

risk of getting obstructed by their tongue the Registered Practitioner may prefer to insert an

alternative airway tube into a nostril to keep the airway open.

When caring for an unconscious patient, the carer must:

1. Ensure that the airway is open at all times.

2. Talk to the patient, telling them what they are doing, and why.

3. Respect the patient’s privacy and dignity as if they were conscious.

4. Ensure that they have help when moving the patient.

5. Provide total nursing care.

The carer should never discuss the patient as if they were not there and not conscious.

The carer should always be discreet and comforting, just as they would if the patient were

fully awake. When nursing any patient the carer must tell the patient what is going on, what is

happening and, when possible, why.

Additional care may be required in some situations. For example if a patient is unconscious

following a stroke there is a Stroke Care protocol which the carer must follow.

4.1.7 Disorientation

The patient may understand English and hear perfectly well but still be unable to comprehend

because they are in a confused or disorientated state. This could be an acute (short term) or

chronic (long term) problem. Examples of acute causes include the patient having an

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infection (urinary tract infections frequently cause confusion in the elderly), a problem with the

salt levels (electrolytes) within the blood, a problem following a head injury, a specific

psychiatric problem or a problem following a general anaesthetic. Chronic confusion is often

caused by one of the dementias. Many patients experiencing early stages of dementia are

fully aware of their episodes of disorientation and are extremely distressed by it. They may

need a change of medication, physiotherapy or speech and language therapy to help them

communicate more clearly. Outside a hospital setting, these can be accessed via the patient’s

G.P. and the carer should act on their behalf to find out what support is available and ensure

that it is arranged.

When the patient has been diagnosed as suffering from one of the dementias they may have

had their capacity to make informed decisions assessed by a qualified Social Worker or a

dementia Specialist Nurse. When this has happened, they may have a legally appointed

designated guardian responsible for making decisions in their “best interests”. Some patients

who are aware of their own decline may of their own volition have elected to pass legal

responsibility to a relative without having had any formal assessment. The carer must respect

the guardian, involving them in all decisions about the patient’s care whenever possible.

When dealing with confused patients it is important to try to keep them orientated in time and

place. Small things can help to achieve this, such as:

• Keeping a large clock in easy view;

• Writing the day and date and leaving it in clear view of the patient; and

• Providing care in a single room where the presence of other people is not a

distraction.

The carer should offer stimulation to the patient depending on their interests, abilities and

diagnosis. For example, the carer might play cards, show photographs, read from the paper

or a book, or help with knitting, playing word games or doing jigsaw puzzles. A level of

recovery is common in many conditions but even when recovery is not likely, stimulation

improves the patient’s quality of life and is part of the carer’s role.

4.1.8 Learning disability

When a patient is known to have a significant learning disability, the carer must avoid

increasing dependence by doing more for the patient than necessary, but should also avoid

expecting too much. They should find out what the patient can understand and do, then tailor

their care accordingly.

The patient may have previously had an assessment of their mental capacity conducted.

When this has happened, they may have a legally designated guardian responsible for

making decisions in their “best interests”. The carer must respect the guardian, involving them

in all decisions about their care. This person will often be a source of reliable information

about the patient and their individual care needs.

Previous carers or relatives of long term patients will often have a wealth of experience about

the patient. They can explain what they can and cannot do, so helping the carer encourage,

maintain or even extend this level of independence, as appropriate. They can also advise

about what upsets, frightens or reassures the patient.

Any carer who fails to take advantage of the experience of their predecessors risks causing

unnecessary distress to both patients and relatives.

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4.1.9 Appearance and body language

First impressions count and are made before any verbal interaction has begun. The carer’s

expression, posture and general demeanour can be positive or negative. The carer should

strive to make it positive – even when the patient is not their direct responsibility.

Within our multicultural society it is important that carers are familiar with and accommodate

any specific cultural requirements the patient or their relatives may have and respect that.

The professional’s appearance is of fundamental importance, if a uniform is worn – it must be

clean. If no uniform is worn, the carer must wear suitable clothes and footwear. A “bare below

the elbows” policy has been required for several years now – for all grades of clinical staff

including medical staff.

Obviously the carer should be clean and should not smell. Perhaps less obviously,

overpowering perfume or aftershave can be offensive, as can the smell of stale tobacco. Hair

should be tied back from the carer’s face, not resting on their shoulders.

Jewellery, including watches, should not be worn by the carer while working for many reasons

including the fact that they are potential carriers of infective agents or may scratch the

patient’s skin.

There are a few basic rules about body language as a part of communicating.

It begins as the carer meets the patient and their relatives, when they should make brief eye

contact and smile. The carer might offer to shake their hands and start by saying “Hello, I am

here to help you” or asking “How can I help you?” The stress on “help” is important because

that is what the carer is there for, to support and advise.

The carer should read the patient’s posture and facial expression. A lot can be seen by

looking in a patient’s eye, without being challenging, of course. The carer should be aware

that their own body stance can send significant messages. For example, arms folded always

sends the message of being “not interested” in what is being said.

How the carer addresses the patient and those with them is important. They should be

addressed by their title and surname, not their first name. If they ask the carer to use their first

name, the carer should be led by them. It is disrespectful to address anyone by their first

name unless they have consented to this.

When the carer is in the patient’s home, they are a guest and must not presume the right to

sit down. They should wait to be invited.

4.1.10 Patient in pain or frightened

When a patient is suffering severe pain, the pain will be their main focus. Anyone who has

had a simple tooth abscess will appreciate how pain can take over your life. It follows that any

attempt at effective communication before the pain has been relieved is unlikely to be entirely

successful. It may “tick a box” on a form, but will not be a reliably accurate record of what the

patient knows and what they want the carer to know.

The carer must get the pain under control as soon as possible and double-check their

answers to any forms that were filled in or important communication that was not conducted

while the patient was still distracted by pain.

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Fear is also a great distraction. When a patient or their relative is fearful and distressed, try to

alleviate that before engaging in critical communication. If in doubt, check the answers you

received when the patient or relative is calmer. It is the carer’s responsibility to ensure that

communication is effective and accurately recorded.

Because fear causes distress and is never helpful, the carer should always avoid using words

or expressions that might cause fear in the patient or their relatives.

4.2 Patient privacy

Most people know that every patient has the right to confidentiality. The obligation to treat the

patient’s details as confidential extends to everyone who works in hospitals, care homes,

prisons, private homes etc., not only to their doctors and carers.

It may be less obvious that patient privacy is not an option either, it is a legal requirement just

like patient confidentiality. This is because, to the patient, privacy and confidentiality mean the

same thing. If the carer uses discretion, both privacy and confidentiality can generally be

maintained.

The carer should presume that the patient wants privacy. This means that they should ensure

that other people are not aware of what care is being delivered or what is being discussed

between the patient and the carer. If any other person is aware of what is going on between

the patient and the carer, the level of privacy being provided is less than optimal. When any

care delivered is less than optimal, the situation must be justified. In some instances the

context may give the carer little choice but if the patient objects, the carer must take action to

gain the privacy that is the patient’s right.

Communication with the patient should be discreet. Conversations should be spoken no

louder than necessary and from close to the patient so that no one else has to hear.

Delivering care in privacy in an area where there are several patients separated by curtains is

a “challenge”. Get close to the patient and speak no louder than necessary. If all else fails

speak as discreetly as possible directly into their ear. The carer must respect their right to

privacy even when they cannot deliver optimal privacy.

Carers may need to take informal notes about a patient to ensure that they remember all that

is relevant to perform their role well. The carer must remember to treat these notes with the

same degree of restricted access as the patient’s formal medical notes. They should not be

taken home after work, must not be left where others could read them, and must never be

disposed of without being destroyed.

It is sad reflection on today’s society that many caring staff feel the need to leave the door

ajar as protection against allegations of impropriety when delivering personal care to a

patient. Others welcome the presence of a chaperone. In both cases, there is a risk to the

patient’s privacy. Carers should judge the risk to privacy against the risk of being accused of

misconduct and find a balance that the patient can accept.

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4.3 Patient dignity

Dignity has become a popular buzz word for those looking for what is amiss in the care

sector.

Most dictionaries define dignity in terms of “self-esteem” or “self-respect”. This means that it is

a feeling within the patient, not something that can be delivered but something that can be

affected. Every carer should know that their actions influence how the patient feels about

themselves, whether or not they show it.

In care work, dignity is fostered by showing respect for the patient during all aspects of care

from verbal communication to personal hygiene or toileting. Consideration of a person’s

dignity should be fundamental to the carer’s dealings with everyone – colleagues, patients or

their visitors.

Respect starts with the way that people are addressed. The widespread practice of using first

names without being invited to do so is potentially disrespectful. The use of first names

usually indicates a friendly relationship and while this is a legitimate goal, it should not be

presumed.

Before friendship, the aim is to have a professional relationship. The carer is generally being

paid to deliver the care they undertake and the patient has usually paid national insurance

and taxes, therefore pre-paying the carer’s wages. Until and unless the patient indicates

otherwise, the carer has no right to address the patient in a familiar way. They should not use

the patient’s first name or familiar terms such as “dear”, “love”, “darling”, “duckie”, etc. All too

often these terms are used when a carer cannot be bothered to find out or remember the

patient’s name, which is entirely unacceptable. Some people do have problems remembering

people’s names and may have many patients to remember. They might start the exchange

with a smile and a glance at the patient’s notes where their name is written, or keep a list of

names in a notebook.

When the relationship between the carer and the patient develops, the patient will tell the

carer how they would like to be addressed and, even if that seems rather formal, it must be

respected. Until then, the patient and their relatives must be shown courtesy and respect in

what is a professional relationship. Generally, this will mean calling them Mrs, Mr, Ms or Miss

– or of course a military or religious title when appropriate.

Each situation will be different. Each person being cared for will be different. Each carer will

approach each patient from a slightly different perspective and all will have a slightly different

set of values. But showing demonstrable respect throughout every aspect of both contact and

care is the minimum standard of care expected. No matter what the situation, it is never

acceptable to speak to or about the patient with any hint of derision. Every aspect of care

delivery should demonstrate that the carer has respect for the patient, their abilities and their

beliefs. There are no exceptions. Ever.

Within all types of ”care” training the use of “self-directed” or “guided training” is often used

when considering “dignity”. This can be a box ticking exercise without the underlying need

being taken seriously. Until recently, concern for a patient’s dignity did not appear to be very

high on the teaching agenda at all. Hopefully the practice of discussion and debate around

issues of dignity in care will increase, so encouraging individual responsibility for

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understanding just how the preservation or building of “Patient dignity” can be achieved by

every carer at all levels in the profession.

4.4 Infection control

In the caring profession, managing the risk of infection is known as “infection control”. At its

simplest, “Infection control” means taking measures that reduce the risk of introducing or

transferring infection to or between people. “People” in this context includes carers, patients,

relatives, visitors and the general public.

Usually an infection involves an unwanted bacteria, virus or yeast entering a new host

(person) and reproducing within them in a way that causes unwanted symptoms.

Bacteria are vital to our wellbeing but the wrong bacteria in the wrong place can be life

threatening. Viruses or yeasts from within the environment can also be absorbed into the

body with undesirable consequences.

Any of these infective agents can enter a person’s body in several ways – breathing, passing

through the skin, via wounds, or by ingestion in contaminated food and water, etc. When this

happens to a healthy and fit person, the body’s defences often manage to destroy the

invaders. However, when someone is weak, already ill, or receiving medication, their

response to these invading bacteria / virus / yeasts can be far less effective. The infections

that result can lead to very unpleasant symptoms, do permanent damage and even be fatal.

It is every carer’s responsibility to reduce the risk of infection to their patient(s) to a level that

is as low as is reasonably possible.

Every aspect of care delivery should automatically include the application of infection control

techniques, some of which are introduced below.

4.4.1 Reducing the risk of infection

The simplest and most effective method of reducing the risk of infection is by using old

fashioned soap and hot running water. As ever, a commercial opportunity has been spotted

and alcohol gel is now widely available to “kill” infections. Alcohol gel is certainly useful when

hand washing facilities are not readily available and is far better than no hand washing at all

but alcohol gel is not usually better than washing your hands. It is still better to wash hands

thoroughly with liquid soap9 and hot running water and dry them thoroughly on a clean towel.

Carers should also be aware that wristwatches and hand jewellery can harbour infection, so

should not be worn when engaged in any activity that involves contact with a patient. This not

only prevents the carer infecting the patient with something they have brought from outside, it

also prevents any infection that the patient may have being able to “hide” on the carer and so

be transferred to another patient. It is in the carer’s personal interests as well, because they

do not want to take the infection home and put it in their family’s sandwiches.

Infection control should also be applied to all equipment used with the patient. Not all

equipment is disposable after being used once. Equipment is often “single patient use”. This

often means that it can be washed (in hot soapy water) then rinsed and thoroughly dried

9 Use liquid soap because no one else has touched it. Shared bars of soap can transfer infection from one user to another.

25

before being reused for the same patient. The drying is as important as the washing because

bacteria love to grow in warm moist conditions.

Other equipment needs to be sterile to control the risk of infection. This equipment is usually

provided by the caring authority (G.P., Hospital, etc.). Whatever this equipment might be, it

must not be contaminated before use so the carer must know how to use it in an acquired

“sterile technique” or “no touch” technique. This should have been covered in the carer’s

training but if not, the carer must ask to be taught it before using sterile equipment. Failure to

use sterile equipment in the right way adds risk of infection instead of controlling it. Many

carers responsible for the day to day care of their relatives undertake sterile technique tasks

regularly and must know how to do it safely.

If the equipment may have become contaminated, before being used it must be discarded.

The carer must be strict about this, acknowledging error when necessary and never exposing

their patient to an infection risk that could be avoided.

The Health Protection Agency publishes a poster10 showing how to wash hands thoroughly.

There is more to it than many realise.

4.4.2 Hidden infections

Any patient who develops an infection is potentially infectious. Any carer who develops an

infection is potentially infectious. Any relative who develops an infection is potentially

infectious. And unfortunately, when we develop an infection we are often at our most

infectious before we develop any symptoms.

10 Health Protection Agency, http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947384669

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To control the risk of spreading an infection that you do not know you have is best achieved

by ensuring personal cleanliness and regular, thorough hand-washing. Thorough hand

washing greatly reduces the risk of spreading infection, no matter what the infection is.

Sometimes patients are found to ‘harbour’ the MRSA type of bacteria without showing any

symptoms of illness. The bacteria are present and could eventually wreak havoc on the

patient if they become weak or have open wounds. And even while apparently dormant, they

can be transferred to staff and other patients. MRSA is an infection that can be particularly

problematic because it is resistant to many antibiotics and often only responds to particularly

strong, potentially toxic, antibiotics. A strict regime of hand washing (including the use of gels)

has been shown to control MRSA.

The carer owes it to their patient to wash their hands routinely, regularly and

thoroughly – and always when moving between patients.

4.4.3 Infection control by isolation

Anyone who is found to have a potentially infectious ailment must be taken out of contact with

other patients to reduce the risk of cross infection. They should be cared for in a separate

room or cubicle (“isolated”) and their movements restricted so that they do not leave the room

without precautions being used to reduce the risk of transmitting the infection.

All carers of patients in isolation (and sometimes their visitors) must wear protective clothing

(PPE11- usually gloves, a plastic apron, and sometimes a facemask) before entering the room

and must follow a strict hand washing routine when they discard these and leave the room.

Ideally the carer responsible for looking after an isolated patient should not also be looking

after other sick patients – particularly those who are at increased risk of “picking up” the

infection. While the wearing of disposable plastic aprons and gloves (and sometimes a

facemask) is designed to reduce the risk of infection transfer, it does not eliminate it. The

carer can inadvertently carry the infective agent on their clothes or shoes, or in their hair. Of

course, the risk of infection transfer is greatly increased if the carer does not remove the

apron, facemask and gloves appropriately and follow this by thoroughly washing and drying

their hands. Any carer who does not know how to use PPE appropriately must ask for

instruction.

The psychological impact on a patient who is isolated and only touched with “gloved hands”

by carers wearing plastic aprons and facemasks can be utterly demoralising. Patients who

have been isolated often report having felt rejected, lonely, frightened and a social outcast.

The patient’s dignity should not be sacrificed to infection control, but the infection must be

controlled so the carer must do what they can to reduce the impact of isolation. It can often

help to find time for a conversation that is not treatment related, reminding them that the

isolation is temporary, not their fault, and so on.

4.4.4 Preventing infection via clinical waste

All carers should know that the correct disposal of equipment and consumables that may

carry infection is an essential part of preventing its spread. Any potentially infected material

11 Personal Protective Equipment – specific equipment worn by the carer to reduce their risk of becoming contaminated

while delivering certain aspects of care to the patient.

27

must be put into clinical waste for incineration. They can be very expensive to dispose of but

cost should never be a consideration.

Clinical disposable equipment should be disposed of in special clinical waste bags or

containers. Any used sharp items (“sharps”) must be disposed of in special sharps containers

that must all be sealed after they have been filled to the designated line on the bin then taken

for incineration.

There is a universal colour for clinical waste bags in the NHS (orange at the time of writing)

and sharps containers. It is obviously important that the correct bag or container be used so

that they are disposed of appropriately.

Gloves and aprons used in the routine delivery of care to patients without infectious diseases

need not be disposed of in clinical waste.

When a carer is looking after a relative at home, their local GP practice or care provider

should provide guidance on the disposal of Clinical waste, often via their nursing support

team.

4.5 Patient consent

Consent means “agreement” or “approval” and the carer should have the patient’s consent or

approval for everything that is done for or to them. The only exception is when a patient is

unable to communicate and needs emergency treatment.

I have heard it said that admission to hospital or attendance at a clinic indicates the patient’s

tacit approval for any treatment or investigations that may take place. It does not. If it did, the

hospital of clinic would have carte blanche to do anything to the patient without asking, even

when the patient is perfectly capable of having a preference and making it known.

For example, if I attended my dentist and he elected to remove all of my teeth because he

thought it was in my “best interests” without asking my permission, this would obviously not

be okay. To extract my teeth without my consent would be a form of abuse. The dentist would

be open to prosecution unless I had been demonstrably unable to make the decision myself,

and unless he could present a medically compelling case for the emergency removal of my

teeth being essential.

When a patient is lucid, orientated, communicative and conscious, there is never any excuse

for not asking their permission before the carer does anything to them. From washing their

hands to taking blood samples, this is always true.

Carers should avoid telling the patient anything when they could just as easily ask for their

consent. For example, it is not acceptable to say “‘I am just going to take some blood from

you” when it would have been just as easy to ask, “Could I take some blood from you?”

Whenever a patient can respond – Ask them, don’t tell them.

Asking is not only likely to increase patient compliance, it is also common courtesy – and

maintains patient dignity. Consent implies choice, so the carer should always find enough

time to be confident that the patient does have a choice. This requires communication and a

willingness to put themselves in the patient’s position.

A common use of the word “consent” is when the patient has to sign a “Consent Form”

agreeing to an intervention (usually surgical). Getting their consent is a legal requirement

28

whenever possible, but is often asked of patients who are not in the right condition to fully

understand what is being asked of them and what their options may be.

I can remember many cases involving older patients, often anxious and afraid, who I have

spoken to after they have signed their “Consent forms”. When I have asked what they have

just signed they frequently have no idea. Some say they could not hear, other’s that they did

not understanding what was meant but they all signed anyway because “doctor knows best”.

The older generation often have a reverence for medical professionals that results in total

trust. This should never be taken advantage of for the convenience of the timetable or

targets. The carer should ensure that they really do understand what is proposed, what the

options are, and what the risks are – because every intervention involves some risk and every

effort should be made to ensure that the patient really does decide. This information is known

as a ‘duty of candour’ and should be provided simultaneously considering and

accommodating both the capacity and condition of each individual patient.

4.5.1 Unable to give informed consent?

Gaining genuine consent is obviously complicated when a patient is disorientated or unable

to understand and communicate because of their condition. The carer should consider

alternative communication techniques before deciding that they cannot communicate.

In some situations the patient might have had an assessment of their mental capacity and a

legal guardian appointed. The legal guardian should be asked for their consent and their

approval recorded and signed. Such decisions are made in ‘the best interest’ of the patient.

Any such decisions can be potentially subject to subsequent scrutiny and justification.

The unconscious patient cannot consent but any carer, nurse or medical practitioner should

still talk to the patient and tell them what is being done. For example, the carer should tell the

unconscious patient that they are going to wash them and the medical staff should warn the

patient of the impending “sharp scratch” if they are going to insert a needle to get a blood

sample. For good carers, this should be second nature and automatic.

Consent with the disorientated patient can be assumed when the action or procedure is

considered to be in their “best interests”. Any “best interest” actions”must be recorded and

justified – and the carer should still explain to the patient what they will do before undertaking

the intervention whenever possible. The only time this can be neglected is when the

intervention is an emergency life-saving intervention that must be conducted without a few

second delay (such as Cardio Pulmonary Resuscitation) ).

4.6 Respecting the patient’s culture and religion

In Britain, our multicultural society means that the range of patients who may need care is

global. Similarly, very many carers were not born and educated in Britain and may have

varied faiths and varied cultural backgrounds. We must respect that in our patients and in our

colleagues, but not allow any variation to affect the quality of care that is provided. There is

no conflict. The other five fundamentals of delivering quality care, Communication, Privacy,

Dignity, Infection control and Consent all allow for the diversity of the patient’s Religious and

Cultural background. It is a carer’s responsibility, whatever their own background, to deliver

these fundamentals to the patient in way that is appropriate to that individual.

29

The terms “cultural diversity”, “ethnicity” and “race” are often used without the difference

between them being clear. Broadly speaking, “cultural diversity” refers to a series of shared

customs or beliefs. “Ethnicity” refers to those shared meanings developed within a social and

economic context with a particular historical and political background. “Race” refers to a

group sharing defined physical characteristics. None are superior to another and all are

constrained by the laws of Britain while in Britain. And all carers must seek to deliver excellent

care that is tailored to the patient whatever their own background.

The only way for a carer to achieve this is by communicating with their patient – asking them,

respecting them, and fostering their dignity. The carer must avoid passing judgement or

applying their own values on the patient, their culture, ethnic background or race.

