Lesson 3
Advanced Principles of Patient Hygiene

3.1 Patient Hygiene

Providing for a patient's hygiene is probably the most basic of all nursing care activities, but it is undoubtedly one of the most important. Not only is it a provision for the patient's physical needs; it also contributes immeasurably to the patient's feeling of emotional well-being.

Purpose of the Patient's Daily Bath

a. Removal of bacteria from the skin.

(1)  Confinement in bed increases perspiration, and bacterial growth is stimulated by moisture.

(2)  Skin irritation from hospital bed linens may result in skin breakdown and subsequent infection.

b. Relaxation effect on the patient.

c.   Stimulation of blood circulation to the skin, respirations, and elimination.

d. Maintenance of joint mobility.

e. Improvement of the patient's self-image and emotional and mental well-being.

f.  Providing the nurse with an opportunity for health teaching and assessment.

g. Providing the nurse with an opportunity to give the patient psychological support.

(1)  The process of building rapport may begin during the initial bath.

(2)  The bath aids in the development of the therapeutic nurse-patient relationship as the patient has the nurse's undivided attention.

Physical Conditions which Encourage Skin Breakdown in a Patient Who is Confined to Bed

a. Immobility. Continuous pressure over any body part impairs circulation to that part and can cause breakdown and eventual ulcerations.

b. Incontinence.  If the patient is unable to control the bladder or bowel functions, skin breakdown is likely to occur due to the presence of moisture and bacteria on the skin.

c.   Emaciation. An emaciated patient may be prone to skin breakdown over bony prominence (heels, elbows, and coccyx).

d. Obesity. An obese patient may have many skin folds where perspiration and bacteria may contribute to skin breakdown.

e. Age-Related Skin Changes.  An older person's skin is very thin and  inelastic. The sweat and oil glands are less active. Thin, dry skin is more susceptible to pressure areas and skin breakdown.

f.  Any Disease or Condition that Affects Circulation. Any disease or condition that affects circulation can encourage skin breakdown in a patient who is confined to bed.

Nursing Intervention to Prevent Skin Breakdown

a. The time of the patient's bath or back massage is the most logical time to thoroughly observe the patient's skin for pressure areas.

b. At the first sign of redness, the area should be washed with soap and water and rubbed with lotion; measures should then be taken to keep the patient off the reddened area.

c.   Report any signs of pressure to the charge nurse.

d. Keep sheets under the patient clean, smooth, and tight to help eliminate skin irritation.

e. Ensure adequate nutrition and fluid intake, according to physician's orders.

f.  Every effort should be made to keep urine and feces off the patient's skin, washing the skin with soap and water and keeping the buttocks and genital area dry (lotion or powder may be used depending upon the patient's skin type) when the patient is incontinent.

g. Obese patients may need assistance washing and drying areas under skin folds (groin, buttocks, under breasts, and so forth.)

h. For the patient with very dry skin, various bath oils may be added to the bath water.

(1)  Soap may be omitted because of its drying effect.

(2)  Lotions and oils may be used after the bath.

Timing of Patient Hygiene Procedures

A patient's bath may be given at any time, according to the patient's needs, but certain routines are generally followed on a ward.

a. Morning Care.

(1)  The procedure followed in the morning affects the patient's comfort throughout the day.

(2)  Each morning before breakfast, the patient should be assisted to the bathroom, or a bedpan or urinal should be provided, according to the patient's activity level.

(3)  The patient is then given the opportunity to wash his/her hands and face and brush his/her teeth. The bed linen is straightened, and the overbed table is cleaned in preparation for the breakfast tray.

(4)  After breakfast, the patient has a complete bath (type is dependent upon the patient's condition and mobility), mouth care, a change of clothing, and a back massage.

(5)  Bed linens are changed; and the unit is cleaned and straightened to provide a comfortable and safe environment for the patient.

b. Evening Care.

(1)  The care the patient receives at the end of the day greatly influences the patient's level of relaxation and ability to sleep.

(2)  An opportunity is provided for elimination; the patient's hands and face are washed; the teeth are brushed; a back rub is given.

(3)  Bed linens are straightened; the patient's unit is straightened to ensure comfort and safety. It is important that there are no items, which the patient could slip on, or fall over, such as chairs or linens, on the floor.

Providing for Selected Patient Needs While  Bathing a Patient

a. Safety.

(1)  The bed may be in the high position during the patient's bed bath, but should be placed in the low position upon completion.

(2)  The side rails should be up after the patient's bath for the patient who is confined to the bed.

(a)  Side rails help to prevent falls for the elderly patient or the patient who is confused or has a decreased level of consciousness.

(b)  The legal aspect requires diligence on the part of nursing personnel.

(3)  The patient's call light should be within easy reach to prevent the need to reach for it and risk falling out of bed and to provide easy access in case of pain or distress.

(4)  Fire safety in the patient care area calls for the following rules:

(a)  No smoking in bed.

(b)  No smoking if oxygen is in use.

(5)  Always wash your hands before entering and upon leaving the patient's room.

b. Privacy.

(1)  Respect for the patient's privacy decreases the patient's emotional discomfort during personal care.

(2)  Keep the door to the patient's room closed.

(3)  Pull the curtains around the unit and drape the patient's body during care.

(4)  Allow the patient to complete as much personal care as possible; self-care is appropriate and provides additional privacy.

c.   Comfort.

(1)  Ensure a comfortable temperature in the patient's room.

(2)  Close any windows and the door to the patient's room to prevent drafts and chilling.

(3)  Drape the patient appropriately during the bath.

(4)  For a bedside bath, maintain bath water between 110oF and 115oF; change the water as it cools and/or gets soapy.

Significant Nursing Observations During the Bathing Procedure

a. Physical Observations.

(1)  Observe the skin under good, natural light.

(2)  Any abnormal skin condition should be described as to its location, color, and size and how it feels to the patient.

(3)  The following skin observations should be checked upon admission and daily thereafter:

(a)  Cleanliness.

(b)  Odor. May be caused by sweat secreted by the sweat glands; by abnormal conditions, such as infection or kidney disease; or by bodily discharges (urine, feces) that need to be cleaned.

(c)  Texture. Smooth and elastic or dry and rough; nutritional deficiencies can influence skin texture.

(d)  Color. Reddened areas that could indicate pressure, cyanosis (bluish tinge) or jaundice (yellowish tinge).

(e)  Temperature. Hot skin could mean fever; cold skin could mean poor circulation.

(f)    Sensitivity. Pain, tenderness, itching, or burning.

(g)  Swelling (edema). Stretched or tight appearing; usually begins in the ankles or legs or any other dependent part; may be associated with injury.

(h)  Skin lesions. Rashes, growths, or breaks in the skin.

(4)  Observations may begin at the head (scalp) and proceed to the feet in a systematic manner.

b. Psychosocial Observations.

(1)  Problems in this area may be related to the patient's present problems.

(2)  The time of the patient's bath may be a good time to find out more about the patient's psychosocial needs.

(3)  Remember that the patient's nonverbal communication may tell you much about the way he/she is feeling.

Basic Principles of Mouth Care

a. Purposes.

(1)  Provide oral care of the teeth, gums, and mouth.

(2)  Remove offensive odors and food debris.

(3)  Promote patient comfort and a feeling of well-being.

(4)  Preserve the integrity and hydration of the oral mucosa and lips.

(5)  Alleviate pain and discomfort, thereby enhancing oral intake.

b. General Guidelines.

(1)  Oral hygiene should be performed before breakfast, after each meal, and at bedtime.

(2)  Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing.

(3)  You should provide for patient privacy during the procedure, as this is an extremely personal procedure for most patients.