Many hospitals and institutions have a pamphlet or folder containing advice about what

should be done to accommodate various religious beliefs. These may include chaperoning,

providing specific foods, designating prayer areas, and acceptable medical practices such as

organ donation, blood transfusion etc. If a carer is working in an institution that does not have

such a resource, I can only suggest that they remind their managers of their duty of care and

suggest that one be compiled as soon as possible.

A good carer must do everything they can to understand, respect and accommodate the

religious and cultural needs of their patient. When a carer finds out anything that was not

obvious about a patient’s cultural or religious needs, they should write it in the patient’s

personal records so that other carers can share that knowledge.

30

5 Applying these Six Principles

Having introduced the Six fundamental principles of nursing care on which the delivery of

competent care delivery relies, it may be helpful to show how these fundamentals can be

applied during basic activities. The range of possible activities is too broad to cover them all,

so I have limited my advice to areas of frequently required care skills. While these broadly

represent the range, others could easily have been included and their exclusion does not

imply any kind of judgement about their value.

Best practice in delivering every aspect of care is influenced by fashions and fads as well as

new equipment, drugs and discoveries that lead to improvements. The details given in this

part of the book about the equipment to use and the procedure to follow represent best

practice at the time of writing and in the eyes of the author. When a reader has other

experience and disagrees about detail, that is as it should be because there is rarely a single

way of doing something or a single piece of equipment that could be used. During the rest of

this book, I sometimes refer to equipment or resources by name. Alternative equipment or

resources are provided in some places and the “norm” is constantly changing, so no preference

on my part should be presumed. While the equipment or resources may differ, the fundamental

principles still need to be applied to the delivery of care.

While reading on, I suggest that readers work out how the application of the Six fundamental

principles would apply to the caring requirements described. They should also consider how

that would vary in the unique context of their own daily caring acts. It will vary because each

care situation is unique and every aspect of the context impacts on the competent delivery of

appropriate care.

The common caring requirements that I discuss below are presented under the headings:

1. Providing appropriate personal care / hygiene

2. Managing nutritional needs / feeding

3. Managing toileting (professionally known as “elimination”)

4. Managing pain relief

5. Making clinical observations

6. Caring for the unconscious and/or dying patient

Whichever caring activity is underway, all carers will be part of a system that has its own

reporting requirements. It is essential to record the care properly and with enough detail to

ensure that others in the system know what has been done, what has not been done, and the

relevant patient specific detail. These reports provide an audit trail that protects the patient

and the carer against misunderstandings. Carers have a responsibility to keep records

properly for the sake of the patient and also themselves.

When a relative is acting as the carer, they should still have someone to report to, recording

their activities and discussing their concerns. When a home carer has urgent concerns, they

should contact the relevant medical professional and keep a record of that contact.

In Britain, the carer has a legal responsibility to deliver excellent care. When the carer is

unable to deliver the required care because of budget constraints or inadequate provision of

resources – the only protection the care staff have is a written audit trail of reports. They

31

should report the level of care provided and the actions they have taken to resolve any lack of

resources.

Despite the fact that senior management appear to have been treated as immune from

prosecution in recent high profile cases of patient neglect12, they are responsible and could

be held liable for any edicts passed down to caring staff or any reports from caring staff that

were ignored to the detriment of the patient(s). Morally, that responsibility extends to

politicians who presume to dictate the use of management systems that sometimes appear to

work to the detriment of patient care.

5.1 Providing appropriate personal care / hygiene

Personal hygiene helps to maintain a patient’s health, comfort, safety and feelings of “well

being”. It covers:

Assisted hygiene. This is helping the patient to wash themselves thoroughly.. When a

patient can do some of the washing themselves, they must be encouraged and

helped to do so.

Freshen-up care. This involves cleaning of hands, face and teeth and is conducted

frequently as a “freshen up”. When appropriate, it should include provision to shave

and brush hair. The carer should also consider making it easy for the patient to use

their own cosmetics or perfume.

Full wash or blanket bath. This is a full body wash for patients in bed who are unable

to wash themselves. When they can do some of it, they should be encouraged to do

so even if that makes the procedure take longer.

Spot washes. This involves the cleaning of specific areas of the body that have

become soiled, as occurs following an episode of incontinence, for example.

Bath or shower. This involves helping the patient take a bath or shower in safety.

Passive movements. This refers to the regular movement of an immobile patient so

that pressure sores and other problems are avoided.

Oral and hair care. Brushing teeth and hair as part of a “Freshen up” routine or on

their own when it would help the patient to feel more comfortable.

Care of nails on feet and hands. This involves trimming finger and toenails for the

patient’s comfort. Even when a patient may be able to do this, the movement involved

in cutting toenails may be undesirable and the carer should help.

Care of nose. This refers to the nostrils, their cleanliness and comfort.

Care of eyes. This refers to the care and treatment of eyes that may have become

infected, dry or encrusted.

After helping the patient with any aspect of personal hygiene the carer should ensure that the

patient is comfortable and has full access to their potential requirements. Doing this may

include elevating their feet, ensuring that their legs are warm, putting the call bell, spectacles,

drink, functioning hearing aids, reading material, radio etc., within easy reach. The carer

12Patients First and Foremost, the Initial Government Response to the Report of the Mid Staffordshire NHS

Foundation Trust Public Inquiry, March 2013.

32

should avoid rushing to next job without ensuring that the predictable needs of the current

patient have been met.

Anyone who is weak or debilitated may require help with their personal hygiene but the carer

has no right to force a reluctant patient to comply. Non residential carers who visit a patient

may be working to a tight timescale that does not allow time to gently persuade a reluctant

patient. The carer should try to negotiate a compromise if they refuse a full body wash,

suggesting just a hands and face wash and a change of clothes might work. The failure to

conduct the expected intervention should be documented, with reasons noted. If possible, the

carer should try to persuade the patient later in the day when their attitude may have

changed.

A patient’s reluctance to fit in with the carer’s personal care regime is acceptable as long as it

does not compromise other aspects of their care. This may be the case when the patient has

incontinence or is at risk of developing pressure ulcers, etc.

Religious, cultural, family, social and economic influences may all affect the patient’s wishes

with regard to their personal hygiene and how and when this is carried out. Negotiation with

the patient usually works – often because it allows the patient to feel able to make the

decision themselves, not simply falling into whatever is easiest for the carer.

Negotiating consent is important and generally makes everyone’s life easier. Attempting to

remove clothes and wash an uncooperative patient can be cruel, humiliating and very hard

work. It is no excuse for the carer to say “it’s what I am being paid to do and I don’t have

much time”. The good carer should be able to avoid this in most cases by negotiating an

agreed outcome.

So it is important to obtain consent from the patient before assisting them with their hygiene

and this includes getting their consent to access their personal belongings such as toiletries

and clothes. The equipment might be already visible and therefore accessible, but the carer

does not have the right to search through a patient’s personal belongings without first asking

for permission. The only exception would be when the patient is unconscious or unresponsive

to any interaction but the carer can still tell them what they are doing. If a relative is present

they might prefer to find things for the carer, so should be given the opportunity.

Remember, the carer must ask for consent but also respect the privacy of the patient and

their personal effects as much as is possible.

The carer must ensure that patient dignity, independence and autonomy is encouraged by

giving the patient the opportunity to conduct their own hygiene routine as much as they are

able. Even when that slows the carer down, it is the needs of the patient that matter, not the

convenience of the carer.

The assistance with personal hygiene that is required will depend on the patient’s general

condition and what, if anything, they are recovering from. Patients do not only recover from

illnesses or conditions, they also need to recover from the medical procedures that may have

been conducted. Following any operation there may be wounds to care for and the patient

may be feeling the after effects of an anaesthetic. Even the use of a local anaesthetic can

make a patient feel pretty awful. Older patients, or those with a concurrent disease such as

diabetes or arthritis, may feel even worse, and can take far longer to recover than a younger

patient.

33

Young or old, few patients feel 100% following any medical procedure. The carer should

anticipate that they might benefit from a “Freshen up”. This might only involve washing hands

and face, cleaning their teeth and brushing their hair. This should be the minimum offered to

any patient who is recovering from a procedure. The patient might decline, but it should be

routine to offer this.

The carer’s involvement in meeting a patient’s personal hygiene needs will depend on the

patient’s ability to do it themselves. If the patient is able and willing to wash their own torso,

hands and face, this should be facilitated. It may take far longer than being washed by an

efficient carer, but the carer must allow the patient to do it themselves when they want to

because the maintenance of a degree of independence can lift the patient’s morale, bolster

their self respect and dignity and have a very beneficial psychological impact that assists their

recovery. When a patient has opted for assisted hygiene, the carer should return to them

when they are ready and complete the care by washing those areas the patient could not

reach, which is usually their back, legs and feet.

Whatever personal hygiene method is used, after it has been completed, it is often

appropriate to encourage the patient to dress in their own clothes during the day and

nightclothes at night. This will help to encourage normality and independence whilst

maintaining dignity and giving a “shape” to their day.

5.1.1 Equipment necessary for both full and assisted hygiene

If the patient is not in a bathroom, some or all of the following equipment will be needed. The

list is not exhaustive. The carer should think about the patient and include anything specific to

their needs.

1. Bowl of Hot water (the water should be changed half way through in all body washes).

2. Two flannels or sponges (whatever the patient uses). One is for the face and the

other for the rest of the body.

3. Two large towels. One is for covering those parts not currently being washed.

4. Soap.

5. Clean clothes (and a continence pad when required).

6. Talcum powder / deodorant / Aftershave, as required by the patient.

7. Any prescribed skin creams or ointments.

8. Dressing gown and slippers if not getting dressed / clothes if getting dressed.

9. Teeth cleaning equipment.

10. Hairbrush / comb including access to a mirror.

11. Cosmetics if desired.

12. Shaving equipment when appropriate.

13. Cloth to clean spectacles, when required.

14. Clean bed linen.

When the patient has a catheter, an alternative type of catheter bag for day use (known as a

day bag) may be required.

If the patient has any other drainage bags they will also need to be changed.

34

5.1.2 Principles applicable to all types of personal care delivery

Prior to all patient contact, infection control considerations mean that carer must thoroughly

wash their own hands with liquid soap and hot running water, drying them thoroughly. They

should only use alcohol gel only when hand washing is not possible.

The carer need not normally wear gloves unless they are dealing with vomit, blood, urinary or

faecal matter, all of which present a risk of infection to the carer. If the carer is likely to be in

contact with bodily fluids, they should protect themselves by using gloves, aprons and, when

appropriate, goggles while they are or may be in contact with the body fluid only.

Whatever the type of personal care the carer is supporting, it is important that this opportunity

is used to communicate with the patient. Whenever communication is possible, the carer

should gain their consent before starting. Consent should never be presumed.

While helping with personal care, the carer can take the opportunity to discreetly assess the

patient’s skin integrity, looking for signs of damage, bruising, cuts, pressure ulcers etc.

Patients can feel exceptionally vulnerable during this care. The carer must be vigilant about

preserving personal dignity, privacy and any cultural or religious requirements.

Any soap used should be rinsed off the skin because if left it can make the skin more

susceptible to dryness, cracking and irritation. Use of emollients, such as aqueous cream, as

a soap substitute may be appropriate because they provide both a cleansing and a

moisturizing effect. Never rub the skin dry, pat with the towel gently – rubbing can damage

the protective outer layer of the patients’ skin.

If the patient has any tubes attached to them and the carer is not fully aware of their purpose,

they must not be touched. Knowing what the tubes are is NOT the same as knowing the

appropriate way of managing them to reduce the risk to the patient. Above all, the carer must

ensure that they do not do the patient harm. It is the carer’s responsibility to ensure that any

such tubes are examined and appropriately managed. When the carer cannot do this, the

requirement for their management must be recording in writing and the carer must contact

their senior nurse / manager to ensure that the need is known,

Following every type of delivery of personal care, the carer must clear away used articles and

clean them in accordance with the rules of the establishment. If there are no specific rules,

then washing any non contaminated equipment with soap and water then drying it thoroughly

will usually suffice. Electric or battery operated equipment should be switched off, unplugged

and can usually be wiped with a dilute hypochloride (bleach) solution, then immediately dried.

Bars of soap should never be shared between patients or staff. Liquid soap from a dispenser

is required because wet, slimy bars of soap provide a perfect medium for bacterial growth and

the spread of infection.

Any potentially infected linen or clothes, such as those that may have been soiled with faecal

matter, should be sluiced using gloved hands then washed in the hottest temperature

possible for the material.

5.1.3 Assisted hygiene (partial self-wash)

The following describes a fairly typical assisted hygiene procedure. It will vary according to

the patient and their context, and will be rather different in their own home.

35

1. Ask the patient if they want to use the toilet / bedpan / commode and assist them to

do so when necessary. Empty any used catheter or stoma (colostomy) bag and

document that as appropriate.

2. With the patient’s consent, gather together the washing requirements including

disposable flannels, toothbrush, hairbrush, razor etc and put them easily within the

patient’s reach.

3. Identify clean night / day clothes as appropriate and make them accessible to the

patient.

4. Prepare a bowl with sufficient water at the correct temperature. The default

temperature is 42ºC but it should be varied when that is what the patient prefers.

When there is no access to water nearby, it can be convenient to prepare two bowls

in readiness.

5. Remove the bedclothes and put them aside where they will not get dirty. Leave either

their top sheet loosely covering the patient or place a large towel over them. When

using a large towel, try to have it pre-warmed.

6. Help the patient to remove their bed-wear, top and bottom, maintaining their modesty

throughout with the judicious movement of the sheet or towel.

If the carer does not know otherwise, they should presume that the

patient is very shy because many are.

7. Remove any incontinence pads, leaving a dry incontinence sheet beneath their

buttocks if it makes them more confident to do so. There is no reason for unwanted

exposure. The sheet or towel can keep them covered throughout.

8. Remove any anti-embolic (TED13) stockings from the patient’s legs and feet.

9. Ensure that the patient has easy access to a dry towel.

10. Confirm that the patient can make contact when then need further assistance, then

leave them to wash all that they can, ideally their face and top half of their body and

their genitalia.

11. When they have completed all that they can, confirm how much they have managed

and help to wash their genitals if they have not done so themselves

12. Remove the bowl and change the water.

13. Then wash and gently pat dry any areas that they were not able to do. This often

includes their legs and feet, back and buttocks.

14. Use any perfumes or deodorants indicated by the patient but avoid applying talcum

powder to skin creases because it can cause soreness.

15. Assist with dressing as required by the patient, encouraging them to undertake as

much as they wish. Do not do more than necessary because this imposes a

13TEDS are a specific type of stockings designed to apply pressure on the deep veins of the legs so reducing the risk of a

deep vein thrombosis or subsequent pulmonary embolus. These have to be prescribed and should never be wrinkled or

cutting into the patient’s skin.

36

dependency that can be demoralizing. Assist them to dress in or out of bed, as

appropriate for each patient. While it may be quicker for the carer to do things for the

patient, it does not help recovery and can erode confidence.

16. Don’t forget to reapply anti-embolic stockings if they have been prescribed.

17. Put the equipment for mouth care, hair care and shaving, as required, either by their

bed or on a bed table beside the chair when they are sitting.

18. If the patient cannot undertake any of these tasks for themselves the carer should do

it for them gently and without undue haste.

Sometimes this whole wash is undertaken with the patient sitting in the chair. When this is the

case, their feet can be placed into the bowl of water. Ensure that feet are dried thoroughly

afterwards, especially between the toes.

It can be a real comfort to the patient to have their feet in a bowl of warm water. Every patient

can enjoy this when they are sitting out in the chair. This need not add unduly to the time

taken because their feet can be soaking while the carer makes their bed and clears away the

other washing equipment.

Before the carer leaves they must ensure that they have cleared everything away, put away

the patient’s personal effects and placed all used equipment in the right places for

subsequent washing or for disposal as appropriate.

5.1.4 Full wash / blanket bath

A full bed wash used to be known as a “blanket bath”. This was because the patient was

covered with a soft fleecy bath blanket throughout the procedure, with only the ‘bits’ being

washed exposed at any one time. This kept them warm, and ensured modesty throughout.

Even though these blankets are no longer used, the same care should be considered – allow

modesty and stop the patient getting cold. Use a large towel (or several small ones) or the top

sheet from their bed to cover the patient and only expose the parts actually being washed or

dried at any one time.

The following describes a fairly typical full wash procedure for the patient who is in bed and

unable to assist. It will vary according to the patient and their context. At all time, the patient

must be asked for their consent, informed about what is happening and have their right to

privacy protected.

1. Ask the patient whether they want to use the toilet / bedpan / commode. If they are

responsive, assist them as appropriate. Empty used urinal / catheter / stoma bag and

document appropriately.

2. Ask the patient if you can give them a bed bath and explain why it is needed.

3. Identify clean bed wear and place it to hand.

4. Prepare a bowl with sufficient water at the correct temperature. The default

temperature is 42ºC but it should actually be varied when that is what the patient

prefers. When there is no access to water nearby, it can be convenient to prepare two

bowls in readiness.

37

5. Remove the bedclothes and put them aside where they will not get dirty. Leave either

their top sheet loosely covering the patient or place a large towel over them. When

using a large towel, try to have it pre-warmed.

6. Remove the patient’s bed-wear, maintaining their modesty throughout with the

judicious movement of the sheet or towel.

If the carer does not know otherwise, they should presume that the

patient is very shy because many are.

7. Remove any incontinence pads without any unwanted exposure. The sheet or towel

can keep the patient covered throughout.

8. Remove any anti-embolic stockings (TEDS14) on the patient’s legs.

9. Tell the patient what you are doing and start the washing sequence with the face and

neck, then the arms, chest, abdomen, and then the genitalia. Expose each part of

their body to wash it separately. Cover whatever is not currently being washed.

10. Use the towel to pat each washed area dry – DO NOT rub because this may remove

the epidermis of the skin. Removal of the epidermis removes a protective layer of the

skin, so making the area more vulnerable to sores or pressure ulcers.

11. Change the water and then wash the patient’s back and buttocks, legs and feet. It is

advisable to have help washing the patient’s back – but if assistance is not available,

take care that the patient does not roll or accidentally get “pushed” out of bed.

12. Use any perfumes or deodorants as indicated by the patient but avoid applying talcum

powder to skin creases because it can cause soreness.

13. Apply any skin treatments that may have been prescribed and replace the patient’s

anti-embolic stockings if they have been prescribed.

14. Dress the patient as required, taking care not to expose more of their body than

necessary while doing so.

15. Bring the equipment for mouth care, hair care and shaving, as required. The carer

must conduct these procedures gently, explaining what they are doing at each stage.

If the patient is capable of doing any of these things for themselves, they should be

encouraged to do so.

While the carer is washing the patient, they should be talking with the patient and also noting

any sores, abrasions, swelling, bruising etc. Talking gives the carer the opportunity to find out

or confirm essential care information – how the patient is feeling, whether they have pain, if

they have any worries or concerns, or even whether they are aware of their surroundings and

what is going on. If the patient is not responsive or not conscious the carer must still talk to

them, explaining what is happening in a way that is calm and unthreatening.

All patients confined to bed should have their bed linen changed at least every 24 hours, and

as required when sweating or incontinence has left the linen wet or soiled. All bottom bed

sheets or draw sheets used must always be wrinkle free. Ensure all creases have been

14TEDS are a specific type of stockings designed to apply pressure on the deep veins of the legs so reducing the risk of a

deep vein thrombosis or subsequent pulmonary embolus. These have to be prescribed and should never be left wrinkled or

cutting into the patient’s skin.

38

smoothed away as the sheet is tucked in. Wrinkled sheets increase the risk of the patient

developing pressure ulcers.

5.1.5 Bath or shower

Within the NHS or in private care homes, ordinary household baths are rarely used because

of the difficulties found in getting many patients safely in and out of a household bath. Some

specialist baths include lifting devices that the carer should be trained to use. While some

advice about using specialist devices is given below, there are too many designs of baths and

showers in medical facilities to cover here. However, some basic rules must be applied

whatever the equipment.

1. The carer should not use the equipment until they feel competent and confident to do

so without endangering their patient. However simple or complex the device, there will

be safety factors to consider. The carer must know them. In many instances the use

of the equipment may be obvious or explained in documentation, or another carer

may be able to demonstrate its use.

2. When assisting a patient to wash in a bath or shower, the familiar principles of gaining

their consent, communicating their preferences, maintaining their privacy and

avoiding any affront to their dignity and respecting any Religious or Cultural

preferences must always be applied.

3. Showers and baths almost always involve standing or sitting on wet surfaces, so non

slip mats should always be used.

4. When the patient has finished, the carer must ensure that all the equipment used has

been cleaned, dried and disposed of, as appropriate .

Home carers whose patient has been assessed by an Allied Health Professional (AHP15) as

being in need of an alternative type of bath or shower may find themselves presented with an

unusual looking facility designed to make patient access safer. They should ensure that they

are confident and competent in its use before doing so.

5.1.6 After the patient has completed any type of personal

hygiene

There are things that every carer should ensure that each patient has access to before they

leave them. This applies after any patient contact, but especially after personal hygiene

routines because they can disrupt the patient’s bed space.

What follows is a very incomplete list of questions that a carer should consider before leaving

their patient. The real list will be patient specific and far longer. These are not questions the

carer should ask the patient, but questions the carer should ask themselves.

Does the patient wear spectacles, and if so, are they within easy reach?

Have they got hearing aid(s)? Are they working? Are they in the patient’s ears?

Have they got access to a TV? Have they a functioning remote control?

15AHP Allied Health Profession. These are highly trained Registered Professionals who are not nurses or doctors but who

work within the health and social care sector – all of whom are Registered and therefore accountable for their own practice.

Most are autonomous practitioners. Examples include Physiotherapists, Occupational Therapists, Social Workers,

Dieticians, Pharmacists etc.

39

Has the patient got something to do – magazines, knitting, cards – the radio?

Are any radio ear-pieces clean?

Does the patient know how to operate the radio, TV, etc?

Has the patient got their call bell? Do they know how and when to use it?

Is the patient comfortable, warm enough, should their feet be elevated?

Would the patient benefit from seeing a clock with the date and time on?

Has the patient got easy access to a drink (as long as they are not denied fluids for

medical reasons)?

Has the patient got a weak or injured side? If so, are all of these resources on the

appropriate side so that they can access them?

Is all tubing (such as catheter tubes) discreet?

Are all drainage bags out of sight but in a position to drain and out of contact with the

floor?

A good carer will have a list in their head for each patient and update it regularly.

5.1.7 Passive movements

Strictly speaking, passive movements refer to the movement of a joint without participation or

effort on the part of the person moving. In many hospitals this definition is extended to include

those movements made by a recumbent patient because they are asked to move in that way.

The patient is asked because the movements reduce the risk of deep vein thrombosis

(DVT16

), pulmonary embolism17

, pneumonia, chest infection, muscle spasm and muscle

wastage.

Passive movements of any unresponsive patient’s limbs should be conducted by the carer at

not longer than four hour intervals, generally when they turn any patient who cannot move

themselves. Patients who are at high risk of developing pressure ulcers because of their

being thin and unable to move themselves should be turned more frequently, at least every

two hours. Again, passive movements can be undertaken as part of this two hourly routine.

All patients confined to bed, or who cannot move much, should be encouraged to make

“passive movements” every hour. Common examples of four hourly Passive movements for

conscious patients who can move are:

Deep breathing – slow and deep, not panting or hyperventilation!

Rotating each foot in circular motion, and

Bending the knees and extending the legs.

Whenever a patient can do this themselves, it must be encouraged by the carer. When the

patient can understand, the reason for doing it should be gently explained. The carer should

avoid over-dramatising the need because that might cause worry and distress. These

movements reduce the risk of undesired events and are simply part of the patient’s treatment.

16 DVT – deep vein thrombosis, a blood clot in the deep veins, commonly of the lower leg. This blood clot can break away

and be transported around the patients body, commonly lodging in the lung causing….17 A pulmonary embolus (a blood clot in the lung) which can be life threatening.

40

5.1.8 Oral care – mouth care

Oral care is necessary for any patient with a restricted fluid intake – whether that restriction is

self imposed, a result of their condition or a medical requirement.

Because the mouth (oral cavity) is a natural environment for many bacteria, infections arise

when the natural state changes and the mouth becomes dry. Mouth infections can cause

localised soreness that may spread to cause serious systemic (large parts of the body

system) infections, so their avoidance is important.

Oral care is conducted to keep the mouth clean, soft and moist, so avoiding cracking and

preventing infection. It can also increase patient comfort dramatically. Mouths are sensitive

and intimate, so mouth care should always be conducted gently and with respect for the

patient’s privacy. Unless the patient is not able to rationalise, the carer should always have

the patient’s consent before starting.

Generally, the carer should make mouth care regularly available when:

1. Any patient is not taking fluids by mouth for whatever reason. Mouth care should be

conducted every two hours for maximum patient comfort, and never less than at four

hourly intervals to avoid infection.

2. If the patient is taking oxygen via a mask, has an infected mouth, or is unconscious,

mouth care should usually be conducted at not less than two hourly intervals,

3. Mouth care should be continuously and discreetly available to all compliant, lucid

patients and “delivered” by the carer to the confused or unconscious patient. Watch

the patient. If their mouth hangs open and they cannot drink, mouth care will be

needed regularly. Generally, mouth care gives such relief to those with a dry mouth

that even the non-compliant or disorientated patient will not object.

4. When any patient is not able to walk around independently or freely, the carer should

facilitate tooth brushing (in mouth or as dentures) night and morning and after every

meal. The amount of toothpaste used should be limited because too much can have a

drying effect. The carer must encourage the patient to rinse the mouth if possible

because this will wash residual toothpaste away and so reduce any drying effect.

The purpose of mouth care can be achieved in any way that keeps the mouth clean, soft and

moist and is acceptable to the patient. The equipment and procedures vary between

institutions. They usually involve the gentle use of a purpose made disposable sponge-stick

or soft toothbrush, moistened with water. There are many mouthwashes available, but water

may be safest agent to use18. There are various oral assessment and recording tools

available if the patient is considered to be at a high risk of oral problems19.

The simplest foam-stick has a plastic handle and an open-cell foam or cotton head. The head

is dipped in water or the preferred mouthwash solution. Some already have a liquid content –

such as lemon and glycerin foam-sticks. The foam on these is soaked in lemon, honey and

glycerin that is brushed over the tongue, gums and mouth lining.

18 Manufacturers of mouthwash products may claim otherwise, but current research suggests that water is the safest and

most effective moisturising agent for oral care. See: http://www.geriatricoralhealth.org/topics/topic07/art/qualified-nurses-

lack-adequate-knowledge.pdf. If antibacterial mouthwash is required chlorhexidine gluconate is an effective antibacterial

agent – Royal Marsden 9th ed. 2015 page 495.19 Use of a single validated tool is recommended by the Department of Health, this ensures consistency of assessment.

41

Foam - or cotton -sticks are not used in some care institutions because there is a risk that the

patient may bite the foam off and choke on it. The carer should assess the patient and

consider whether this is likely. If they think it is, the problem should be resolved by the use of

a soft toothbrush. Institutions that do not use foam-sticks usually use soft toothbrushes to

conduct mouth care, again soaked in the preferred liquid. A soft toothbrush is usually more

effective than foam or cotton sticks.

Many institutions have a preferred mouthwash, or the patient may have their own. Rather

than argue about the advantages of using water, the carer should respect the patient’s or

institution’s view and keep the mouth moist. The important thing is that the oral care must be

undertaken before the patient develops a dry, sore or cracked mouth, not which mouthwash

is best.

When a patient is compliant and able, they may be able to use a mouthwash themselves.

They may have their own, or may accept the mouthwash favoured where they are. Common

mouthwashes used in the NHS include:

The mouthwash Corsodyl which has antibacterial and antifungal properties but the

high alcohol content can make it sting uncomfortably.

The mouthwash Chlorhexidine Gluconate 0.2% which should be diluted 5ml in 100 ml

water, and retained in the mouth for one minute before spitting it out. While mouth

care may be needed far more often, Chlorhexidine mouthwash should only be used

twice a day.

There is evidence (and it is obvious) that the use of a toothbrush is actually more effective

than the use of a sponge-stick but it can be hard to brush a patient’s teeth without introducing

distress or discomfort, so the carer should generally only use a toothbrush with the patient’s

consent. If the patient can use a toothbrush themselves, that should be encouraged.

While conducting mouth care, the carer should pay attention to the following:

Respect the patient’s right to privacy and ensure that no one else can see what is going

on. This can be critical when a patient wears dentures and is self-conscious.

Examine the patient’s lips. If they are dry, cracked or bleeding, the appropriate treatment

should be applied. While vaseline is generally effective, the carer should know that it must

not be used when a patient is receiving oxygen therapy. E45, aqueous cream or aquagel

are suitable alternatives

If the patient’s tongue looks coated and there are signs of a fungal infection, the carer

must report the problem so that a Registered Practitioner or doctor will examine the

tongue and prescribe any antifungal treatment that may be required.

A coated tongue that is not infected can be cleaned with a soft toothbrush and a Corsodyl

50/50 with water or similar mouthwash.

Examine the patient’s mouth for problems such as decay, excess tooth-plaque or rubbing

dentures. If there may be evidence of dental disease or denture problems the carer

should record the problem so that a Registered Practitioner or doctor can make an

examination.

42

When a patient wears full or partial dentures, these must be removed to clean the

underlying areas. While the denture(s) are removed, give the patient water or a

mouthwash to rinse the mouth. Generally, dentures should be removed at night and

placed in water or a suitable cleaning solution, but only with the patient’s consent.

Removing a patient’s dentures can affect their self-image, dignity and self respect, so

always requires their consent whenever the patient is conscious and rational unless there

are compelling medical reasons to remove them.

If the patient has a dry mouth, the carer should prevent this by ensuring that the patient

drinks frequently or has more regular mouth care. If the patient is unable to drink, the

carer may consider whether it is safe for them to suck ice. Regularly irrigating their mouth

with water that is not swallowed will effectively moisten it but spillage must be mopped up

immediately. The carer should also consider using a saliva spray or pastilles. If the

approaches suggested are not safe because the patient cannot swallow properly,

consider thinly smearing a moistening gel such as “Aquagel” thinly onto the patient’s

tongue and gums. Whatever the carer decides is appropriate, they should consult the

patient and get their agreement whenever the patient is conscious and rational.

When the patient may have ulcerated or bleeding gums or mucosa20, the carer might try

cleaning the areas with small, soft, round-ended toothbrush and a smear of fluoride

toothpaste. Any toothpaste used should be rinsed away, then apply a thin layer of

aquagel or similar to the affected areas regularly.

When the patient complains of soreness or mouth pain, the carer may consider the use of

a topical analgesic (pain killer) such as ‘Difflam’ or ‘Bonjela’ which can be bought from

most chemists. Bonjela is rubbed gently onto the affected area. ‘Difflam’ is a mouthwash

that should be diluted 50/50 with water. A simple and effective aspirin mouthwash can

also be made using 2 x 300g soluble tablets and repeated four times a day, but the carer

must always check with the Registered Practitioner or doctor to ensure that the treatment

used is acceptable. Mouthwashes should not be swallowed, of course.

Some patients suffer from the opposite to a dry mouth. They hyper-salivate and cannot

swallow it all. This can result in dribbling, choking or sore skin. The carer should apply a

barrier cream to the area affected by saliva. ‘Cavilon’, ‘diprobase’ or ‘vaseline’ can form an

effective barrier to protect the skin. When a patient’s oral moisture loss is excessive, the fluid

loss should be estimated so that it can be replaced in the calculation of the patient’s required

fluid input. The carer should report the fluid loss in writing so that a doctor can prescribe

medications to reduce the fluid loss. The products suggested here are only suggestions, a

healthcare professional may well advocate alternatives.

When an antifungal mouthwash has been prescribed, it should be used when nothing else

will be delivered via the mouth for a reasonable time (at least an hour). This allows the

antifungal mouthwash time to destroy the fungus and reduce the discomfort. When an

antifungal mouthwash is given to an unconscious or immobile patient, the carer must deliver

the solution with the patient lying on side to reduce the risk of choking. Obviously, place a

towel under their head before using the mouthwash which may be squirted into the mouth or

applied using a sponge-stick. Turn the patient and deliver the mouthwash on both sides, so

increasing the likelihood of it being effective all around the mouth and tongue.

20 The mucosa in this context refers to the inner lining of the cheeks, roof and floor of the mouth.

43

When the mouth care has been completed, the carer must ensure that all equipment used

has been cleaned and dried or disposed of, as appropriate, and that the patient is

comfortable.

5.1.9 Shaving

Shaving can be done using an electric razor or a “wet shave”. Generally, the carer should

encourage any patient who can do this themselves to do as much as they can. The carer can

then complete any bits they have “missed”. Doing more for the patient than is necessary can

affect the patient’s self esteem and increase dependency, instead of promoting recovery.

Generally shaving should be a regular part of the patient’s daily personal hygiene routine

unless the patient does not want to shave or there are medical reasons for not shaving.

The shaving requirements will vary, but all wet shaves will involve having access to hot water,

soap or foam, a mirror, towel and, when wanted, aftershave lotion. Either the patient’s own

razor should be used or a disposable one provided. When the carer shaves the patient, they

should talk to the patient explaining what they are doing and flattening the skin when

necessary to ensure an even shave. Most disposable razors are designed to be used at

limited angles. Holding the razor at the wrong angle can make it likely that the skin will be

damaged. When a carer has never used a wet razor, they should practice on themselves

before approaching a patient with a razor. Shaving someone is easy, but there is a knack and

it should never be rushed.

For all electric shaves, the patient will need access to both a mirror and their own functional

electric razor. Following use it may need to be recharged and the shaving head may need to

be cleaned. The carer should ensure that this happens, and do it for the patient when they

cannot do it themselves. Shaving a patient with an electric razor is easier than giving a wet

shave but should still be done slowly and gently, taking instructions from the patient

whenever they can give them.

When the patient has shaved, the carer should offer to help with any areas that have been

missed, then ensure that all shaving equipment is cleared away, washed and dried or

disposed of, as appropriate.

5.1.10 Care of nails on hands and feet

Care of finger and toe nails is important because, particularly in diabetic patients, the nails

and areas around them can easily develop sores that do not heal readily. This raises the risk

of infection and causes discomfort to the patient.

Nail care should be included as part of the patient’s personal hygiene routine. It covers not

just cutting nails, but also cleaning under and around them so is a daily requirement. When a

patient does not want their nails to be cut, their preference must be respected unless there is

a compelling medical reason to cut the nails. Generally, the patient will allow their nails to be

cleaned even if they are reluctant to have their nails cut. If a patient wants the clippings

collected, the carer must do this without comment.

Whenever a patient can clean and cut their own nails, they should be encouraged and helped

to do so. Many patients cannot comfortably bend to reach their feet and clean or cut their own

toenails, so the carer will often have to do this for them. If a patient has a preference for the

shape of their nails, their preference must take precedence over default advice, of course.

44

Soaking the fingers or feet in warm soapy water before cleaning and cutting nails can make

the process easier and more efficient.

The area around nails should be cleaned using a nailbrush. The nailbrush should never be

shared with other patients because they can harbour bacteria and be a cause of infection

transfer.

The area beneath the nails can be cleaned using a nail file. Cut or clip finger nails level with

the tip of the toe or finger. The corners of a fingernail can be shaped using an emery board.

Toe nails should be cut/clipped straight across. The emery board must never be shared

between patients because it can be a cause of infection transfer.

Patients who have diabetes may have an increased risk of circulation problems in their legs

and feet. They should always have their toenails cut by a podiatrist (chiropodist).

During the care of finger and toe nails, the carer must examine the areas and record any

area(s) of skin dryness, inflammation, or calluses in the patient’s personal notes. Any

indication of infection should be brought to the attention of appropriately qualified medical

staff as soon as possible.

After caring for finger and toenails, the carer must ensure that all the equipment used has

been cleaned and dried, or disposed of, as appropriate.

5.1.11 Care of the nose

The carer should consider, offer and include nasal care as part of the patient’s personal

hygiene routine. When a patient has access to tissues and can blow their nose, it may not

often be necessary, but in some cases it is essential. When a patient has tubes inserted via

their nostrils or is receiving oxygen through nasal prongs, they frequently develop a sore or

encrusted nose.

Before providing nose care, the carer must explain what they are doing and why. Noses are

sensitive, so the care must be conducted with patience and with respect for the patient’s

privacy.

Each nostril should be cleaned using a gloved hand using warm water and gauze soaked

with saline21 solution, then apply a gel such as Aquagel (not vaseline) to reduce dryness. Any

areas of soreness should be recorded and reported appropriately.

Feeding tubes require very specific assessment before changing the dressing / securing tape,

so this should only be conducted by appropriately qualified staff. If the carer thinks it is

needed, they should report the need and record it in writing.

5.1.12 Care of eyes

To maintain healthy eyes and preserve sight, eyes must be kept moist and free from infection.

Most patients will need no special eye care but there are several regularly used drugs that

can increase the risk of the patient’s eyes become dry and prone to encrustation that can

cause infection. The unconscious or dying patient is also significantly at risk of eye

encrustation.

21 A teaspoonful of salt dissolved in a pint of cool boiled water could be used in this instance.

45

Eye care can be divided into two activities - washing and irrigation. All carers should be

competent to wash a patient’s closed eyes but the irrigation procedure should not be

conducted by any carer who has not been trained and assessed as being competent to

undertake it.

As with each aspect of care, the carer should explain to the patient what they plan to do –

asking for the patient’s consent before starting.

If the patient has an infection in one eye, the eye without an infection should be cleaned

before the infected eye. This reduces any risk of spreading the infection.

To clean sticky matter and encrustations from a patient’s closed eyes, the carer should use a

solution of 0.9% sterile saline solution (salty water) or sterile water22 to wet a low lint soft

gauze. Using a gloved hand, wipe the gauze gently from the nose outward, then turn the

gauze to repeat with its clean side. Wipe gently – applying no pressure to the eyeball. Repeat

the wiping action until any encrustation has been removed, never using the same piece of the

saline soaked gauze more than once. Make sure that the lid stays closed and that the gauze

does not come into contact with the eye, and always use separate gauzes for the right and

the left eye.

After caring for the patient’s eyes, the carer must ensure that all the equipment used has

been cleaned and dried, or disposed of, as appropriate.

Some patients have an artificial eye. This may be removable or implanted. All removable

artificial eyes should be removed daily and cleaned. Artificial eyes can be cleaned using

sterile water, or a proprietary solution that the patient may have. Usually the patient will be

able to either remove the eye themselves or tell their carer how to do it. When the patient

cannot do this, the carer should document the problem and seek advice

5.1.13 Care of hair

When a patient is lying in bed, their hair can become knotted and matted. This can be

uncomfortable and can embarrass the patient, lowering their self esteem. If hair is dirty it can

harbour infection and present a health risk. The same can be true of bearded male patients

who must be offered the same hair care facilities for their beards.

Generally, each patient’s hair should be combed or brushed thoroughly at least once a day.

Whenever a patient cannot do this for themselves, it is the carer’s responsibility to assist. As

always, if the patient can do part of the task themselves, the carer must facilitate this. As with

each aspect of care, the carer should always explain to the patient what they plan to do and

get their consent and assistance whenever possible. Hair care is generally a private activity,

so the patient’s privacy must be respected whenever possible.

The carer should not use the same brush or comb for more than one patient.

Patients should be given the opportunity to wash their hair whenever it looks as though it

needs it, or when the patient asks. When a patient cannot do this themselves or has

restricted movement, this can be challenging but the carer must find a way. Some institutions

will have equipment and a process to follow, in other places the carer may need to use a little

22 Sterile water may be preferable a saline solution when a patient is aware – because it is less likely to sting.

46

ingenuity. When caring for a long-stay patient, it can become part of a routine that the patient

can look forward to.

Hair washing is always worthwhile because, for many patients, having clean and tidy hair can

provide a huge morale boost.

In nursing, rest and private care homes, there is often an arrangement with a mobile

hairdresser who will visit at pre-arranged times. This service is usually (but not exclusively)

only available to patients who are not confined to their bed. If it is available, the patient must

be made aware of it and encouraged to take advantage of it when appropriate.

While it may not be possible to accommodate a patient’s desire for frequent hair-washing,

regular brushing and combing is part of basic nursing care and failure to offer it with as much

assistance as necessary would constitute neglect.

5.2 Managing nutritional needs – feeding

Some conditions or diseases increase the risk of the patient developing a poor nutritional

status which raises the risk of unnecessary complications such as pressure ulcers (bed

sores), poor tissue regeneration (healing), infection and unnecessary patient suffering.

Examples of patients with a higher than average risk of having a poor nutritional status are:

Those who have suffered a stroke and have difficulty swallowing as a result

(dysphagia).

Those who have been recently diagnosed as diabetic and their condition has not yet

stabilised.

Patients who are receiving enteral feeding (enteral feeding is feeding via a tube into

the stomach and is discussed below).

Patients with any malabsorbtion syndrome, whereby their gut cannot absorb or

metabolise food thoroughly.

Patients receiving what is known as “Parental nutrition” (usually through a central

venous line). Parenteral nutrition is a liquid food, comprised of specific nutrients and

vitamins that are delivered into a large central vein of the patient.

Patients with known liver (Hepatic) disease.

Patients with known kidney (Renal )disease.

Patients who are grossly obese, known as “morbid obesity”.

Patients with anorexia nervosa.

Patients with pancreatic disease.

Patients who are or who have recently been nursed in a critical care unit.

Patients who have had major gastrointestinal surgery.

Patients with advanced stages of dementia.

Patients who meet the above criteria will not necessarily have a problem with their nutritional

status, but the carer should be aware of the increased risk.

47

When the carer suspects a patient may be malnourished, specific assessment is required that

will identify both whether this is correct and whether there are other factors that require

special dietary supplements to be administered

Most patients eat normally through their mouths, known as “Oral Feeding”. Their carer must

ensure that the food provided meets any religious or cultural requirements. They must also

ensure that the food is presented to the patient in a position that makes it easy for them to

reach and provide assistance when required. Some may need the food cut up for them,

others may need help moving the food to their mouths. When a patient takes oral sustenance

with assistance, the carer should never try to make them eat faster than their natural speed.

When the patient has not eaten much it can be appropriate for the carer to encourage them to

continue, but the carer must not oblige or bully the patient.

The portion should be agreed (consent) and adjusted to suit the patient. An elderly anorexic

will be unlikely to want to even look at an enormous plate of fish and chips while a ravenous

young man will not want a paltry portion. The carer should know their patient and ensure that

the size of portion meets their needs.

Some common physical infirmities, such as arthritis may make it impossible for a patient to

use normal cutlery. If this is the case, an Occupational Therapist should be asked to assess

the patient’s needs and provide appropriate eating utensils. When the carer thinks there is a

problem, they should report it and ensure that the problem is satisfactorily resolved.

Some patients are thin, frail, and have a low body mass. Their diet is commonly

supplemented with nutritional drinks. These are prescribed by a dietician / doctor and their

ingestion is important, so the carer must record their use accurately. The carer should also

encourage the patient to drink them. Patients with a low appetite may be reluctant so the

carer may need to remind them that they are part of the treatment and will improve the way

they feel. Nutritional drinks are often quite large and may be too much for the patient to drink

in one go. The carer should ensure that they are not left on lockers or bed-tables for hours

because they can easily grow bacteria. Refrigerate an opened drink supplement. In warm

conditions, record approximately how much was drunk and then dispose of the partially

consumed drink.

The carer must only ever encourage, not oblige the patient to eat or drink. The patient has the

right to decline. If the carer is concerned that they are not eating enough or they are not

eating prescribed supplements, the carer must record this reluctance.

Eating should be an enjoyable process for the patient. When they require help, that can be

demoralising so the carer should make the process as easy as possible

Before serving any meal the carer should:

Offer toileting to any patient who may be in need. When patients have been given a

diuretic (medication to make the patient pass a lot of urine), their needs can be

sudden and urgent. Then ensure that any toileting equipment has been removed

Remove any aprons or gloves that have been used to deliver other aspects of care,

then wash their hands thoroughly. Some institutions require the use of a specific

apron for delivering food and the rules of the institution should be followed.

Ensure that the patient is comfortable, usually in a sitting position.

48

If the patient has dentures, check that they are wearing them, or if they want to wear

them.

When protection for the patient’s clothes is required, ensure that it is clean. It is not

acceptable to use protection that has previous stains.

Ensure that there is a suitably positioned bed-table or other surface on which the food

can be placed.