(4)  Oral care for the unconscious patient should be performed at least every four hours.

(5)  Lipstick, chap stick, or vaseline may be applied to the lips to keep them from drying out.

c.   Nursing Records. Nursing observations for the patient's mouth should be recorded in the clinical record, noting such factors as:

(1)  Bleeding.

(2)  Swelling of gums.

(3)  Unusual mouth odor.

(4)  Effect of brushing the teeth. Note if there is bleeding when you brush the patient's gums and teeth.

d. Conscious Patients with Dentures.

(1)  General considerations.

(a)  Many patients are sensitive or embarrassed about wearing dentures; therefore, the patient's privacy should be respected when the dentures are cleaned.

(b)  Dentures must be handled carefully; they are fragile and expensive, and the patient is handicapped without them.

(c)  If the dentures are left out of the mouth for any period of time, place them in a covered opaque container with the patient's name on the container.

(d)  Dentures must be kept in water to preserve their fit and general quality; the color may change if they become dry.

(e)  You may avoid breaking the dentures while cleaning them by holding them over a basin of water with a washcloth folded in the bottom.

(2)  Dentures are brushed in the same way as natural teeth; be sure to rinse them well.

(3)  The denture cup should be labeled with the patient's name and room number.

(4)  Never use hot water to rinse the dentures as it could warp them; use cool or lukewarm water.

(5)  The patient's gums and soft tissues should be cared for at least twice  per day while the dentures are out of the mouth; a soft-bristled toothbrush, swab, or gauze-covered tongue blade dipped in mouthwash should be used to cleanse the gums, tongue, and soft tissues.

e. Patients With Mouth Complications. The following problems are common in patients receiving chemotherapy and radiation therapy:

(1)  Bleeding.

(a)  Observe the patient's mouth frequently for the amount of bleeding present and the specific areas.

(b)  Do not floss the patient's teeth; use a Water-pikŪ.

(c)  Brush the teeth and clean the mouth using one of the following methods:

1  Brush the teeth carefully with a very soft toothbrush.
2  Wrap a tongue blade with a gauze sponge saturated with a prescribed solution; carefully swab the teeth and mouth. Do not use lemon/glycerine swabs or commercial mouthwash because they contain alcohol, which causes burning.

(2)  Infection.

(a)  Observe the patient's mouth for appearance, integrity, and general condition.

(b)  Wear clean gloves during the procedure.

(c)  Obtain a culture, if ordered.

(d)  Do not floss the teeth if the mouth is irritated or painful.

(e)  Assist the patient with brushing the teeth and cleaning the mouth, using a soft toothbrush or a gauze-padded tongue blade.

(f)    Rinse the mouth with water and the prescribed solution, if ordered.

(3)  Ulcerations, to include stomatitis.

(a)  Basic procedure for the patient with an infection should be followed.

(b)  If the patient's mouth is extremely painful, rinsing the mouth with a local anesthetic, as prescribed by a physician, may be necessary.

(c)  Mouthwash and other solutions which contain alcohol should not be used for the patient with ulcerations as they are frequently very painful.

f.  Unconscious Patients.

(1)  Oral care should be performed at least every four hours.

(2)  Oral suctioning may be required for the unconscious patient to prevent aspiration.

(3)  A soft toothbrush or gauze-padded tongue blade may be used to clean the teeth and mouth.

(4)  The patient should be positioned in the lateral position with the head turned toward the side to provide for drainage and to prevent aspiration.

Back Massage as a Patient Comfort Measure

a. Decreases muscle tension and promotes relaxation.

b. Increases circulation to the area.

c.   Aids in the development of the therapeutic nurse-patient relationship.

Basic Principles of Back Massage

a. The psychological benefits of back massage cannot be overstressed for the hospitalized patient.

b. The following statements illustrate the concept of therapeutic touch as an integral part of the domain of nursing.

(1) Touch can be perceived as a manifestation of caring and communication between the nurse and the patient.