When providing assistance with eating, the carer should:

Sit in front of the patient or slightly to their side.

Interact with the patient, encouraging discourse as if dining together.

Ask whether the food is suitable and to their liking.

Offer the food in small amounts. Each mouthful must be chewed properly and

swallowed before the next is offered.

Offer frequent drinks – preferably not using a feeder cup. Feeder cups have a place in

helping a patient to feed themselves but whenever possible the carer should use a

normal cup, adding a drinking straw when necessary. Feeder cups emphasise the

patient’s vulnerability and can be a degrading affront to their dignity. They are not

often necessary provided the delivery of fluid is not being rushed.

Do not appear to be in a hurry. A patient should not feel obliged to hurry or say they

have had enough because their carer is busy. Rushing feeding causes poor chewing,

poor digestion, indigestion, constipation or worse still, choking and possibly death.

A pleasant, satisfying meal can make a great difference to patient morale, and mealtimes can

become highlights in their day.

Every carer should be aware of the appropriate action to take if a patient chokes while eating.

This should have been covered during their training. It is the carer’s legal responsibility to

ensure that they know what to do if choking occurs.

When the meal has been completed, clear the equipment away and document it when

required. It is usually appropriate to offer the patient a freshen up wash, including oral care.

Why some patients are reluctant to eat

There is always a reason for a patient not eating and it is part of their carer’s responsibility to

communicate with the patient, identify the cause and rectify it whenever possible.

Common reasons for a reluctance to eat include:

1. The patient is feeling anxiety.

2. The food offered is inappropriate, either in consistency or by failing to conform to the

patient’s religious or cultural requirements.

3. The food looks unappetising.

4. The patient is in pain.

5. The patient needs to go to the toilet.

6. The patient has no teeth, painful teeth, or a sore mouth.

49

7. Physical infirmity, unable to cut up their food or handle the cutlery easily.

8. The patient is suffering from depression.

9. The patient cannot reach the food easily. The plate may not be at an appropriate

height for the patient’s position.

10. The patient cannot see what they are eating or what is on the plate – those with visual

problems might like to be told what they are being given and their hands guided to

their cutlery and drink.

11. The patient is confused and does not understand what they are expected to be doing.

12. The patient is anorexic.

13. The patient is feeling nauseous.

14. The patient has been given too large a portion.

15. The patient does not like what they have been given.

Many of these can be rectified and all should be recorded and reported because they can be

critical to a patient’s welfare.

Why some patients are reluctant to drink

Getting patients to drink enough can be a problem because the more they drink the more

they want to go to the toilet. Many patients don’t drink much because they don’t want to have

to keep going to the toilet. They may want to avoid the effort and discomfort of making their

way to the toilet independently, or they may want to avoid asking for help and the loss of self

esteem involved in needing toileting assistance.

This is a serious problem because if they don’t drink enough they risk developing a urinary

infection. This may be a low grade infection but it is unpleasant, makes the patient need to

pass urine more and makes urinating painful,. Untreated, the infection can develop into a

significant infection that can make the patient confused and even more reluctant to drink. It is

not uncommon for this to lead to the patient being hospitalised to receive intravenous fluids

and intravenous antibiotics. Admission to hospital can lead to the patient being encouraged

into a “dependency mould”. Their bed may be a long way from a toilet. They may rarely be

offered the opportunity to be escorted to the toilet and so become dependent on bedpans or

commodes. Their confidence in their ability to walk can be eroded, reducing their ability to

cope independently in a way that leads to them eventually being institutionalised.

The solution is very often to remove the problems that a patient has about urinating

frequently. This is not as simple as regularly offering a commode or a bedpan. Whenever a

patient is capable of walking to the toilet, the offer should be to escort them to the toilet so

that their confidence in their own ability is enhanced rather than eroded. This may take a little

more time, but can pay great dividends to the patient.

To encourage fluid intake, all patients should have access to drinking water at all times

unless there are medical reasons to restrict fluid intake. Easy access to a toilet will often

encourage compliance.

5.2.1 Swallowing difficulties (dysphagia)

Patients with known swallowing difficulties should have a “swallow assessment” to ensure

they are not at risk of food going the “wrong way” and ending up in their lungs. The

50

assessment is often conducted by a Registered Practitioner or a Speech and Language

Therapist. (SLT23). If food does “go down the wrong way”, the patient can develop a

pneumonia which can be fatal. The assessment will determine whether the patient can safely

eat and drink.

When it is not safe for the patient to eat and drink, the patient will be declared “Nil By Mouth”

(NBM) and need alternative methods of feeding. This decision requires a significant life style

change and will have a major impact on both the patient and their relatives.

Any patient declared NBM will require frequent oral care (mouth care).

Sometimes it is decided that a patient can eat but that the food must be mashed or pureed.

Sometimes a decision is made that all fluids must be thickened. Thickened fluids are used to

reduce the risk of choking because they are easier for the patient to control in their mouth.

Effectively, nothing slips down their throat until they decide to swallow. Thickened fluids are

made by adding a thickening powder to everything that the patient drinks – cold drinks, hot

drinks, soups and nutritional supplement drinks. The consistency can be varied and the

correct consistency should be indicated by those making the assessment.

The consistencies are generally known as:

Stage 1: syrup consistency

Stage 2: custard consistency

Stage 3: pudding consistency

Those conducting the assessment will also advise on the type of drinking cup that is best for

an individual patient. Open cups are often better because beakers can send the fluid to the

back of the throat too quickly.

5.2.2 Enteral Feeding

When a patient has had a “swallow assessment” and is found to be at significant risk of

choking on foods and fluids of any consistency, an alternative means of feeding is required. If

the problem is expected to be very short term, the patient may have an intravenous line

inserted through which a special feed is delivered intravenously.

When the patient may be expected to need longer term feeding, enteral feeding is commonly

used. This involves passing liquid feed directly into the patient’s stomach. Enteral feeding is

achieved either by using a tube inserted into the patient’s nose (known as an enteral feeding

tube24) which ends in their stomach, or by passing a tube through their abdominal wall and

into their stomach (known as a Percutaneous Endoscopic Gastrostomy or P.E.G.25 tube). The

liquid feed delivered through the tube contains the patient’s complete nutritional

requirements.

23SLT – an Allied Health Profession whose skills include the ability to undertake a “swallow assessment’” and identify any

risks inherent with patients who may have swallowing difficulties.24 An NG is a tube that is delivered “Naso” (in the nose) and passes into the stomach (Gastric).25 P.E.G – Percutaneous Endoscopic Gastrostomy – through the abdominal wall directly into the stomach (gastrostomy),

51

5.2.3 Enteral feeding tubes

An enteral feeding tube is often used when the patient’s need for this method of feeding is not

expected to continue for more than a few weeks. It may also be used while waiting for a

P.E.G. tube to be inserted.

Delivering nutrition by an enteral tube can be very demoralizing for the patient who may have

just experienced a life changing event such as a stroke or receipt of a serious diagnosis. In

these situations, both the patient and their relatives should be expected to be upset, angry or

grieving. The presence of a feeding tube will not be reassuring. The carer must provide plenty

of that.

The carer should regularly and discreetly examine the enteral tube’s securing method and the

nostril through which the tube passes. Using a gloved hand, treat any sores or dryness using

a lubricant such as aquagel or vaseline. Replace the means of securing the tube to the

patient whenever it could be become detached. Make sure that the tube never passes in front

of the patient’s vision. There is no reason why it should, so obstructing the patient’s sight

would be thoughtless and inconsiderate. The carer should remember that when a patient’s

condition is such that they need enteral feeding, that patient needs the utmost support and

consideration as a person as well as a patient.

When inserting the enteral tube up a nostril it is possible to accidentally push the tube down

“the wrong way” into their lungs. A patient with a normal swallow reflex would know this and

could be relied on to cough, but in the patient who has difficulty swallowing they may not feel

this incorrect insertion and not cough – resulting in the tube being incorrectly inserted26.. The

enteral tube has a thin guide wire inside it. After the tube has been inserted, the guide wire

must be left in place until the patient has had an x-ray of their chest. The guide wire will show

up on the x-ray, so providing confirmation that the end of this tube is in the stomach and not

in the bronchus or lungs. The guide-wire is then removed, the tube is secured to the patient’s

cheek or nostril and liquid feeds delivered. The feed is usually pushed through the tube by a

feed pump that slowly delivers the feed into the patient’s stomach.

Not only do feeding tubes potentially demoralise the patient they also increase the risk of

nasal sores and most importantly, they require extreme vigilance to ensure that the tip of the

tube remains in the stomach and does not move from the stomach into their lungs – known

as tube misplacement. That may sound unlikely but it can occur.

Vomiting or coughing can be the cause of tube misplacement. So can securing the tube to

the patient’s nose or cheek in a way that becomes loose. When a tube appears to be “coming

out” the carer must never simply just push the tube back down again because there is a high

risk of accidentally pushing the feeding tube into the patient’s lungs instead of their stomach.

There are markings on the outside of the tube, the number written on the tube where it exits

from the nose should be recorded at the time of satisfactory insertion. This number should

remain the same and be checked prior to starting any enteral (tube) feed.

26 The risk is very high and is recorded by the Department of Health as being a “never” event, of such magnitude that it

should never happen.

52

5.2.4 Testing for enteral tube misplacement

In order to ensure that the tip of the feeding tube has not become misplaced a test must be

conducted before any feed is attached to the nasal feeding tube.

This test involves using a clean syringe that is attached to the end of the enteral tube using a

gloved hand. The syringe plunger is withdrawn just enough to draw back a small amount of

fluid into the syringe body. A few millilitres is all that is needed.

The syringe is then disconnected from the enteral tube and the content squirted directly onto

a piece of pH paper. If the result shows a pH result of 5.5 or less, this indicates a very acid

result and means that the tip of this tube is safely in the patient’s stomach. It is important that

pH paper is used, not litmus paper. This is because some people have acid secretions in their

lungs, caused by some lung diseases or medications. If litmus paper were used it would not

provide the information required for best, safe practice. When a carer has any concern that

the enteral feeding tube may have become displaced, such as when the patient has been

coughing violently or vomiting, they must not attempt to deliver any feed through it. The carer

must report their concern, recording it in writing and seek advice from a suitably qualified

Registered Practitioner or doctor. Another x-ray may be conducted to confirm that the tip of

the enteral feeding . tube is placed in the patient’s stomach and not their lungs.

5.2.5 P.E.G. (percutaneous endoscopic gastrostomy)27 feeding

tube

When enteral feeding may be required for longer than three or four weeks, a P.E.G. tube is

often used instead of the enteral feeding tube.

The P.E.G. tube is inserted while the patient is either under a general anaesthetic or under

sedation, so this usually occurs in a hospital or clinic setting. The tube is guided directly into

either the stomach or jejunum (a specific part of the small intestine) using an x-ray type of

imaging. When correctly in place, a type of balloon or “button” is inflated to prevent it falling

out again. This means that a P.E.G. is unlikely to become displaced, but the site where it is

inserted into the abdomen can become sore or infected.

5.2.6 Care of the P.E.G. insertion site

The carer must regularly clean the tube insertion site using sterile low lint gauze soaked in

saline. While doing this they should look for any encrustation, swelling or signs of infection.

The carer must report any indication of swelling or infection immediately.

Sometimes the P.E.G. tube is secured to the patient’s abdomen by a dressing or tape fixing.

When this is the case, the carer must ensure that the patient’s skin is not sore or dirty

underneath this. Before removing the tape fixing, the carer should note the number on the

outside of the tube – this will be indicated in millimetres or centimetres. The skin underneath

the tape fixation can be examined, cleaned and dried if appropriate The measurement should

be the same when the tube is reattached to the tape fixation device..

27 P.E.G. or percutaneous endoscopic gastrostomy is sometimes referred to simply as a “gastronomy”.

53

When checking the insertion site, the carer should gently rotate the P.E.G. tube through a full

turn (360°). This can help to prevent the tube becoming stuck to the stoma track inside the

patient.

In some cases the tube exit area may have been sutured. If sutures are present, the carer

must check that they are secure and report immediately if they seem to be insecure, are

moist, look red or infected

The carer should not cover the P.E.G. insertion site with a dressing unless it is leaking

because leaving it uncovered promotes healing and prevents infection.

The carer should not use talcum powder or skin creams around the tube insertion site.

5.2.7 Feeding using enteral or P.E.G. tubes

Whichever tube is used, the feed is delivered using a slow feeding pump that delivers a

specific amount every hour. The amount delivered can be adjusted to suit the patient’s needs.

The feed can be delivered continuously, intermittently or in specific volumes over a set

timespan.

Continuous feeding has the advantage of maintaining a constant blood glucose level in the

patient. This is generally well tolerated by the patient’s body but it can restrict patient

movement because they are attached to the machine most of the day.

Intermittent feeding can be delivered by gravity (a large syringe is attached to the end of the

feeding tube, filled with the liquid feed and elevated to allow the liquid feed to drain by gravity

down the tube into the patient) or by using a feed pump. This intermittent approach generally

has the advantage that the patient can choose when to be fed, so have the opportunity to get

out of bed and do other things. Each pumped feed may be delivered over an hour or two but,

because the feed is not continuous, a larger volume must be delivered in a shorter time. If the

patient feels too full or uncomfortable the feed must be stopped. If they allow their stomach to

become too full, they may vomit. Whether the feed is stopped or ejected, the patient is not

getting the required sustenance and this must be recorded and corrected.

Giving a specific volume of food in a limited time is known as “Bolus” feeding. While this has

similarities to eating at mealtimes, it can be very intensive and because of the ‘richness’ of the

food it can result in poor digestion and absorption of nutrients.

The content of the patient’s feed will be prescribed by a dietician who must take note of any

religious or cultural requirements and preferences. The content should be discussed and

agreed with the patient or their legal representative whenever possible. When discussion is

not possible, the dietician must consult the patient’s notes to ensure that any religious or

cultural requirements are accommodated.

All feeding equipment should be sterile when starting a feed. The carer should remember,

that the care environment is generally warm and the feeds are full of nutrition, so providing an

ideal environment for infective agents to flourish if they can gain access. It is up to the carer

to ensure that they do not.

The carer should wash their hands thoroughly in liquid soap and under hot running water

before setting up the feed.

54

After a feed, the tube should be flushed with water to prevent any food residue blocking the

tube.

After use, the feed pump should be wiped with an appropriate disinfectant wipe28, never

immersed in water.

5.2.8 Other enteral feeding notes

The carer should reduce the risk of aspiration of the feed into the lungs by ensuring that the

patient is at a 45° angle (or more) throughout the feed whenever possible.

If nausea or vomiting occur at any time , this must be recorded in the patient’s record and the

dietician informed. Sometimes reducing the duration of delivery may reduce nausea.

Feeds can give patients loose stools or diarrhoea. This can be reduced by delivering the feed

to the stomach at a slower rate. All enteral and PEG feeding is prescribed and therefore must

be delivered as prescribed by the dietician.

When a patient receiving enteral or PEG feeding becomes constipated, the carer should

examine the amount of water that has been delivered via the tube. Water is usually

prescribed as part of their nutritional regime and should be sufficient to reduce the risk of

constipation. Again, this should be reported to the dietician who may prescribe an apperient

such as senokot liquid which can be delivered via the feeding tube. When a feeding tube

becomes blocked, this is always caused by the carer having failed to flush the feeding tube

adequately following the feed. Whenever a feed is completed, the tube should always be

flushed with water to prevent it blocking. When a tube is blocked, flushing with warm water

can sometimes push through the blockage, but it should never be forced through the tube

because that could make the tube burst.

Patients receiving enteral feeding of any type have a significant risk of developing a sore or

dry mouth – but generally this will only happen when the carers have not ensured adequate

and thorough oral care.

5.3 Managing toileting - elimination

This most basic animal requirement frequently causes the most distress to patients and / or

their relatives. Many patients feel embarrassment and a loss of dignity because their toileting

needs are suddenly the concern of others. The carer should anticipate this and do all that

they can to help the patient conserve their self-respect, dignity and pride. This involves

anticipating and respecting the patient’s needs.

A previously healthy person may have never discussed their toileting habits in their entire life,

considering it indelicate, personal and ultimately private.

Another patient may have managed to be independent in their own home where they were

close to a familiar toilet that they could access using various pieces of furniture as hand holds

to negotiate their way there and back. In a hospital or other institution they will suddenly be in

unfamiliar surroundings. The toilet may be far away and will almost certainly be functionally

impersonal. They can no longer get to the toilet and can feel totally dependent on others.

28 The type of wipe will often vary. When no wipes are available, a clean cloth soaked in a mild soap and water solution will

generally be sufficient.

55

Loss of one’s independence, dignity and familiar surroundings at the same time as having a

medical condition is not easy for them. The carer should anticipate this and do all they can to

make toileting an issue of little concern. This does not necessarily mean using commodes or

bedpans. These are often for the carer’s convenience, not that of the patient. A sick patient

may appreciate no longer having to negotiate their way to the toilet but as they get stronger,

walking to the toilet can be a vital part of their rehabilitation, so the carer should assist with

that. .

Many elderly patients may be prescribed diuretic tablets that make them increase their urine

output. If patients are receiving these diuretics intravenously (via a drip into a vein) these

drugs will work fast. The carer should presume that the patient will need frequent and

URGENT bedpans or commodes, without which the patient may have an “accident”. The

“accident” may not be of great significance to a carer who was slow to respond but it can be

devastating to the patient who is suddenly labelled “incontinent” for the first time in their lives.

Carers should predict and respond to toileting needs efficiently and never show irritation or

judgment following “accidents”.

Many elderly patients have a history of urgency or stress incontinence, a condition that often

affects women after the birth of their children. When a carer finds that a patient has a long

history of this they should consider (with the patient’s consent) asking for the patient to be

referred to the specialist nurse, via the G.P. or hospital. There are specialist nurses working

with continence problems and they can sometimes help.

Similarly, many elderly (and some younger) men suffer prostatic (prostate gland) problems

resulting in frequent and urgent needs to urinate and / or poor urinary output. These men may

lose their toileting independence if their bed is a long way from a toilet. The fact that men can

use a bottle urinal often reduces this problem but the bottle urinals may introduce other

problems. They are often stacked up on the locker or bed-table – a practice that is neither

aesthetically pleasing nor hygienic. The carer should imagine how they would feel if a

neighbour visited them at home and there was a bedpan full of urine on the floor or table

beside them. Leaving these toileting essentials on public display is potentially embarrassing

to the patient and / or their visitors – so their carers should avoid that. And it is also

unhygienic.

Most patients cope very well, especially when they have considerate and respectful carers.

Carers should consider the following problems and minimise them whenever possible:

1. The patient’s position in relation to the toilet can have a significant impact on whether they

remain independent, and so may affect whether they are ever able to go home. The beds

of those with a predictably frequent need should be positioned conveniently for the toilet.

When that is not possible, the need for a bedpan, bottle urinal or commode should be

presumed and offered.

2. Calls for toileting assistance should always be answered promptly.

3. Communication about toileting should be especially discreet. The patient’s dignity and

privacy are rights that the carer must respect.

4. The gender of the carer may influence the patient’s acceptance of the carer’s involvement

in facilitating their toileting requirements. This is not silly. It may be “coy”, but that is the

56

patient’s right. Whenever possible the carer should facilitate it. When a patient insists, the

carer must respect their needs.

5. The drugs that the patient is taking may make them need frequent bedpans, bottle

urinals, commodes or visits to the toilet. This should be predicted and provision made to

meet their needs.

6. The patient may be terrified of being in hospital and “doing things wrong” so they just do

as they are told, even though that leaves them humbled and embarrassed. The carer

should not take advantage of their compliance but should try to find out what they need

and deliver it whenever possible.

All of this must be considered for every patient. Those who have urinary or bowel problems

may have more intense needs for toileting assistance and this should be predicted and

catered for by their carers.

Urinary Tract Infections (U.T.I.) do not always cause a temperature (pyrexia) in patients in the

way that many infections do29. However even mild U.T.I. frequently makes it painful to pass

urine (a condition known as dysuria) and makes the patient want to pass urine frequently.

The urine may smell unpleasant and the elderly patient may display signs of confusion. The

carer should always consider the possibility that the patient has a U.T.I. if the patient has

become confused. Check for the symptoms mentioned, document the problem and ensure

that the relevant senior staff respond appropriately.

5.3.1 Screening urine samples

In many medical institutions, every new patient will have their urine routinely screened using a

“reagent strip”. This is a quick and simple test that can identify problems, but it is not infallible.

It is a simple health screening tool that may reveal early indicators of disease that have not

yet caused symptoms in the patient.

Before testing a patient’s urine, the carer should gather together PPE30

, a clean bedpan or

bottle urinal to collect the urine, urine testing reagent strips and a way to time the passage of

60 seconds. The carer will also need the relevant documentation to record the results.

To conduct the test:

1. To get the sample to test, the carer should ask the patient to pass urine into a clean

bedpan or bottle urinal and explain why it is needed.

2. The urine sample should be observed, as well as tested. If the urine looks very dark,

cloudy or contains blood or other defects, this must be recorded.

3. Wearing appropriate PPE, the carer should remove a urine testing strip from the tub.

One end of the reagent strip will have several small faintly coloured squares on it.

This end should be dipped into the urine sample for a second, just time for the urine

to come into contact with the reagent strip.

4. Excess urine should be removed by tapping the urine testing strip against the side of

the receptacle.

29 The failure to show the symptoms of UTI is not uncommon among elderly patients.30 PPE - Personal Protective Equipment, depending upon the infection and risk, this might include gloves, apron,

facemask, overshoes, gown, goggles, etc.

57

5. The carer should wait for 60 seconds, then hold the reagent strip parallel to the

reagent strip tub and compare the colour of the urine testing strip against the scale on

the side of the tub.

6. The carer should dispose of the strip appropriately, remove their PPE and wash their

hands with soap and hot running water before documenting the result. When the

carer suspects that something abnormal has been detected, they must report the

matter to the responsible Registered Nurse or doctor and document this without

delay.

It is worth noting that some drugs affect urine test readings, giving false positive or negative

results. Examples include Vitamin C, L-dopa, Naladixic Acid, and Aspirin.

This test can provide a significant clue that a patient has a U.T.I. because bacteria are made

of protein. If there are bacteria in the urine, the reagent strip will indicate an abnormal protein

level. Protein can be present for many other reasons other than a UTI but it is a possible

indicator of a UTI.

Sometimes other urine samples are required. These are often sent to a pathology department

for further scrutiny. The pathology department reports the result of the tests to the relevant

doctor and the doctor arranges appropriate treatment or further investigations as required.

Commonly, the pathology department will ask for a Mid-Stream-Urine (MSU) specimen.

5.3.2 MSU – mid stream urine specimen

Ideally, this will be taken from the first urine passed by a patient in a day.

To collect this specimen, the carer will need a sterile urine collection kit often known as a

MSU kit. These kits may include a wipe for the patient to clean their genitalia before starting

to pass urine. Some institutions do not use the wipe, preferring the patient to use soap and

water instead. The carer will also need gloves and an apron to wear when transferring the

collected specimen and the Pathology department’s documentation.

The carer will also need a compliant, orientated and independent patient who understands

what is needed and has agreed to give the sample.

Collecting the sample

1. The patient is asked to clean their external genitalia with soap and water, washing all

soap away.

2. The patient should then pass the first part of their urine into the toilet (or bedpan or

urinal), the next part directly into the sterile cup supplied with the MSU kit, and the final

part into the toilet or receptacle. Urination should be continuous, without stopping and

starting, so the cup must be passed in and out of the stream of urine. In this way, the mid

(middle) of the stream of urine has been collected – giving a “mid stream” urine specimen.

3. The patient passes the sample cup to the carer who pours the urine from the cup into the

sterile specimen pot and seals it.

4. The patient washes their hands thoroughly.

58

After transferring the specimen and sealing the sterile specimen pot, the carer should remove

their PPE and wash their hands before ensuring that the pathology department’s

documentation is complete before sending the specimen to them.

5.3.3 CSU specimens

The CSU acronym may be used to describe two types of specimen, Clean Specimen of Urine

and Catheter Specimen Urine (from which the acronym is derived).

Type 1 CSU collection – Clean Specimen of Urine

When a patient is unable to provide a mid-stream specimen of urine but can still use a

bedpan or a bottle urinal, a “clean catch” specimen can be obtained. As with an MSU

specimen, the specimen is ideally collected first thing in the morning.

To collect this specimen, the carer will need a sterile urine specimen pot, gloves and an apron

for use when transferring the collected sample into the specimen pot. They will also need a

clean bedpan or bottle urinal and the relevant Pathology department’s documentation.

The bedpan or bottle urinal should have been recently cleaned – it should not be one that has

been on the shelf for hours.

Collecting the sample

1. The patient is asked to clean their external genitalia (assisted as necessary) with

soap and water, washing all soap away.

2. The patient is given a clean bedpan / bottle urinal and asked to pass urine into it.

3. Taking care to avoid spillage, the carer pours a sample of the urine they have passed

into a sterile specimen container.

After transferring the specimen into the sterile pot the carer should remove their PPE and

wash their hands and ensure the relevant pathology department’s documentation is complete

before sending the specimen to them. The specimen should not be allowed to sit at room

temperature for any significant time because it may grow bacteria that were present in the

non sterile bedpan or bottle urinal and so give a misleading positive results.

CSU – type 2 collection – Catheter Specimen Urine

As the name suggests, this specimen is collected from the patient’s catheter bag. Specimens

should be taken from the first urine captured following catheterisation and when there is a

suspicion that the patient may have a U.T.I.

To collect this specimen, the carer will need:

1. PPE – gloves and an appropriate plastic apron.

2. A sterile urine specimen pot.

3. An alcohol swab.

4. A sterile 10ml syringe.

5. The relevant Pathology department’s documentation,completed before taking the

sample.

59

Urinary catheters have a urine collection port built in. They might be a small coloured area or

a special port on the side of them. Because urinary catheters are designed to continually let

urine drain from the bladder into the urine drainage bag there is no accumulation of urine

anywhere except in the urine drainage bag. It is NEVER acceptable to collect a urine

specimen from a urine drainage bag. In order to encourage an accumulation of urine in the

catheter itself. it is necessary to apply a clean clamp to the outside of the urinary catheter, just

below the urine specimen collecting point, between this and the urine collecting bag.

Collecting a CSU specimen is a “no touch” process that is conducted as follows:

1. A clean clamp is attached to the catheter as described above.

2. When urine has accumulated, the collection port on the catheter bag should be cleaned

with an alcohol swab and allowed to dry. This is important because failure to let the area

dry means that any bacteria on the port may be introduced into the catheter (and the

patient) when the syringe is attached to the port.

3. Open the sterile syringe and push the syringe nozzle directly into the collection port of the

catheter.

4. Slowly withdraw the plunger of the syringe. Urine should be seen entering the syringe.

5. When at least two millilitres of urine have been collected, remove the syringe from the

catheter bag collection port and rub the collection port with the alcohol swab again.

6. Ensuring that the specimen bottle lid is removed and facing upwards (so that it does not

come in contact with any surfaces) gently squirt the urine into the sterile specimen pot.

After transferring the specimen, the carer should remove their PPE and wash their hands

before ensuring that the completed pathology department’s documentation is sent with the

specimen to them.

5.3.4 Urinary incontinence

Urinary incontinence is the involuntary passage of urine. This might involve passing a small

amount of urine “by accident” or the involuntary emptying of a full bladder – sometimes into a bed

that the patient is lying in or onto a chair where they are sitting. Whatever the amount, this has two

effects upon the patient – embarrassment and of them lying or sitting in urine.

Specific diseases or medications can increase the risk of this happening, to both men and women.

The carer should respond promptly to help the patient out of their wet clothes / bedclothes, to

ensure that the urine is washed off their skin and that clean dry linen is provided.

If further incontinence is anticipated it would be appropriate to apply a barrier cream to the

affected area – to prevent what is effectively a “nappy rash” developing. It may be appropriate for

the patient to wear a pad to absorb the urine. There are many pads on the market, and, depending

on the volume of urine involved, they can be very discreetly worn.

The practice of putting incontinent patients into large nappies or placing large incontinence pads

under the patient’s bottom is unacceptable and degrading. Any incontinence device applied should

be discreet and regularly changed with full skin care provided as necessary.

Discretion is the appropriate word to describe how all incontinence should be dealt with.

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Carers should avoid making comments like “it’s not a problem” and “don’t worry, I’m used to

it”. However well meant, this kind of statement can be interpreted as being patronising. The

carer might be accustomed to it, but the carer is not the priority in this equation of care. The

patient is.

Carers sometimes elect to catheterise (Section 5.3.5) an incontinent patient and this is often

an appropriate action. Catheterisation immediately reduces the risk of skin soreness caused

by urine burning the epidermis of the skin. It can provide a discreet solution for the patient

and dramatically increase their quality of life and independence. Catheterisation certainly has

advantages. but is not without risk. If the incontinence is a short term problem the

disadvantages (such as serious infection, loss of bladder tone, etc.) may outweigh the

advantages.

Urinary catheterisation should never be undertaken for the carer’s benefit only – it is not a

convenience tool designed to prevent staff having to deal with wet beds.

5.3.5 What is a urinary catheter and why are they used?

Sometimes patients have health problems that mean they can achieve better independence

and quality of life by having a sterile tube inserted into their bladder to drain the urine away.

This is known as a urinary catheter.

Occasionally a urinary catheter is inserted, the bladder drained and the urinary catheter then

removed completely. This is known as intermittent catheterisation.

There are two main types of Urinary Catheter, the “urethral” and the “supra pubic” catheter.

Both are sterile tubes designed to transmit urine from the patient’s bladder to a sterile urine

collection bag (often called a “Catheter bag”) outside of the patient. When a patient has a

urinary catheter inserted that is expected to be retained for several weeks or months, a

special design of long-term catheter should be used.

As the names imply, the “urethral” catheter tube is passed into the patient’s urethra and so

upwards into their bladder. The “supra pubic” catheter tube is inserted through the patient’s

abdominal wall, just above their pubic bone straight into the bladder. Both have a tip with

small holes in it that allow the urine to drain. Both have small balloon inflated after they have

been properly inserted. This balloon prevents the catheter “falling out”. The inflated balloon

usually lies at the trigone (bottom of the bladder). It is pressure on this area of the non

catheterised bladder that makes us feel we need to pass urine. A patient with the catheter

balloon pressing on this area of the bladder can make them feel that they need to pass urine

urgently, and this frequently occurs with recently catheterised patients. This is unpleasant but

usually resolves over a few hours as the body becomes accustomed to the presence of what

is a “foreign body”.

Sometimes, especially when a patient is not drinking much fluid, urine can deposit crystals on

the catheter tip (inside the bladder) resulting in a blockage that prevents drainage into the

catheter bag and makes the patient experience significant pain and discomfort.

Every type of urinary catheterisation carries a significant infection risk for the patient. If either

the urinary catheter or any of the equipment used to catheterise the patient is not sterile,

infection can easily track inside the patient and can ultimately be fatal. .

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Both urinary catheter insertion and the removal can be very distressing for patients – as can

the very fact that they have a catheter. Their embarrassment and potential loss of dignity are

very real. Both can be minimised by the way that the carer undertakes the maintenance of the

catheter and catheter bag.

Every patient who has a urinary catheter should be encouraged to drink plenty of fluids – this

reduces both the risk of infection and of crystal formation at the catheter tip.

The carers should avoiding taking unnecessary urine specimens because each access to the

catheter port to collect a specimen increases the risk of infection.

5.3.6 Care of the urinary catheter and catheter bag

The urinary catheter is usually attached to a catheter bag that will need to be emptied on a

regular basis. The emptying regime will vary according to the patient’s condition and intake of

fluids. Patients receiving intravenous fluids may need larger catheter bags than others.

Whatever the size of bag, if any catheter bag is allowed to fill completely the weight of urine it

contains can tug on the bladder causing pain and may even cause long term damage. A full

catheter bag is also more bulky and more visible, adding an unnecessary potential for patient

distress. Carers must ensure that catheter bags are never left un-emptied for so long that

they become full.

Some patients will require catheterisation after surgery and their treatment may include the

infusion of fluids intravenously. When this occurs, it can be necessary to accurately identify

their urine output on a regular basis because their subsequent treatment will be influenced by

their urine output.

When a urinary catheter is to be maintained for several days or weeks there is not usually a

need for the patient to be given intravenous fluids. Without intravenous input, the amount of

urine the patient produces will be much less and smaller catheter bags (known as “day” or

“leg” bags) can be used during the day. These smaller bags have straps that are used to

secure the catheter to the patient’s leg which often allows them to be concealed under the

patient’s clothing and so be more discreet.

To reduce the risk of infection, the patient will need information and encouragement to care

for their catheter. When a patient cannot provide this care, the carer must do it for the patient.

Catheter care involves:

Washing the urethral meatus (where the catheter exits the body) at least once a day and

more frequently if needed, for example if the patient is faecally incontinent. The urinary

catheter tube should be routinely cleaned as part of each episode of relevant personal

care. Using a gloved hand and a warm soapy piece of gauze, the carer should wipe the

tube in an action moving away from the patient and towards the urinary catheter bag.

Ensuring that the patient drinks fluids frequently – to dictate a specific amount here would

be dangerous because many elderly patients have concurrent health problems (for

example heart failure) that could be made much worse by the patient drinking too much

fluid.

Every urinary catheter bag should be hung in a way that ensures drainage by gravity. It

should be hung either from the bed frame, on a special stand or on the patient’s leg. A

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catheter bag must never be placed on the bed surface beside the patient. Wherever the

urinary catheter bag is hung, it must never be allowed to touch the floor.

Emptying the catheter bag at least twice daily and every time that the catheter bag is

approximately half full. This reduces the risk of the weight of urine pulling on the neck of

the patient’s bladder.

5.3.7 Emptying / changing the urinary catheter bag

Every time that a urinary catheter bag is emptied, the closed urine drainage circuit is broken

and there is a risk of infection being introduced. An infection can track into the patient causing

a urinary tract infection, renal damage or even septicaemia which can be fatal. This means

that emptying a catheter bag requires care and the application of infection control procedures.

The carer should gather together the following in preparation for emptying a urinary catheter

bag:

PPE – usually gloves and a plastic apron – there may be a specific colour of apron

required locally

A clean jug or other receptacle to empty the urine into.

Cover for the urine collection receptacle,

Either an alcohol swab to clean the ‘tap’ on the urinary catheter drainage bag or a

new sterile urinary catheter bag.

Screens or curtains or other means to ensure patient privacy.

Relevant documentation to record the event.

The carer should follow this process:

1. The carer must ask the patient’s permission to empty the bag discreetly – this has

nothing to do with anyone else. If the patient is unconscious or unresponsive, the

carer must still explain what they are going to do.

2. The carer should wash their hands thoroughly, reducing the risk of introducing

infection, then apply non sterile gloves and an appropriately coloured plastic apron.

3. If the urinary catheter bag has a drainage tap at its base, wipe the tap with an alcohol

wipe and allow it to dry. The drying destroys bacteria. If the catheter bag cannot be

drained or is to be replaced, the old urine collection bag will need to be detached.

Before detaching the old bag ensure the new bag is opened and the attachment to be

inserted into the catheter has had the cap removed but that it is still sterile. Detach the

bag and place it into the collection receptacle while simultaneously attaching the

sterile urine collection bag. When the catheter bag can be drained rather than

changed, hold the clean urine collection receptacle underneath the bag without letting

the drainage tap touch the receptacle. Wipe the drainage tap with an alcohol swab,

allow it to dry before sliding the tap open.

4. Slide or twist open the tap and allow the urine to flow into the receptacle.

5. When the bag is empty, close the tap, then wipe the tap again with an alcohol swab.

6. Ensure that the urinary drainage bag is appropriately positioned to ensure drainage

and that the patient is comfortable.

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7. Measure the volume of urine being taken away, then cover the receptacle and take it

to empty in the appropriate area.

After cleaning or disposing of the urine, bag and collection receptacle in appropriate places,

the carer should remove their PPE and wash their hands before completing the

documentation required.

The carer should change all urinary catheter bags (with emptying taps) after they have been

used for seven days (or earlier) and record the fact that the bag has been changed both on

the bag and in the patient’s care record. The bag should also be changed if it has been

compromised – for example, if the drainage tap has been resting on the floor.

If a patient has a leg bag, when possible the carer should attach a secondary urinary

drainage bag to the end of the leg bag for over-night use. When this is done, there is no need

to disconnect the leg bag from the catheter overnight.

5.3.8 Urinary catheter removal

To avoid risk of infection, the removal of urinary catheters must be conducted using an

aseptic or “no touch” technique.

Before removing a urinary catheter, the carer will need to collect together the necessary PPE,

(usually gloves and an appropriate plastic apron), a receptacle in which to place the catheter

and urinary catheter bag and a sterile 10ml syringe, still in its sterile packaging.

The carer should follow this process:

1. The carer must ask the patient’s permission to remove the catheter discreetly – this

has nothing to do with anyone else. If the patient is unconscious or unresponsive, the

carer must still explain discreetly what they are going to do..

2. The carer should wash their hands thoroughly, reducing the risk of introducing

infection, then apply non sterile gloves and an appropriately coloured plastic apron.

3. Then place the clean receptacle for the urine bag and catheter in an easily accessible

position.

4. The patient should ideally be lying on a bed.

5. Taking care not to touch the syringe nozzle, the carer should open its packaging and

apply it directly to the inflation point of the urinary catheter. Then let the plunger of the

syringe move back by itself so that it fills with fluid – this is the sterile water that was

inflating the balloon inside the patient’s bladder. It is vital to ensure that no more fluid

can be withdrawn. Leave the syringe attached to the inflation point. Never try to

withdraw the sterile water by pulling the plunger back, let this happen by itself. If the

carer actively withdraws the plunger of the syringe it causes wrinking of the deflated

catheter balloon and possible damage to the patient as the catheter is being gently

removed.

6. When a patient is responsive, ask the patient to take a deep breath. As they do so,

gently withdraw the whole catheter. The deep breath does not assist in extracting the

urinary catheter, it is an effective distraction technique. NEVER tug the catheter out. If

it does not slide out, it is likely that some fluid is left in the balloon inside the patient.

The carer should try to withdraw more fluid. (If the syringe had been removed from

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the inflation point it would no longer be sterile.) If the catheter still will not slide out, the

carer must refer the problem to a Registered Nurse Practitioner or doctor

immediately.

7. After the catheter has been fully removed, place it into the receptacle brought for it.

8. Ensure that the patient is comfortable – in whatever position they wish

9. Take the receptacle with the catheter and catheter bag to the sluice / bathroom as

appropriate.

10. Examine the catheter – visually inspect it to ensure it is all there. After this has been

confirmed it can be disposed of.

11. If there is any suspicion that part of the catheter has broken off and been retained

inside the patient, the carer must inform either the Registered Nurse Practitioner or

doctor urgently (retaining the catheter to show them).

After cleaning or disposing of the catheter and collection receptacle in appropriate places, the

carer should remove their PPE and wash their hands before recording the removal in the

patient’s notes. If the patient’s records require information about the volume of urine being

excreted the carer must record the volume of fluid in the urinary drainage bag.

After a urinary catheter has been removed, the patient’s bladder may take a few days to

develop its tone again. It is vital that the carer record if and when the patient passes urine

following a urinary catheter removal. This is because sometimes the patient’s bladder no

longer feels full when it is full of urine, and they cannot pass urine when they try to. This is

known as urinary retention. Conversely sometimes the patient feels they need to pass urine

urgently when they only have a small amount of urine in the bladder, almost as though their

bladder had “shrunk”.

Any problems must of course, must be recorded in the patient’s notes and reported to the

Registered Nurse Practitioner or doctor as appropriate.

5.4 Bowel care

Having bowels open is a basic bodily function, but one that can cause the patient immense

distress if they are constipated or too embarrassed to “go”’.

There is no ”normal” frequency of bowel movements – each individual is different. The carer

should aim to maintain what is both normal and comfortable for the patient.

There are two main deviations from normal with regarding to bowel actions, diarrhoea and

constipation. Either condition can be a symptom of disease or caused by poor fluid or

nutritional intake, lack of activity, infection or a side effect of drugs delivered to treat pre-

existing conditions.

Diarrhoea can occur either due to infection within the gut, as a side effect of medication or

(surprisingly) as a result of constipation when the constipated faecal plug blocks the bowel

(causing constipation) but the liquid faecal content drains around it.

The patient with diarrhoea may feel weak, nauseated, unwilling to do much and totally

humiliated if incontinent.

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Appropriate treatment will depend on the symptoms – and may involve the carer having to

collect a stool in a stool specimen pot. Sometimes specimens are required from more than

one sample. When it is necessary to look for occult (hidden) blood, for example, three

samples from three separate bowel movements must be collected on individual cards.

Diarrhoea samples are often sent for culture (growing) in a Pathology department. This can

help to identify the nature of any infection. Many infections resolve themselves but some

require specific medication.

Constipation occurs when there is delayed movement of intestinal content through the bowel

but what constitutes “delay” is patient specific. Some patients may not defecate for three days

but pass motions without pain at regular three day intervals. Others who miss a day may be in

discomfort.

The patient with constipation might feel distended, bloated, unwell, weak, lethargic, have a

headache, not like moving and prefer not to drink. They might well be confused if at the same

time as feeling constipated they have any diarrhoeal symptoms. Failure to move and drink

can aggravate their constipation so the carer should encourage both whenever possible.

Constipation requires clearing the faecal blockage and then preventing its recurrence by the

use of stool softeners, stimulant laxatives or osmotic agents.

The use of suppositories or enemas as a means of clearing a blockage in the bowel is

common. Provided that there is no ileus (where the bowel stops moving as it digests food),

gynaecological or colonic obstruction, the use of suppositories or enemas should not cause a

physical problem. Sometimes the blockage can be so hard or bulky that it could tear the

anus, causing bleeding and pain, so the rectum should be prepared with adequate lubricant

gel.

5.4.1 Risks associated with faecal incontinence

The patient with diarrhoea will be losing fluid and so at risk of becoming dehydrated.

The faecally incontinent patient is at significant risk of developing excoriation, (soreness). If

faeces is not immediately removed from the peri-anal area, the bacteria within the faeces can

either track inside the urethra causing a urinary tract infection, or mix with any urine in the

same area and break down the outer protective area of the skin, causing soreness. The

stronger the patient’s urine the greater the risk. The mixing of both faeces and urine together

significantly increases this risk.

When the outer layer of skin has broken and become sore, the patient is at increased risk of

developing pressure sores (sometimes known as pressure ulcers).

Incontinence sheets were used but they had a tendency to break up or become packed into

lumps that actually caused areas of pressure. This is why they are no longer routinely used.

Clean, wrinkle free, cotton sheets do not have this problem.

A main risk is to the patient’s self image and morale (dignity). When a patient is incontinent,

the use of large, bulky highly visible nappies must be avoided. If incontinence pads or

nappies must be used, they must be of minimal bulk and should be discreet enough to allow

the patient to receive visitors without embarrassment.

There is never an alternative to the patient having access to toileting facilities.

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5.4.2 Administering an enema or suppository

The administration of enemas or suppositories to remove a constipation blockage has the

potential for the patient to feel humiliated and embarrassed. The process itself may be

distressing and the aftermath must be managed to minimise distress to the patient.

When caring for a patient who has received either an enema or suppositories, the carer must

ensure that the patient has privacy, call bell, access to a toilet, commode or bedpan, and

should be on hand if the patient needs help. When a patient has not had this treatment

before, the carer may need to be particularly supportive.

5.4.3 Administering suppositories

The basic equipment required when administering suppositories is:

PPE – usually non sterile gloves and an appropriate plastic apron.

The prescribed suppositories.

A small amount of lubricant gel on a gauze (examples KY jelly or aqualgel) or when

glycerine suppositories are to be used, a small bowl of warm water to place them into.

Sheet or towel to place under the patient’s buttocks.

Immediate patient access to a toilet, commode or bedpan and toilet paper.

Immediate patient access to a call bell to summon assistance.

Hand-washing facilities for the patient.

To administer suppositories, the carer should put on their PPE and follow this process:

1. Prepare your equipment required and ensure that the patient has privacy.

2. Discreetly explain to the patient what is necessary and why, asking for their

agreement. If the patient is unconscious or unresponsive, the carer should still explain

what is happening, and why.