(2) Tactile communication between healthy and ill individuals can have highly beneficial results.

c. herapeutic touch may make some patients uncomfortable; you are entering their personal space and their feelings must be respected, so make sure you ask the patient if he/she would like a back rub.

d. Agents used for back massage.

(1)  Lotions or emollients.

(a)  Lotions and emollients reduce friction and lubricate the skin.

(b)  They are appropriate for most patients, especially those with a tendency toward dry skin; that is, elderly patients.

(2)  Rubbing alcohol.

(a)  Alcohol evaporates quickly, so it has a cooling but very drying effect.

(b)  A certain amount of alcohol is absorbed by the skin so it should not be used on infants, elderly patients, or patients with liver disease.

(3)  Powder.

(a)  Powder reduces friction but also has a drying effect on the skin.

(b)  It may be appropriate for those patients who perspire freely and/or are confined to bed.

e. General guidelines.

(1)  A back massage should take about five to ten minutes and can be given with the patient's bath, before bedtime, or at any other time during the day.

(2)  Determine if any patient allergies or skin sensitivities exist before applying lotion to the patient's skin.

(3)  The greatest relaxation effect of a massage occurs when the rhythm of the massage is coordinated with the patient's breathing.

Guidelines for Shaving a Male Patient

a. If the patient is alert, question him about his shaving habits, and follow his routine as closely as possible.

(1)  Gather equipment and supplies.

(a)  Towels.

(b)  Washcloth.

(c)  Basin with hot water.

(d)  Shaving cream.

(e)  Razor.

(f)    Soap.

(g)  Aftershave lotion.

(2)  Wet the wash cloth, wring out any excess moisture, and apply it to the beard area (to soften the beard).

(3)  Apply shaving cream to the beard.

(4)  Shave the beard on the cheeks and upper lip in the direction that the hair grows.

(5)  Shave the beard on the neck against the direction of the hair growth.

(6)  Wash off any remaining shaving cream.

(7)  With clean water, finish washing the patient's face.

b. Always use an electric razor on patients with bleeding disorders to prevent uncontrollable bleeding from facial cuts.

c.   Do not use plugged in electric razors on patients who are receiving oxygen therapy because of the danger of combustion; safety razors or rechargeable battery operated shavers are safe.

d. Consult with the charge nurse before shaving any patient who has had facial surgery or who may have hemophilia.

e. Patients who are combative, suicidal, or disoriented should have supervision and assistance while shaving.

Perineal Care

a. Perineal care is often referred to as "pericare;" it consists of external irrigation of the vulva and perineum following voiding or defecation and is part of the routine A.M. and P.M. care.

b. Patients may be able to perform their own perineal care or may need partial or total assistance from the nurse.

c. Embarrassment on the part of the patient and the nurse can be effectively dealt with by ensuring patient privacy during the procedure and not totally exposing the patient's genital area.

d. Key points.

(1)  Ensure patient privacy.

(2)  Wipe from front to back (vagina toward rectum) on female patients to avoid contaminating the vagina or urethral meatus.

(3)  Do not use the same washcloth for any other portion of the patient's bath.

Bed Patient's Hair Care

a. Principles for Shampooing the Bed Patient's Hair.

(1)  The supine position is preferred for weaker patients.

(2)  Patients with significant heart or lung disease will not tolerate being supine; they must be in a sitting position.

(3)  Hair care should be given regularly during illness, just as it would be normally.

b. Purposes of Hair Care.

(1)  Hair care improves the morale of the patient.

(2)  It stimulates the circulation of the scalp.

c.   Shampooing removes bacteria, microorganisms, oils, and dirt that cling to the hair.


Nothing points out loss of independence quite as much as an inability to perform personal hygiene unassisted. Your thoughtfulness and the professionalism you exhibit when assisting a patient with hygiene needs will foster that patient's feelings of independence, confidence, trust, and comfort.