3. Ask the patient to lie on their left side and help them to achieve this when necessary.

Position the patient so that their buttocks are facing the side of the bed

4. Lower the patient’s underclothes (or remove them as the patient prefers), then place a

towel or special sheet under their buttocks.

5. Keep all parts of the patient’s body that do not require immediate access covered up.

6. Apply gloves.

7. Prepare each suppository, lubricating it with gel or softening it in warm water.

8. Using a gloved index finger gently insert each suppository into the rectum as far as

possible.

9. When the suppositories are in place, the carer should remove their gloves and

dispose of them appropriately before helping the patient to get into a more

comfortable position.

10. Ensure that the patient has immediate access to toilet or commode and to their call

bell. The carer should ask to be told when they have finished or are ready to wash

their hands.

11. Generally, the longer the suppositories can be retained, the more effective they are.

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After leaving the patient, the carer must ensure that all the equipment used has been

cleaned, dried and disposed of, as appropriate .

5.4.4 Administering an enema

The basic equipment required when administering an enema is:

PPE – usually non sterile gloves and an appropriate plastic apron.

A small amount of lubricant gel on a gauze (examples KY jelly or aqualgel).

The prescribed enema which may be a small “micro” enema or larger sachet.

If the enema is an “oil” type, a small bowl of warm water in which to place the oil

enema before insertion is required.

Sheet or towel to place under the patient’s buttocks.

Immediate patient access to a toilet, commode or bedpan and toilet paper.

Immediate patient access to a call bell to summon assistance.

Hand-washing facilities for the patient.

To administer an enema, the carer should put on their PPE and follow this process:

1. Prepare the equipment required and ensure that the patient has privacy.

2. Discreetly explain to the patient what is necessary and why, asking for their

agreement. If the patient is unconscious or unresponsive, the carer should still

explain what is happening, and why.

3. Ask the patient to lie on their left side (helping them to achieve this when

necessary. Position the patient so that their buttocks are facing the side of the

bed.

4. Lower the patient’s underclothes (or remove them as the patient prefers), then

place a towel or special sheet under their buttocks.

5. Keep all parts of the patient’s body that do not require immediate access covered

up.

6. Apply gloves.

7. Ensure that the nozzle of the enema has been opened and has been well

lubricated with gel.

8. Using a gloved index finger gently insert the nozzle into the rectum as far as

possible, then squeeze the enema until it is empty.

9. When the patient is responsive, ask the patient to clench their buttocks as the

enema nozzle is removed. This can help reduce the risk of enema fluid following

the nozzle out of the patient.

10. After the enema has been administered and the empty container removed from

the patient’s buttocks the carer should remove their gloves and dispose of them

appropriately before helping the patient to get into a more comfortable position.

11. Ensure that the patient has immediate access to toilet or commode and to their

call bell. The carer should ask to be told when they have finished or are ready to

wash their hands.

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Both suppositories and enema are most effective when they are retained for as long as

possible before the patient goes to the toilet. In practice this is very difficult and often worries

the patient who is concerned that they may be incontinent.

5.4.5 Colostomy / ileostomy

Sometimes when a patient has a diseased or injured bowel or section of their gut it no longer

functions properly. This can mean that the affected section of the bowel or gut has to be

removed or provided with a period of “rest”. A colostomy / ileostomy allows this and may have

been undertaken as part of a planned procedure or as an emergency operation. It involves a

surgeon forming an artificial opening by making a piece of bowel open directly out of the

patient’s abdomen. The surgeon might then remove the diseased portion of bowel and

sometimes after a period of allowing the gut to “rest” the operation is later reversed. This

artificial opening from the bowel to the patient’s abdomen is known as a stoma. The stoma

allows the expulsion of the contents of the colon or small intestine into a special type of bag.

Depending on what part of the bowel has been accessed, the procedure is known as either a

colostomy (when the colon was accessed) or an ileostomy (when the small bowel was

accessed).

The patient with a colostomy or ileostomy not only has to cope with a diagnosis that might

well distress, the presence of this colostomy or ileostomy bag will mean a serious lifestyle

change that will undoubtedly require significant carer support.

When they are first in place both colostomies and ileostomies frequently involve the

production of gas. This gas can dislodge the colostomy or ileostomy bags from the patient’s

abdomen with catastrophic effects. Thankfully this gas does reduce but initially the carer

should presume a problem and take a proactive approach to check for gas and avoid such

accidents.

The carer should empty the bag before it is full and always before meals. It should be

emptied into a toilet when possible. Always avoid adding to a patient’s discomfort or

embarrassment. If the smell is bad, consider placing an aromatic device in the room.

I cannot overemphasise the importance of the carer’s reaction to both the sight of the stoma

and the contents of the bag. A burst or dislodged bag can have a catastrophic effect on both

the patient’s morale and confidence.

5.4.6 Cleaning a colostomy or ileostomy bag

There are many types of colostomy and ileostomy bags. Some attach directly to the patient’s

skin around the stoma, other have a special flange attached to the skin around the stoma .

The flange is kept in place for as long as possible, the bag is attached onto the flange, and

changed as required.

Some types of colostomy bags have a clip at the bottom that allows the bag to be emptied

and re-clipped.

The basic equipment required for changing a colostomy / ileostomy bag is:

PPE – usually non sterile gloves and an appropriate plastic apron.

Bowl of warm water and gauze / cotton wool or non perfumed wet wipes.

Small clean hand towel, kept for this purpose.

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Clean replacement bag.

Plastic bag to hold used cotton wool etc., and the used stoma bag

To change a colostomy / ileostomy bag, the carer should gather the necessary equipment,

put on their PPE and follow this process:

1. Discreetly explain to the patient what is necessary and why, asking for their

agreement. If the patient is unconscious or unresponsive, the carer should still explain

what is happening, and why.

2. Undertake the change of bag in a toilet area when possible. Arrange the patient so

that they are comfortable while allowing access to the stoma area and bag.

3. Ensuring the patient’s privacy, expose the area where the bag is attached. When the

bag is attached directly to the skin it can be hard to release the sticky area wearing

gloves. If necessary, loosen the corners of the sticky area before applying gloves.

4. Peel off the plastic from the skin. This will remove the bag and contents at the same

time. Place the bag into a waste bag immediately. Close the waste bag to reduce the

release of unpleasant odour.

5. If the patient has a flange, remove the bag and contents from the flange and place the

bag into the waste bag immediately. Close the waste bag to reduce the release of

unpleasant odour.

6. Use warm water and cotton wool, gauze or non perfumed wet wipes to clean the area

around the stoma.

7. Dry the area using the towel retained for this purpose.

8. Apply a new adhesive bag or flange bag as appropriate.

9. Remove PPE (disposing of it appropriately) then provide any help necessary to make

the patient comfortable, ensuring that their bag is discreetly concealed.

After leaving the patient, the carer must ensure that all the equipment used has been

cleaned, dried and disposed of, as appropriate.

5.4.7 Emptying a “clipped” colostomy or ileostomy bag

When the patient has a “clipped” bag it is usually because they have had a colostomy for a

long time and it has become “predictable”. This sometimes means that it fills at predictable

times and often contains a well formed stool.

The basic equipment required for changing a colostomy / ileostomy bag is:

PPE – usually non sterile gloves and an appropriate plastic apron.

Unsterile jug of tepid tap water.

Tissue / gauze for wiping the outside of the bag.

A few drops of deodorizing fluid, as prescribed.

To empty a “clipped” colostomy or ileostomy bag, the carer should gather the necessary

equipment, and follow this process:

1. Discreetly explain to the patient what is necessary and why, asking for their

agreement. If the patient is unconscious or unresponsive, the carer should still

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explain what is happening, and why. When it is possible, the carer should

encourage the patient to move to the toilet area where it is easier to contain

unavoidable odour and so preserve the patient’s dignity and privacy.

2. When the patient is compliant and able, ask whether they want to empty the bag

themselves. If so, the carer should ask whether they should remain in case of

difficulty.

3. When a patient does not want to empty the bag themselves or wants the carer to

remain, the carer should put on their PPE.

4. To empty the bag, the clamp at the base of the bag is released and the bag is

emptied directly into the toilet (or a suitable receptacle).

5. The tepid water is poured into the bag, rinsing it, and the water emptied into the

toilet (or the suitable receptacle).

6. When the interior of the bag is clean, the outside is wiped with gauze / toilet roll /

tissue and the clamp replaced.

7. The carer should remove their PPE (disposing of it appropriately) then provide

any help necessary to make the patient comfortable, ensuring that their bag is

discreetly concealed.

8. When a patient has emptied their bag themselves, the carer must encourage the

patient to wash their hands with soap and water.

9. Before moving to the next patient, the carer must wash their own hands

thoroughly with soap and water.

After leaving the patient, the carer must ensure that all the equipment used has been

cleaned, dried and disposed of, as appropriate.

5.4.8 Problems with colostomies and ileostomies

Apart from the psychological / emotional problem of coping with a bag of faecal matter lying

on their stomach, the patient may also suffer uncontrollable wind evacuation that is

embarrassing and distressing. The fitting of a colostomy / ileostomy will often have coincided

with a serious diagnosis that the carer should expect to have been deeply unsettling, turning

the patient’s world “upside down”.

Associated physical problems include the fact that all new colostomies and ileostomies collect

very loose stools in the colostomy bag. The contents become firmer as the body adapts to its

presence. Any development of diarrhoea will require vigilance over the bag changing regime

and especially diligent skin care around the stoma.

When a patient with a colostomy or ileostomy becomes constipated, a suppository can be

administered via the stoma. Whenever possible, the carer should seek to prevent

constipation

The skin around the stoma is at risk of becoming sore or inflamed. Scrupulous cleaning and

drying reduces the risk but when soreness has been identified the carer must apply a barrier

cream (designed for the purpose) and / or change of type of colostomy / ileostomy bag.

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The barrier cream must have been designed for the job and not be greasy, because greasy

creams will stop the bag sticking. The correct barrier creams have a paste like consistency

and must be allowed to dry before the bag is attached. Specialised barrier creams should be

available via an appropriate Specialist Nurse, Registered Practitioner or G.P.

Everyone finds that some foods “disagree” with them, whether or not they have a colostomy

or ileostomy. When a patient reports a problems with specific foods or medication affecting

their digestion, the carer must record this and ensure that the problem is avoided whenever

possible.

5.4.9 Post-toileting needs

Whenever a patient has used a toilet, bedpan, commode or bottle urinal, the carer must

ensure that they are given the opportunity to clean their hands. Whenever possible, this

should involved washing with soap and water. When it involves using a handwipe, a disposal

bag must be easily accessible and emptied regularly.

Bedpans, commode liners and bottle urinals can be multi-use or disposable. Most are multi-

use and must be sterilised between uses. The receptacle should be emptied in the

appropriate place before being put through a sterilisation process.

In the patient’s own home, the toilet receptacle is usually emptied and rinsed in the toilet

bowl. A mild solution of bleach can be used to sterilise the item when required. This is

achieved by filling the receptacle with a mild bleach solution and leaving for 20 minutes or

longer, then empty down the toilet and rinse with clean water.

Within institutions, all surfaces of a commode should be wiped after each use with wipes,

taking the commode apart to do so. In patient’s homes, the commode surfaces should be

cleaned regularly with appropriate disinfecting wipes or warm soapy water, taking the

commode apart so that all surfaces are cleaned. Wherever the commode is, a more rigorous

cleaning regime should be followed when the user has a clostridium infection.

5.4.10 Pressure ulcers

A pressure ulcer is sometimes known as a “bed sore”. The definition of a pressure ulcer31 is

“an area of localised damage to the skin and underlying tissue caused by pressure or shear

and / or a combination of both”. It is an ulcer caused by an unrelieved pressure on an area of

the skin which restricts the blood supply. When blood flow is reduced, insufficient oxygen is

delivered to the tissue in the area and, as a result, some of that tissue dies – tissue necrosis.

The reduced blood supply also diminishes the removal of tissue “waste products” that a full

blood flow would carry away. As a result, the waste products accumulate to the level where

they become toxic to the living tissue and the epidermis of the skin in the area breaks down.

When that protective epidermal layer has been compromised, the underlying tissues become

very vulnerable to the further tissue necrosis that is known as “ulceration”.

Unless immediate action is taken to reduce the pressure, the ulcer will get deeper and deeper

until it reaches the bone.

31 NICE guidelines, Sept 2005.

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Pressure ulcers can also be caused by friction or shearing forces that damage the epidermal

layer of the skin. This may occur when a patient is moved using poor manual handling

techniques such as dragging.

Pressure ulcers form more readily in areas that have reduced subcutaneous tissue – areas

where the bone is near the surface such as elbows and heels. Patients who have little

adipose (fat) tissue over bony prominences or with an inefficient circulation of their blood are

also at increased risk of developing pressure ulcers.

Pressure ulcers are graded into four classifications of “stages”:

Grade 1: Non blanchable erythema (redness)

Grade 2: Partial thickness

Grade 3: Superficial ulcer

Grade 4: Deep ulcer.

Category 1, Stage 1: Non-blanchable erythema

This is characterised by an area of intact skin with non-blanchable32 redness in a localized

area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler

than adjacent tissue. Category 1 can be difficult to detect in individuals with dark skin tones

that do not show signs of visible blanching when healthy. In these instances, the colour of the

erythema may differ from the surrounding area. Those with darker skin may be classed as

being at greater risk of suffering a Stage 1 pressure ulcer than pale skinned individuals.

Category 2, Stage 2: Partial thickness

This is characterised by the thickness of the skin being reduced, presenting as a shallow

open ulcer with a red pink wound bed, without slough or bruising33. It may also present as an

intact or open/ruptured serum-filled blister. This category should not be used to describe skin

tears, tape burns, incontinence associated dermatitis or maceration .

Category 3, Stage 3: Full thickness skin loss

This is characterised a full thickness tissue loss. Subcutaneous fat may be visible but bone,

tendon or muscle is not exposed. Slough (darker tissue) may be present. It may include

undermining and tunnelling but bone or tendon is not visible or directly palpable (feelable).

The depth of a Category 3 pressure ulcer will vary according to its location. The bridge of the

nose, ear, occiput and malleolus do not have (adipose) tissue and Category 3 ulcers in these

areas can be shallow. In contrast, areas of significant adiposity (fat) can develop extremely

deep Category 3 pressure ulcers, which can be very painful.

Category 4, Stage 4: Full thickness tissue loss

This is characterised by full thickness tissue loss with exposed bone, tendon or muscle and

often includes undermining and tunnelling. Slough may be present. The depth of a Category

4 pressure ulcer will vary according to its anatomical location. The bridge of the nose, ear,

occiput (back of head) and malleolus (ankle) do not have adipose tissue and Category 4

32 Skin is “blanchable” when it temporarily turns a lighter colour after being pressed for a few seconds.33 Bruising would indicate a deep tissue injury.

Slough is made up of white blood cells, bacteria and debris, as well as dead tissue, and is easily confused with pus

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ulcers in these areas can be shallow. Category 4 ulcers can extend into muscle and/or

supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to

occur. Exposed bone/muscle is visible or directly palpable. This is a very painful ulcer and

often has a quite pungent smell.

When a pressure ulcer has developed, they are very slow and difficult to heal. This is

because they must heal by granulating from the bottom upwards and from the sides inwards,

never simply by healing across the top. They require very specific care and dressings. In a

hospital environment, a Specialist Nurse known as a Tissue Viability Nurse can generally

advise on appropriate dressings. When no such expertise is available, it will be the

responsibility of the medical doctor to prescribe appropriate dressings.

Pressure ulcers should never happen. They take many months to heal, or may never heal.

They are very painful and frequently become infected and smelly. They are costly to treat

and, more importantly, they cause patients and their relatives unnecessary anguish and pain.

The pain and the smell frequently leave the sufferers demoralised and anguished.

Let’s be clear, a pressure ulcer is ALWAYS caused by poor standards of care. In

many cases a pressure ulcer is the direct result of neglect.

Any patient who has limited or no movement of their body inevitably has large parts of their

body staying in the same position for long periods of time.

Certain factors significantly influence the risk of an immobile patient developing a pressure

ulcer. These risks have allowed specialists to devise assessment tools34 designed to identify

those patients at increased risk. By predicting those at high risk, the carer can act proactively

to prevent pressure ulcers happening. Whatever assessment tool is used, the assessment

must be repeated every three days (or sooner if there is a change in the patient’s condition)

and the care adjusted as necessary.

5.4.11 How to prevent pressure ulcers developing

The simple way to prevent pressure ulcers forming is for the carer to prevent areas of the skin

being subjected to compression (and so a restriction of the blood supply) for long periods.

The carer should identify those areas of the body that are at risk and ensure that the patient

moves or is moved appropriately at regular intervals.

The areas at risk will depend on the patient’s position. The main risk areas of the patient who

is immobile in a sitting or prone position are:

Back of the head (especially if the patient has thinning hair)

Shoulders and elbows

Spinal column

sacrum

Heels and toes.

The main risks areas for the patient lying on their side are:

Ears

Shoulders

34 One assessment tool is a waterlow chart: there are others in use throughout the U.K.

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Elbows

Hips

Knees

Ankles.

Other factors that increase the risk include:

Patient’s weight, (very thin patients have little subcutaneous fat);

Grossly overweight patients, (layers of tissue can press onto each other);

Dehydrated or poorly nourished patients;

Patients taking chemotherapy drugs;

Patients taking large doses of steroids;

Patients on whom steroid cream has been applied to any of the pressure ulcer “risk

areas”;

Incontinent35 patients;

Unconscious patients;

Aged patients (because poor circulation often increases with age);

The dying patient (their gradual “shutting down” reduces the blood pressure

maintaining their circulation).

Whenever a patient has an increased risk, a proactive approach is required. This can include

providing increased nutrition and fluids, and frequent movement. Timely cleaning of areas of

skin affected by incontinence will also help to reduce the risk.

The simplest way to lower the risk of a pressure ulcer developing is to “turn” the patient,

changing their position so that no area has compression for more than four hours at most.

Patients identified as being at very high risk should be turned every two hours. Unfortunately,

this is not always as simple as it seems because patients have preferred positions for comfort

and sleeping. Obliging a reluctant patient to move into an uncomfortable, painful or

distressing position is unacceptable. All regular movements should accommodate the

patient’s preferences whenever possible. This might require analgesia (pain killers) in

preparation for the movement.

Because pressure ulcer development involves restricting the circulating of blood to and in the

area, another approach is to stimulate blood flow in the area. An effective (if old fashioned)

method is to wash the area in warm soapy water. The warmth stimulates the circulation, the

soap reduces skin flora, and it has the added bonus of making the patient feel refreshed! If it

is done, the skin must be thoroughly dried to prevent soreness. This must be done by patting

the area gently with a soft towel, never by rubbing – because rubbing may destroy some of

the protective epidermis. Soap can also dry the skin, increasing the risk of skin damage.

Unfortunately, the time it takes to collect the required resources and undertake this every few

hours may make it impossible for carers who have many responsibilities. Those caring for a

patient at home may have time to use this approach. It can certainly be effective in the

prevention of pressure ulcers with some patients.

35 Incontinence does not cause a pressure ulcer but the protective epidermis of the skin can be destroyed by being in

contact with urine or faces for any length of time, so significantly increasing the risk of a pressure ulcer developing.

75

Other old fashioned treatments were less effective. For years, it was accepted practice to rub

either talcum powder or cream into the area at risk. This was not a good idea because the

talcum powder damaged the epidermis and boggy creams encouraged bacterial growth and

possible skin damage.

The risk of developing pressure ulcers can be reduced by using specialised equipment36 that

is designed to reduce pressure by keeping the weight off the limbs. While effective, these can

leave the patient feeling cold unless a blanket or fleece is put between the equipment and

their skin. There are also many special mattresses designed to prevent areas of pressure

developing. These include various types of electric profiling, airbeds and water beds. In an

institution, the carer should get advice about the appropriate type of equipment and its

availability from the Registered Practitioner, Physiotherapist or Tissue Viability Nurse. Home

Carers should seek advice from the patient’s G.P. or Community Nurse.

Finally one of the simplest things that can reduce the risk of pressure ulcers developing is for

the carer to always ensure the patient is not resting on creased sheets. Creased sheets

increase the risk of developing skin damage and pressure ulcers, and can generally be

corrected by smoothing the sheet and tucking it in securely.

When a carer finds areas of redness or broken skin on a patient, they must record and report

this to those responsible for the patient’s medical treatment urgently.

It is every carers responsibility to reduce the risk of pressure ulcers by:

1. ensuring that the patient is moved appropriately at the frequency instructed,

2. ensuring that the patient’s skin is kept clean (remembering that creams do not prevent

pressure ulcers but can form a barrier to prevent epidermal damage of the skin);

3. ensuring that that any special mattresses are used in accordance with their

instructions;

4. ensuring that bed linen is soft and wrinkle free.

SSKIN Bundle

The SSKIN bundle is an example of a simple tool designed to remind the carer about best

practice in the prevention of pressure ulcers.

SSKIN =

S surface Consider the type of mattress/cushion. If an air mattress is it inflated,

and working?

S skin integrity Check for signs of pressure ulcers two hourly if the patient is

considered to be at high risk

K keep moving Keep repositioning the patient. Turn the patient. When possible,

stand them up, lift their legs or sit them out on a chair.

I incontinence Ensure that any incontinence, urinary or faecal, is dealt with rapidly

and the patient left clean and dry.

36 Such as a leg trough or bed cradle.

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N nutrition Consider the type of diet that the patient is receiving and whether they

would benefit from the receipt of supplements including extra fluids.

5.5 Managing pain relief

No patient should be in pain. It is a subjective experience and is as severe as the patient

reports it to be – so when a patient reports pain, the carer must act to alleviate it.

The carer must recognise the presence of pain before it can be relieved. The patient’s report

is enough, but is not the only indicator of pain. The quietest patient is often the one in

constant pain and feeling too ill to move or too stoic to complain.

If pain may be an issue, the carer should ask themselves:

Is the patient’s skin pale, grey or waxy?

Has the patient got rapid respirations?

Has the patient got a rapid pulse?

Does the patient’s skin feel clammy to the touch?

Is the patient’s body stance or movement awkward or reduced? Do they appear to be

in pain when they move – or are moved?

Are they crying or showing signs of distress?

All are indicators of pain and should prompt the carer to ask the patient searching questions.

If the patient can communicate and is lucid, it is relatively easy to identify and rectify any pain

they are suffering. Identifying and rectifying pain in the confused or disorientated patient

requires a little more carer ingenuity and the carer could start by considering the clues

suggested above. These clues are only suggestions and certainly not an exhaustive list of the

possible symptoms of a patient being in pain.

When a patient is in pain, the carer must record that fact and ensure that it is immediately

brought to the attention of the person responsible for their medical treatment. There are many

pain killers available, many of which have a targeted efficiency that is astonishing, so there is

usually no need for any patient to be in prolonged pain. An exception may occur when a

patient is already receiving medication that may be incompatible with the pain killers.

Sometimes a patient has a medical history that results in “normal” pain killers being

ineffective. These patients may need different or stronger drugs.

To assist in its treatment, the carer should encourage the patient to describe the pain and its

location as clearly as possible. Pain is often difficult to describe so it can help to suggest

words and phrases that the patient may find appropriate. Some useful descriptors are:

Constant pain; comes and goes; I feel it every time I (do something)

Sharp pain; dull ache; throbbing pain; feels bruised; deep pain; surface pain;

Makes me feel sick; cannot be ignored; fades but returns suddenly.

Many institutions have pain assessment score sheets that are used to record the patient’s

expressed level of pain. A simple score of 1-10 added to one of the descriptors suggested

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can provide a useful description of the patient’s pain level. Because the patient estimates the

score, any change in pain should show up reliably when the question is asked again.

Pain is sometimes less bearable because of a patient’s concurrent worries such as personal

problems or anxieties. Addressing these may reduce anxiety and reduce the pain being

experienced. The patient may appreciate the opportunity to talk about these things, both as a

distraction from the pain and a path towards its reduction.

Generally, a degree of pain is inevitable following surgery and, paradoxically, movement is

often the quickest way to achieve pain reduction by promoting healing. In such situations,

gentle movements taken in conjunction with analgesia (pain killers) can be entirely positive

even if uncomfortable, provided that the movement does not exacerbate any other problems

the patient may have.

Pain may be a short term or long term problem. Short term pain management is usually

easier to achieve because the patient is recovering from the cause of the pain. Longer term

management is more difficult because the cause may be increasing for months or possibly

years. When a patient has a deteriorating condition, the type, dose and frequency of pain

killers required will inevitably change as their condition deteriorates. Within an institution, the

medical staff or an appropriate Specialist Nurse should adjust the prescriptions to reflect the

changed need. Within the patient’s own home, appropriate analgesics (pain killers) should be

prescribed by the patient’s G.P. or an appropriate Specialist Nurse, adjusting the medication,

its dose and delivery as appropriate.

When a patient has a long term debilitating and deteriorating terminal disease, effective pain

management is critical. A Hospice is the institution with the experience to be best able to

manage the patient’s pain appropriately. A Hospice can also can also provide respite for the

home carer and for the patient. Hospices are not just somewhere for a patient to go to die.

They are a refuge and sanctuary for many with a terminal prognosis – and a terminal

prognosis does not necessarily mean that death is imminent.

5.5.1 Delivering varied pain killers (analgesia)

I will refer to these drugs as “pain killers” because that is what the patient knows them as.

Pain killing drugs can be given in a variety of ways, as described below.

1. Tablet or liquid painkillers are often very easy for the patient to take orally. When a

patient has difficulty opening their mouth, the pain killers can be given in liquid form

using a special oral syringe (which is purple in colour).

2. Pain killing drugs given rectally, usually by suppository, are very effective and are

usually effective for several hours..

3. Pain killing drugs are often given via an injection, usually intravenous (IV), when the

pain is excruciating and immediate relief is required. This injection should always be

administered by a doctor of an appropriately trained Registered Practitioner. Pain

killers given intravenously will have an almost immediate effect and last for quite a

long time.

4. Pain killing drugs can be given by injection intramuscularly (IM). The injection should

always be administered by a doctor or an appropriately trained Registered

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Practitioner. These will take slightly longer to take effect but usually last for several

hours.

5. Pain killing drugs can be given via an IV infusion that the patient themselves can

control. This involves the patient having a special infusion attached to their vein and a

device with a control button. Whenever they press a button on the device, a small

amount of strong pain killer is delivered into their veins. The device restricts the total

amount they can have in a given amount of time because too much of this drug can

be dangerous. It records the button having been pressed even when no drug is

delivered. This type of delivery is known as a PCA (patient controlled analgesia)

pump. Staff caring for a patient using this type of PCA pump should be assessing and

recording how many times the patient has pressed the button to receive pain relief. If

they see that the patient has pressed the button often but that the machine restricted

the amount of pain killer they were given, the care staff should record this and inform

the Registered Nurse Practitioner or doctor responsible for the patient. The strength

of pain killer in the device should be changed to a more effective strength so that the

patient does not need to request pain relief as often.

6. Pain killing drugs can also be delivered by a special patch that is impregnated with

the pain killing drug and when attached to the skin slowly releases the drug, often

over 72 hours.

7. Pain killers can also be delivered by a continuous injection into the subcutaneous

(S/C) tissues.

Both of the final two methods (6 and 7 above ) have the advantage that they continually

deliver a small amount of pain relief that gradually builds up. When it has built up, this can

give the patient a constant and effective dose of pain killer that uses less of the drug than is

required using other methods. Pain killing drugs can have side effects, so using less of them

whenever possible without distressing the patient makes sense. The delivery devices must be

regularly maintained or changed in order to ensure a continuous dose. If the dose is allowed

to stop, the pain killing effect will be reduced and it will take time to build up to an effective

dose again – so the carer must be diligent about maintaining the means of pain killer delivery

appropriately.

5.5.2 Common side-effects of pain killers

A major side-effect of many types of pain killer is constipation so all patients regularly taking

pain killers of any type should be monitored for signs of constipation by discreetly identifying

and recording their bowel movements. If their bowel movements provide cause for concern,

the carer must record the fact and ensure that the responsible Registered Nurse Practitioner

or doctor takes appropriate corrective action.

When pain killers are given intravenously, there is also the risk of the strong pain killer

affecting the patient’s brain, causing it to “forget” to tell the patient to breathe. This condition

is known as “respiratory depression”. When a carer is looking after a patient who is receiving

these IV painkillers, it is part of their legal responsibility to be aware of both the signs of

respiratory depression and the appropriate resuscitation procedures and equipment required

to rectify the problem if it occurs.

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5.6 Making clinical observations

Clinical observation starts with observing how the patient appears. This may seem rather

obvious, but with the plethora of medical gadgets currently available, staff are often forgetting

to simply “look” at their patient.

Any machine that is used to provide a reading is only providing part of the information used to

assess a patient. It is only a machine, and a machine that is generally tuned to a broad set of

parameters intended to reflect what is “normal” or “healthy”. The machine’s scale is generic

but each patient is unique. It follows that the mechanical assessment should be examined in

the context of what is normal for each specific patient.

For example, a patient might usually have a pulse of 72 beats per minute (as recorded in their

notes) and then their pulse is found to be 96 beats per minute – which will be an indicator of a

significant change from the “norm” for that patient. Significantly, both of these beat rates fall

within the “normal” range set in pulse reading devices, so the device will not indicate a

deviation from the norm and a carer who relied solely on the device would miss an early

indicator of a problem.

Every machine is only a tool in the “toolkit” of clinical assessment. It does not replace the

intelligent and patient specific assessment that should be regularly conducted by the carer.

5.6.1 Observation of the patient

The carer should always approach the patient with an assessment of how they look. When

the patient is known, this assessment will be a comparison with previous assessments. Is the

patient awake and looking happy; communicative; withdrawn, tense; confused; less than fully

conscious; showing indicators of discomfort or pain; flushed or pale, etc. When a patient’s

pallor is of concern, the carer should examine where the colour is, cheeks, lips, neck etc.,

looking for a localised explanation and asking for the patient’s input whenever they are

responsive.

When a carer knows a patient well, their observations can be a very reliable indicator of a

change in the patient’s condition. Even when the carer does not know the patient well, the

observations provide earlier indicators that should be followed up on the patient’s behalf.

5.6.2 Responsive to communication

The patient’s level of responsiveness is often hugely relevant to their wellbeing. If their level

of responsiveness varies, there will be a reason (positive or negative). When approaching a

patient who is not known, the carer must ensure that the patient can see and hear them and

that the conditions for communication are in place. See Section 4.1 above.

When there is anything unusual about their response there will be a reason and it is the

carer’s responsibility to find it out. Start by assessing the patient’s temperature, pulse and rate

of respiration (T.P.R.). These basic parameters provide an important initial assessment of the

patient’s current condition. Compare it with the patient’s record because any change may

indicate physical deterioration that requires further investigation or treatment. Alternatively, a

change could indicate that the patient is uncomfortable and may require assistance to move.

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5.6.3 Temperature, Pulse and Respiration (T.P.R.)

Assessing a patient’s TPR is a core skill that every carer should have.

Before starting this assessment, the carer must explain their intentions to the patient and gain

their consent whenever possible. Within institutions it is also appropriate to confirm the

patient’s identity because actions and clinical decisions will be taken on the results of these

clinical observations and the patient’s record must be available.

5.6.4 Temperature

A person’s temperature usually fluctuates in accordance with their circadian rhythms, often

being between 0.5 – 1.5°C higher in the evening than in the morning. It also rises during

ovulation or following eating and drinking. It can also rise in response to bodily infections or

as an immune response to specific triggers. In the elderly it does not always rise in response

to bodily infections.

An unusually low temperature (more common in the young or elderly) is known as

hypothermia and can be life threatening. A temperature below 35°C is known as clinical

hypothermia.

Sudden temperature rises usually indicate infection, but not always. A high temperature is

known as pyrexia or hyperthermia. There are several grades of hyperthermia:

Low grade: a temperature rise from the patient’s normal up to 38°C. This is

common in mild infection, trauma or post surgery.

Moderate to High grade: a temperature between 38 and 40°C. This is often

infections in the respiratory system, wounds, or urinary infections.

Hyperpyrexia: a temperature of 40°C or above. This is usually caused by

serious illness, environmental factors or damage to the brain.

But a rise in temperature can also be caused by problems other than infection. Other

common causes include: alcohol withdrawal; stroke; response to prescribed or self-

administered drugs (which may be an allergic reaction); some types of overdose; gout; an

immune response (to a blood transfusion, for example), etc.

It is worth noting that as people age they do not develop a temperature in response to an

infection as reliably as they did when they were young.

The patient’s temperature is usually taken using a thermometer. The temperature can be

measured in the patient’s mouth, armpit, ear or rectum.

1. A correctly used oral (mouth) thermometer should report the patient’s oral

temperature accurately. This is not necessarily the same as their core body

temperature but usually provides the baseline for a patient’s “norm”.

2. Any rectal reading provides a reading that is approximately 1°C higher than oral

temperature.

3. Any (armpit) axillary reading will usually report a temperature 0.5 to 1°C lower than

the oral temperature.

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4. A correctly used tympanic (ear) thermometer will record a temperature that is

approximately 1°C higher than the patient’s oral temperature.

Within specialist care areas such as the Intensive Care unit (ITU) or in operating theatres,

additional methods of measuring temperature may be used.

While institutions generally have preferred equipment, many types of thermometer are

available to the home carer. It is important to read the instructions and not allow differences

between devices and / or the place where the temperature is measured to be misleading.

5.6.5 Measuring temperature orally

Commonly, disposable paper temperature assessment strips are used to measure a patient’s

temperature by placing them under the base of the patient’s tongue and leaving them there

for 60 seconds. These are often used for patients being nursed in isolation from other

patients. When these are not used correctly, the recorded temperature can be as much as

1.5°C out. Keeping them still under the base of the tongue for 60 seconds can be

uncomfortable for patients, especially when a patient is breathless or has a cold. While some

argue that the 60 second delay is time consuming, I counter this by saying that the time can

be well spent by making an accurate visual, pulse and respiratory assessment - and by

talking to the patient, but they cannot respond until the 60 seconds is up!

Alternatively a mercury (glass) thermometer is used by placing the thermometer bulb under

the patient’s tongue and leaving it there for several minutes. The mercury thermometer is no

longer used in many institutions because mercury is poisonous and it is possible for a patient

to bite the thermometer and release the mercury. A mercury thermometer should never be

used with children or patients who are not reliably responsive and compliant. Mercury

thermometers have largely been superseded by aural (tympanic, in the ear) thermometers.

5.6.6 Measuring temperature rectally

Taking a patient’s temperature rectally requires the use of a rectal thermometer or disposable

probe. The equipment varies and the maker’s instructions should be followed. Formerly,

rectal thermometers were often used to take the temperature of infants and children, but they

have now been largely superseded by the use of tympanic thermometers. This method is

rarely used for adults unless they are severely hypothermic (extremely cold). A rectal reading

is not reliable when the patient has a full rectum.

5.6.7 Measuring temperature axially (under the arm)

The digital axial thermometer is a small hand-held device with a "window" showing the

temperature in numbers. The equipment varies and the maker’s instructions should be

followed. Formerly favoured for use with patients who were considered at risk of injury or non

compliance with the use of an oral thermometer, these are now rarely used. The probe or a

disposable paper thermometer would be placed under the axilla and left for several minutes.

While the risk to a non compliant patient was reduced, they were often unable / unwilling to sit

still for several minutes with their arm against their chest while the thermometer ”cooked”.

Axial thermometers have been largely superseded by use of the aural thermometer.

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5.6.8 Measuring temperature aurally (in the ear)

Tympanic Aural thermometers are commonly used in many institutions. The equipment varies

and the maker’s instructions should be followed. Aural thermometers are electronic battery

operated devices and measure temperature via a probe inserted into the patient’s ear. The

probe has a disposable cover that is discarded after use. Aural thermometers provide a fast

temperature reading, taking only a few seconds but the probe must be inserted properly for

the reading to be accurate. Inaccurate readings can also result when the patient’s ear is full of

wax.

5.6.9 Measuring a pulse

Changes in pulse rate can be an early indicator of the patient’s condition deteriorating, so it is

often taken regularly and recorded for comparison. Recording the patient’s pulse before any

intervention can provide a “base line” against which to measure change, so should be done

whenever possible.

A pulse can be felt where a patient’s artery is close to the skin surface and passes over a firm

area, such as ligament or bone. The more fatty layers there are above an artery, the more

difficult it can be to detect the flow through it.

It can usually be felt in nine areas of the patient’s body, but the commonest arteries used are

the radial (felt in the wrist), brachial (felt on the inside of the upper arm), carotid (felt in the

neck) or femoral (felt in the groin).

Three things are assessed when taking a patient’s pulse properly, the rate, the rhythm and

what we call the “amplitude”, which means the force and volume of the pulse.

5.6.10 The pulse rate

The “normal” pulse rate of each patient will vary according to factors including, age, co-

existing morbidity (illness), posture, movement, electrolytes (blood salts), body temperature,

emotion, infection, medications taken, activity and any cardiac problems.

The average pulse of a six year old is 100 beats per minute (often known as BPM) and a

general average for an adult is around 80BPM. These are crude averages. Each patient is

unique and so, whenever possible, the patient’s pulse should be recorded before any

treatment or surgical inventions are made. The patient’s “normal” pulse provides their “base

line” pulse rate.

A “tachycardia” is an abnormally fast pulse rate, generally one of more than 100 BPM.

However, this might not be abnormal if a patient has just physically exerted themselves, such

as by hurrying up a flight of stairs. The pulse rate should be viewed in context. If there is

doubt, this can often be resolved by taking the pulse again after 15 minutes. When a patient

does develop a tachycardia, it might be a significant symptom of bleeding or infection.

An abnormally slow pulse is known as a” bradycardia”. Usually if a patient has a pulse of 50

BPM or fewer, they will be referred to as being bradycardic. Such slow rhythms can be

caused by drugs, a cardiac problem or as a sign of raised intracranial pressure (pressure

within the brain). It can also be an indication of a patient who is very physically fit. Once

again, the significance of the pulse rate is patient dependent.

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5.6.11 The rhythm

Each contraction of the heart produces a pulse. The two atria in the heart contract together

squeezing blood into the ventricles of the heart. Then the ventricles contract, squeezing blood

out into the rest of the body. The action of the two ventricles can be felt in the pulse as the

“lub dub”. After the “lub dub”, the heart has a brief ‘resting’ period before the next “lub dub” is

felt. The pulse should have a regular rhythm.

If any part of the heart or its electrical conducting system is not working as well as it might,

the pulse can be “irregular”. When the irregularity has pattern it is referred to as being

“regularly irregular”. When the irregularity seems random, it is referred to being “irregularly

irregular”’.

When the two atria contract more rapidly than the two ventricles, this known as “atrial

fibrillation”. When this happens, not every contraction of the atria can be felt so the pulse

feels irregular and can seem to stop for periods. This occurs when weaker beats do not reach

the radial artery, so cannot be felt.

Variations in the rhythm of the patient’s pulse can be an indicator or serious problems and

must be recorded in the patient’s notes, and the carer should ensure that the responsible

Registered Nurse Practitioner or doctor is informed.

5.6.12 Amplitude

The term “amplitude refers to the apparent volume of blood in each beat, or the strength of

the pulse. The arterial walls of most younger people are less hard than the elderly and the

artery expands and contracts more readily, so making the pulse feel different. With

experience, the carer can learn to distinguish between a thready (weak) or a bounding

(forceful) pulse. Both can have important clinical implications and should be recorded.

5.6.13 Taking a patient’s pulse

The carer should discreetly explain to the patient what they are doing and why, asking for

their agreement. If the patient is unconscious or unresponsive, the carer should still explain

what is happening, and why.

The pulse is usually taken by feeling the radial pulse (at the wrist). However there are two

important and significant exceptions.

1. When a patient has the cardiac condition known as atrial fibrillation, it is usual for one

carer to listen with a stethoscope placed over the patient’s heart area and the other to feel

the radial pulse at the same time. Both listen to the number of beats per minute, then

document these. The two will not be the same and the difference can be very important

when determining the patient’s medication needs.

2. When a patient is clinically shocked and very unwell, taking the radial pulse can be totally

unreliable. This is because when a patient is extremely unwell, or dying, their body

automatically “prioritises” where the oxygen in their blood is taken. It does not prioritise

their fingers or toes. It prioritises their heart, lungs, liver, kidneys and brain. So the

amount of blood being delivered to the radial pulse at the wrist will be reduced and can be

very difficult to detect. When taking the pulse of any patient who is very sick or clinically

compromised, the carer must take the pulse “centrally”, meaning in the groin or neck.

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5.6.14 Assessing the radial pulse

With the patient’s consent whenever possible, the carer should place one of the patient’s

arms across their chest with the palm of their hand facing downwards. The carer then places

the second and third fingers of their own hand onto the patient’s wrist immediately below the

thumb. Some small adjustment may be necessary because the patient’s radial pulse might be

found in a slightly different spot. When found, the pulse will usually be obvious to feel under

the carer’s fingertips.

Using a watch or clock with a second hand, the carer must count the number of beats (lub

dubs) that can be felt for either 30 seconds or a minute. When only feeling for 30 seconds,

the result should be doubled to give the beats per minute (BPM). When taking pulses is a

new skill, or the result causes concern, it should be taken for a full 60 seconds.

When the pulse has been taken, the non registered carer must record the result accurately

and report any concerns to the Registered Nurse Practitioner

5.6.15 Respirations

A patient’s respirations refers to the intake and outlet of breath while they breathe. It involves

counting the number of times their chest rises to take in oxygen every minute, but much more

than just that. Assessing a patient’s respiration has a history of being the least acquired skills

amongst many carers, including Registered Nurse Practitioners and medical staff.

Most cells within the patient’s body requires regular oxygen to function. This is usually

obtained by respiration (breathing in), while expiration (breathing out) removes waste

products from these cells.

The brain controls all aspects of respiration automatically and unconsciously but the patient

can also alter the rate or depth of respiration consciously.

When a patient’s physical condition begins to deteriorate significantly, the body automatically

tries to take in extra oxygen, increasing the respiratory rate so that the patient breathes faster

and deeper whenever possible.

In many clinically deteriorating patients who are becoming compromised and in danger of

significant further deterioration, the first clinical sign is an increase in their respiratory rate.

The patient’s pulse will then rise to accommodate this need. If these early signs are not

detected and appropriate treatment given, there is often an increased risk of patient mortality.

A common early symptom of insufficient oxygen (hypoxia) is sudden agitation in a previously

relaxed patient. Confusion and pallor can be later indicators, as can a greyish blue tinge

around the lips. The carer should never think that a patient who has not got a blue tinge to

face and lips is getting enough oxygen. By the time they are looking “blue” they are seriously

compromised and areas of the body are not getting enough oxygen. Insufficient oxygen can

cause tissue to die and must be addressed urgently. If it is not, insufficient oxygen will

ultimately cause death. The golden rule is never to wait for a patient to look ”blue” before you

think he or she is not getting enough oxygen.

Before starting to count the number or respirations per minute, the carer should ask

themselves the following questions:

Is the patient sighing, coughing, gasping, wheezing or croaking?

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are both sides of their chest moving when they breathe?

are they using accessory muscles to breathe – raising their shoulders, holding their

head up, do they have nostrils flaring open as they inhale?

Do they appear to be breathing in for longer than they are breathing out?

Are their breaths deep or shallow?

Does the patient appear paler than usual?

Do they have any cyanosis – blue tinges to their lips, nose or fingers?

Having answered those questions, the carer should count the number of respirations that the

patient makes over 60 seconds. Very rapid but shallow breathing is known as

“hyperventilation”.

A rapid respiration rate of breathing at a normal depth is known as “Tachypnoea” and is

commonly a response to in infections. On average, the respiratory rate increases by seven a

minute for each 1°C rise in the infected patient’s temperature.

A very slow respiration rate is known as “hypoventilation”.

A decrease in the rate or depth of respiration in a patient with a head injury can be a sign of

serious deterioration that requires urgent medical intervention.

5.6.16 Assessing the patient’s respirations

Recording the patient’s respirations before any intervention can provide a “base line” against

which to measure change, so should be done whenever possible.

Without moving their hands, when the carer has finished taking the patient’s radial pulse they

can record the patient’s respiratory rate. This is done by keeping their hand in the same

position on the patient’s wrist over their chest and feeling how frequently the patient’s chest

rises and falls within 30 seconds. When only feeling for 30 seconds, the result should be

doubled to give the respiration rate per minute. When counting respirations is a new skill or

the result causes concern, they should be counted for a full 60 seconds.

5.6.17 Blood pressure (B/P)

BloodPressure can be assessed either manually (using a stethoscope and

sphygmomanometer) by those with the appropriate skill or by using an electronic device that

undertakes the reading automatically.

Two measurements are taken to record a patient’s blood pressure – the systolic and the

diastolic measurements. When the B/P is recorded, the systolic reading comes first, and the

diastolic second, so 100/60 means that the patient has a systolic pressure of 100 and a

diastolic pressure of 60.

When listening for the patient’s blood pressure using a stethoscope, the systolic blood

pressure is the first sound that is heard as the sphygmomanometer is slowly deflating. It is the

noise made by the contraction of the ventricle as it forces blood out of the heart and is

measured in mm Hg. The diastolic is identifiable when the pulse gets much quieter or the

sudden absence of sound. What you are hearing is the minimum pressure against the wall of

the blood vessel wall , an indication of blood vessel resistance.

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There is no “normal” blood pressure – situations vary and readings of the same patient’s B/P.

can vary considerably when taken only a few minutes apart. This is why no patient should be

diagnosed as having a high B/P (hypertension) on the strength of a single B/P. reading. The

diagnosis should be made after three recordings taken with the patient at rest over several

days. It may also be assessed by using a 24 hour Blood Pressure Monitor (there are many on

the market) to record regular blood pressure recordings while the patient is engaged in their

normal activities37.

As a rule of thumb, anything between 100/60 and 140/90 can be considered a “normal” B.P.

Common factors that can lead to a high B/P reading include:

Sodium or fluid retention. The patient’s blood ‘salts’ are not as they should be.

Tachycardia, rapid pulse.

Obesity.

Increased blood volume, the patient has too much blood.

Vasoconstriction, the patient’s blood vessels have constricted for some reason.

Hormones.

Stress.

Exercise.

These do not always mean that the patient is hypertensive.

Common factors that can lead to a low B.P. reading (hypotension) include:

Haemorrhage, bleeding.

Alcohol.

Bradycardia. When the patient has a very slow pulse, usually lower than 60 BPM

Decreased blood volume. The patient does not have enough blood.

Dehydration. The patient is drying out because of raised salt levels or insufficient fluid

intake.

The risks of persistent hypertension are well known and include heart disease and strokes.

The risk of hypotension as a sudden event can also be catastrophic.

Blood is circulated throughout the body taking oxygen to all the tissues and removing ‘waste

products’. If the blood is not being circulated properly the tissues don’t get enough oxygen,

the patient becomes hypoxic and tissues die. The symptoms of this happening will vary

according to the areas affected.

In an acutely ill situation a drop in B./P.does not usually occur immediately. The body

“compensates” for the problem and the respiration rate increases and gets deeper. The pulse

rises and the patient may look pale as blood is diverted by hormonal action so that it is

concentrated in the vital organs. During all this, the patient’s B/P often appears to remain

more or less unchanged.

37 NICE guidelines on diagnosing hypertension 2013.

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Notice that the base line respirations and pulse do change. It is the carer’s job to recognise

these changes and record and report them as a matter of urgency BEFORE the patient’s

blood pressure drops.

5.6.18 Recording a patient’s blood pressure

There are electrical and manual ways to take a record of a patient’s blood pressure. Both

have to be used by the carer with skill and concentration.

The manual way is called ausculatory (“listening”) and usually involves measuring the blood

pressure in the brachial artery in the arm. It involves using a manual sphygmomanometer.

The electronic B/P reader (often referred to by the trade name, Dynamap) is also usually

conducted using the brachial artery in the upper arm.

Both manual and electronic methods involve applying an inflatable cuff attached to a length of

tubing between the cuff and the machine.

The electronic devices do not require any skill other than the application of the appropriate

size of cuff (which is a size approximately 2/3 of the patient’s upper arm width) and pressing a

button on the machine to start it operating.

The electronic devices are exceptionally easy to use, requiring no more than the press of a

button but they can be unreliable / inappropriate because they do not assess weak

heartbeats, do not identify irregular heartbeats and are known to give unreliable results when

a patient is hypotensive (has a low blood pressure).

The ausculatory (manual) method is more reliable, but requires greater skill to use properly.

The manual assessment requires use of a stethoscope, the bell of it which should be cleaned

with an alcohol wipe between each patient, and the ear pieces similarly cleaned between staff

using them.

Whichever method is used, the B/P cuff should be cleaned with disinfectant or an antiseptic

wipe between patients. When the patient is known to have an infection, the machine itself

should be wiped with an appropriate disinfecting wipe and the actual cuff washed in warm

soapy water and allowed to dry completely before using again.

5.6.19 Recording a patient’s blood pressure using a manual

sphygmomanometer

The carer should discreetly explain to the patient what they are doing and why, asking for

their agreement. If the patient is unconscious or unresponsive, the carer should still explain

what is happening, and why.

1. If the patient is compliant and mobile, the carer should generally ask them to sit, then

wait several minutes before taking the recording. When two separate readings must

be taken, one lying down and one upright, the lying down blood pressure should be

recorded first. Unless the patient was already lying down, the carer should wait three

minutes between their movement and taking the reading.

2. The patient’s arm should not have an intravenous infusion running in that limb. A B/P

reading should not be taken on a lymphoedematous area, in the vicinity of shunts or

on the side of a mastectomy. Having selected the arm from which to record the B/P,

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the carer should ask the patient to remove any restrictive clothing that will be in the

way, helping if necessary.

3. The carer should ensure that the patient’s arm is supported on a pillow because

holding an unsupported arm out for this procedure would require muscle contraction

that can affect the reading.

4. The carer must ensure that they have the correct size of inflatable cuff, then wrap the

cuff around the patient’s upper arm, ensuring that the centre of the cuff bladder is

placed over the brachial artery. There should be at least 2.5 cm (more than an inch)

between the bottom of the cuff and the anticubital fossa – where the elbow bends and

the arm is creased. Pushing the stethoscope bell underneath the blood pressure cuff

is not the correct method of taking a reading.

5. If it has not already been done, the carer should wipe the stethoscope bell with an

alcohol wipe between each patient. When the stethoscope is used by others, its ear

pieces should be treated similarly.

6. The carer should already have examined previous readings so that they know what to

expect. Generally, the higher the blood pressure the more highly inflated the cuff will

have to be. This can be uncomfortable for the patient so the high pressure should not

be held for longer than necessary. The carer should expect to inflate the cuff to 30

mm HG higher than previous recording systolic readings.

An alternative that can be useful when a patient’s previous readings are not known is

for the carer to inflate the cuff very slowly simultaneously feeling the patient’s radial

pulse. When the radial pulse cannot be felt, the pressure shown in the cuff gives an

approximate systolic B/P. This allows the carer to know what approximate pressure

will be needed. They should deflate the cuff and wait 30 seconds before inflating the

cuff again, increasing the pressure to 30 mm HG higher than the estimated systolic

reading that they had just obtained.

7. Then place the diaphragm (bell) of the stethoscope over the pulse point of the

brachial artery – in the anti-cubital fossa (crease of the elbow) and inflate the cuff to

the anticipated level.

8. Deflate the cuff gradually in 2 mm HG stages, listening for the start of the pulse. The

sound of the “lub dub” of the pulse will suddenly be heard. This is the systolic blood

pressure reading.

9. Keep slowly deflating the cuff while listening for the “lub dub ” of the pulse to either

suddenly stop or suddenly become much quieter. Some patient’s blood pressure goes

quieter, in others it appears to suddenly stop. This is the diastolic blood pressure

reading.

The result must be recorded in the patient’s records and any concerns or deviations from the

patient’s previously recorded B/P should be reported to the Registered Nurse Practitioner or

medical staff. After finishing the B/P reading the carer should ensure that the patient is

comfortable, and clean the stethoscope bell (and ear-pieces when appropriate) before

replacing the equipment in its designated place.

Common reasons for recording incorrect blood pressure readings include:

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Carer error;

Worn connections or tubing;

Incorrect size cuff;

Wrongly positioned cuff (usually the cuff is too low and covers the pulse area);

Patient not resting / sitting as suggested prior to the recording being made.

5.6.20 Recording a patient’s blood pressure electronically

Electronic cuff devices can be especially useful when a patient has a well-padded anticubital

fossa (inside of elbow) and the pulse is difficult to hear through the stethoscope.

Taking a patient’s B/P with an electronic B/P reading device is as simple as attaching the cuff

appropriately. This will vary by device, so the user should follow the manufacturer’s

instructions. But the use of electronic cuff devices to take a patient’s B/P can have several

important disadvantages.

Disadvantages of electronic cuff devices:

The available cuff is often a single size and may not fit the patient well.

The cuff may be unclean.

The machine always inflates to a pre-set range – and this can be very uncomfortable

or bruising for patient.

The machine does not record weak beats that are not strong enough to reach the

brachial artery.

These machines are unreliable when recording low blood pressures (hypotension).

The machine will not detect a weak or irregular pulse.

The machines cannot assess other indicators, such as the patient’s skin colour,

whether the patient’s skin is clammy or hot and dry, or how the patient feels, or their

tone of voice;

The machine reduces contact with the patient.

So beware, taking a B/P using an electronic method may be simple, but it can cause

problems and does not replace the carer / patient contact that is an essential part of a full

assessment.

Whenever an electronic B.P device gives a result indicating hypotension, the

reading must be taken again using a manual method.

5.6.21 Oxygen saturation levels – known as “Sats”

Oxygen saturation levels (often known as “sats”) in a patient’s blood can be measured using

a detector that attaches to a soft clip on a patient’s finger, toe or ear. The normal oxygen

saturation range is between 95 and 98%. This is slightly lower in patients with COPD38 ,

patients with COPD should have SATS of between 88 and 92%. A reduced ”Sats” reading

can indicate that the patient is clinically deteriorating and is not getting sufficient oxygen to

38 Chronic Obstructive [Pulmonary Disease, such as chronic bronchitis, emphysema

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their vital organs and peripheral circulation. Or alternatively a reduced reading could mean

that:

The patient’s fingers or toes are cold;

The patient is anaemic;

The patient is hypotensive; they have a very low blood pressure

The patient is wearing nail varnish.

If any of these situations applies, the clip should be attached to the patient’s earlobe for an

alternative reading.

After use, the probe and the machine should be wiped with an antiseptic wipe and allowed to

dry between patients.

Sats devices are increasingly used in the community as well as hospitals, often for patients

with chronic lung conditions as a method of assessing their lung function at that moment in

time. But they should be used with the same caveat as with all devices. They are useful and

can prove an excellent indicator of the patient’s condition, but they are only one tool in the

“toolbox” of patient assessment.

5.7 Care of the unconscious and / or dying patient

To begin with, it is necessary to define “‘dying”? In broard terms, we are all getting closer to

death, so slowly dying. The newly diagnosed patient with a terminal prognosis might

reasonably interpret that as “dying” although their death may not be imminent. A patient with

such a prognosis will require support from their carers, and that support can often be given by

simply listening to them.

In general within medical institutions the term “dying” is only used when death is imminent.

The term might be used to describe a sudden deterioration in the patient or to describe a

longer protracted death. For some people in some circumstances, patients, relatives and their

carers, the imminent death will be partly perceived as a welcome release from anguish.

People react to terminal diagnosis and death in individual ways and many medical institutions

do not have the facilities and support networks that they need. This is not a criticism but an

acceptance of the competing demands on their resources. If the hospice sets the gold

standard for providing support to the dying and their relatives, then all carers should aspire to

that standard within the context where they are working. There is much that carers can do,

and many achieve a great deal without much more than common sense and good will.

When a carer feels that there may be something further that could be done for the patient or

their relatives, they should record this in the patient’s records and verbally report this,

ensuring that those in a position to respond receive their report.

5.7.1 The anticipated (expected) death

After a patient has been ill or suffering for a long time the relatives may feel that the death will

be a release, and then feel guilty because they are almost wishing their loved one away.

When a relative need to express this, the carer should be there for them, listening and never

judging.

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The patient might want to talk to the carer about their impending death and the carer should

welcome this trust. It can be hard to know what to say, but just holding their hand can provide

comfort. The patient will often want to spend protracted time with their relatives and loved

ones and this must be accommodated whenever possible. Carers should remember that

relatives will need sustenance and they should be offered it whenever possible. In some

institutions, financial assistance for food and parking may be available, and the carer should

ensure that they know about any special arrangements that may be available. There may be

nothing the carer can do about the big issue they are facing, but the carer should smooth

away the small issues whenever possible.

Relatives have the right to be present while their relative dies, provided that their presence is

not detrimental to the welfare of other patients or staff. They should be allowed to be there at

all hours (not just visiting hours) unless their behaviour is impossibly disruptive. Any carer

who denied this would be ignoring the fundamental principles of care, behaving unreasonably

and possibly breaching the legal rights of the patient and their relatives.

As death approaches, the dignity of the dying is paramount. Basic nursing care must be

maintained throughout their decline and the carer should address any Religious or Cultural

needs of both the patient and their relatives. Each institution should provide “Religious and

Cultural” resources to guide the carer when the relatives cannot.

There are special nursing instructions such as the “care of the dying pathway”39 (the Liverpool

Pathway that used to be followed should have been superceded by alternative guidance) that

provides advice on everything from discussing the situation with the patient to preventing the

patient from suffering with pain, nausea or bronchial secretions in the last days of life.

Generally, this pathway is only started when the patient is expected to die within the next few

days. Provided that it does not conflict with any religious or cultural factors the Liverpool Care

of the dying pathway for the terminal / dying patient, or a similar pathway, should be followed

whenever a patient’s death is imminent.

Within hospitals and many institutions specific palliative care advice is available. When the

patient is dying in their own home, there any several types of support designed to help the

patient and the relatives or carers within the family. Their involvement is not imposed, but

negotiated. Sometimes family carers want to retain overall control and when this is the case,

it should be accommodated. When the family would rather not cope alone, the help and

advice can include taking control when that is what the relatives or family carers want.

Unpaid carers can access advice and support via their (or the patient’s) G.P. even when they

have previously been managing independently. The emotional effects of imminently “losing” a

relative or friend often renders the family carer exceptionally vulnerable and they should be

expected to need more support than they may have previously.

After the patient has just died, the relatives may well like some time alone with them. The

carer should respect this. When there are large numbers of relatives, the carer may need to

ask their managers how best to accommodate them while they wait to “pay their last

respects”.

39 http://www.endoflifecare.nhs.uk/care-pathway/step-5-care-in-the-last-days-of-life/liverpool-care-pathway.aspx

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5.7.2 Communicating with the dying patient

The carer should always remember that it is widely believed that the unconscious patient can

very often hear what is said around them. The carer should encourage relatives to talk to

(and touch) their loved one if they appear to want to. There are often many things that need

to be said.

The carer should always tell the unconscious dying patient what they are doing and why.

Every aspect of the six principles of care covered in this book should be addressed and

followed as appropriate for the patient throughout. Dignity and privacy must be maintained

throughout every aspect of the basic nursing care delivered.

5.7.3 Sudden death

When a patient dies, this may result in the care staff attempting full resuscitation (this is most

common in a hospital but it could happen anywhere). This can be especially hard for any non-

medical staff present. Relatives and visitors may react in strange ways, and say some

unexpected things. Sometimes relatives can be very angry or aggressive or equally can

appear totally calm or shocked. There is no right or wrong response.

When a patient dies suddenly this can also be a shock to other patients within the area who

are often distressed by the “speed of events” and might show this in different ways. The

situation will affect everyone, including the carers – and especially those carers who had

direct dealings with the patient. Affected carers should take time to discuss a sudden death

with their colleagues.

No-one ever said being a nurse was not going to hurt. And the day that a

carer does not care is the day they should find another job.

If a carer ever feels particularly distressed over any death, they should discuss it with their

senior colleagues and, if necessary, seek professional support. Support can help to alleviate

shock and grief and should not only be available to patients and their direct relatives but to

carers as well.

When a carer is looking after a relative or loved one at home and they suddenly die, this can

leave the carer bereft in more ways than one. They have lost the relative and also the caring

that has often become a purpose in their life. Family, friends, G.P. and support services

should rally around and ensure that the carer is supported until the change can be accepted.

Following any episode of CPR40 in response to the sudden death of a patient, it is important

to clear away as much of the CPR equipment as possible before bringing the relatives in to

see the deceased. Certain equipment may have to be retained in the deceased patient (such

as tubes) but these can often either be covered or cut back so they are less visible.

5.7.4 Washing the deceased patient in hospital

The carer should not forget to refer to the Religious or Cultural requirements of the deceased

patient and / or their relatives and try to accommodate those needs at all times.

40CPR, cardiopulmonary resuscitation often involving chest compressions in an effort to ‘restart’ the patients heart. This is

not the same as resuscitation – resuscitation is a much broader remit and can include several clinical interventions

including drug and fluid administration, surgery etc. , plus of course CPR.

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When death has been confirmed, unless otherwise requested, the deceased patient should

be laid flat and their eyes closed (if not already). This can be achieved by gently closing the

eyelids and then applying wet cotton wool balls or wet gauze on the eyelids.

If the deceased wore dentures, they should be replaced if not already. Wet them with water to

ease insertion.

If the deceased’s mouth is gaping open, place a rolled towel under their chin to hold it closed

until rigor mortis (stiffening of the body) occurs.

When the death was a sudden, unexpected event, any cannula (often referred to as needles

but in fact they are usually fine plastic type tubes in the vein) , or catheters should not usually

be removed until after a post mortem. When the death was expected, a post mortem is

unlikely to be required so it is possible for it to be acceptable for all tubes, cannula, etc., to be

removed from the body and dressings applied to the sites when appropriate. The carer

should check the relevant policy at the institution where they work when they are uncertain

about which ‘tubes’ should be removed at this time.

The issue of jewellery should be considered. Usually this only involves ensuring that the

deceased’s wedding ring is in place but there may have been other requests that the patient

made while alive and these must be respected.

Ideally the patient should be left for an hour. Any relatives who were not present might wish to

come in say “goodbye” at this point. It is vital that they see the arrangements of the deceased

demonstrate a caring attitude that is in accord with their expressed Religious or Cultural

requirements. The carer should always check that the cotton wool on the eyes and the towel

under the chin are removed before they allow the relatives to see the deceased.

After any relatives have visited, it is usual practice in hospitals for the body to be washed and

prepared to be taken to the mortuary. Outside of hospital this is often done by the undertaker

who collects the body. The family will decide which undertaker to use.

The carer will need all of the equipment necessary to give a full body wash (see Section

5.1.4) plus a disposable shroud, clean sheet, three identification labels and adhesive tape.

The patient or their relatives might require the patient to be dressed in specific clothing.

Within some cultures or religions they would prefer the carer not to touch or wash the

deceased and will undertake this themselves. For this reason it is vital that the carer is

conversant with the patient’s religious or cultural requirements following their death.

When undertaking the final body wash for the deceased, the carer must wash and dress the

deceased as they would have done when the patient was alive. Many carers find themselves

talking to the deceased as they do this, which is respectful and human.

It is not necessary to plug any orifice (body openings) unless the deceased is leaking fluid

copiously. It is normal for there to be slight incontinence but this is usually self limiting and

when the cavity is empty, there is no further leakage. A body leaking continuously should be

placed in a special body bag as an infection control measure. When used, the bag should be

closed with the zip running from the deceased’s toes to their head. This requirement would be

unusual out of hospital setting. The undertaker should be able to advise carers in other

environments when this is a requirement.

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In hospital while preparing the body, the carer should ensure that there is an ID41 band

around the deceased’s wrist and attach three identification labels with the deceased’s name,

date of birth and ward recorded on them. One ID label is taped to their chest on top of the

shroud. The second is attached to a bandage that is gently attached to both big toes, so

keeping the feet together in an upright position. When the deceased has been dressed, the

sheet underneath the body is folded over the and taped together, so enclosing the face. The

third label is taped to this sheet over the deceased’s chest. This should mean that the body

has four methods of identification attached when it is taken from a hospital ward.

Many nurses / carers like to cross the patient’s hands on their chest with a flower placed

under their wrists. This is acceptable – as long as it does not conflict with any of the

deceased’s religious requirements or those of their relatives.

5.7.5 Death in other institutions or at home

After the patient has died, their death will require confirmation, usually by the deceased’s

G.P. who, unless they are a locum doctor, might know their medical history.

An undertaker is contacted and they will collect the deceased’s body. Whether the body is

washed and dressed before collection is a personal decision, made by the family. The

undertaker is then the main person who can advise the next of kin about any post mortem

requirements and the funeral arrangements. The undertaker will arrange for any identification

labels required.

Some institutions, especially those within the Hospice movement, maintain contact with the

deceased’s family for much longer and support them within their initial grieving period.

Unfortunately very few hospitals in Britain routinely undertake this. Support does not have to

be institutionalised. I worked with one Accident & Emergency sister who always contacted the

next of kin of every person who had either died within the department or been brought into

the department while having CPR that proved ultimately unsuccessful. She brought comfort to

many although these actions were never acknowledged at a senior level. For a real carer like

her, that did not really matter.

The real carer supports the needs of the patient and their relatives without

expecting any special recognition.

41 Identification label – with written details of the patient’s full name, date of birth, hospital registration number and ward

area.

95

6 Useful reference material for the new carer

The book I most recommend is: Royal Marsden Hospital Manual of Clinical Nursing

Procedures (Professional Edition), Lisa Dougherty; Wiley-Blackwell, 2015. ISBN-10:

144433509X: ISBN- 978-1-118-74592-2 9th Edition (I advise buying the latest edition).

There is also a student nurse edition. These are designed to provide more extensive

information than can be provided in this book.

There is an enormous amount of potentially useful information available via the internet, but I

respectfully remind the reader that not everything on the internet is correct or up-to-date.

The National Institute for Health and Clinical Excellence (NICE) www.niceguidelines.co.uk. At

the website, enter the name of the disease you are dealing with and the screen will show any

links to disease specific NICE guidelines, support groups and information sites that are

available.

Alternatively, use a search engine to type in the name of the patient’s illness and the words

‘support groups’ or ‘care forum’. For example, for advice or support when helping a patient

suffering with any type of dementia, you could either type ‘dementia care forum’ or the

‘specific type’ of dementia care forum in the search engine.