providing incontinence care

Assessment
Assess the patient's ability to perform perineal care
Assess for the presence of irritation, excoriation, inflammation and swelling

Planning
Perform hand hygiene
Prepare necessary equipments:

• commercially prepared package washcloth/moistened cotton wool pads
• incontinent sheets
• napkin
• clean linens: gown/pyjamas, bath blanket, top and bottom sheets, draw sheet
• clean gloves
• linen hamper
• ZnO cream
• disposable plastic bag or receptacle

Implementation

Gather equipment and bring to client's bedside

Identify the patient

Explain the procedure and gain cooperation

Provide privacy

Perform hand hygiene and adopt other appropriate infection control precautions

One nurse works on one side of the bed and the second nurse on the other side

Prepare the bed, and position the client appropriately

• raise bed to comfortable working height. Lower side rails
• remove top linens. If the linens are reused, place them on the bedside table/chair
• assist client in a dorsal recumbent position (lying down/legs flex)

The other nurse works on the opposite side.

Don gloves

Loosen pants or gown

• keep client covered by bath blanket if desired
• expose perineum

Observe skin condition for any presence of irritation, excoriation, inflammation and swelling. 

Place incontinent sheet under the buttock

Clean the soiled area by cleansing from tip of penis down to shaft. Pay attention to the gluteal folds, scrotal folds.

Cleansed tip of penis at urethral meatus using circular motion. Then cleanse shaft of the penis and scrotum. Cleansed the scrotum and the underlying skinfolds carefully

Use a clean washcloth for each area of the perineum in order to prevent cross contamination

Roll up the front side of the napkin

Pull or roll the client to the lateral position

Thoroughly clean up the fecal elimination with cotton swaps and thoroughly dry the area

Apply protective skin barrier cream if indicated.

Remove and discard the gloves and wash the hands

Change the draw sheet or the linen if soiled

Put the new napkin in correct position

Lie flat the client and adjust the position of the napkin

(Avoid any shearing force, roll the client back and forth if need to adjust the position of the napkin)

Body mechanics

Establishing body alignment
Establish a firm base of support by placing both feet flat on the floor, with one foot slightly in front of the other
Distribute weight evenly on both feet
Slightly bend both knees
Hold abdomen firm and tuck buttocks in so that spine is in alignment
Hold head erect, and secure firm stance
Use this stance as the basis for all actions in moving, turning and lifting clients
Maintain weight to be lifted as close to your body as possible
Align the three natural curves in your back, i.e. cervical, thoracic and lumbar
Prevent twisting your body when moving the client

Maintain proper body alignment
Begin with the proper stance outlined as above
Evaluate working height necessary to achieve objective
a) Test parameters of possible heights (i.e. bed moves within an appropriate range of 18 inches from floor)?
b) Establish a comfortable height in which to work; usual height is between waist and lower level of hip joint
Test that this level minimizes muscle strain by extending your arms and checking that your body maintains proper alignment
If you need to work at a lower level, flex your knees
Make accommodations for working at high surface level (?)
Work close to your body so that your centre of gravity is not misaligned and your muscles are not hyper-extended
Use your longest and strongest muscles (biceps, quadriceps, and gluteal) when moving and turning clients
Whenever possible, roll, push, and pull objects instead of lifting
Plan muscle movements to distribute workload before you actually begin turning, moving, or lifting clients
Move muscles in a smooth, coordinated manner
When working with another staff member, coordinate plans and movements before implementing them

Transferring a patient from bed to stretcher

Planning
Collect the necessary equipment:
- draw sheet or transfer board (patslide)
- stretcher
- blanket (optional)

Implementation (three persons)
Perform hand hygiene
Identify the patient and explain the procedure
Move the bed and equipment to make room for the stretcher. Make sure assistants are available
Lower the head of bed completely or to a position that is as low as the patient can tolerate
Raise the bed to a comfortable working height and slightly higher than the level of stretcher to make it easier to move the patient. Lower the side rails
Place a draw sheet under patient if one is not in use. Use the draw sheet to move patient to the side of bed where the stretcher will be placed
Roll the draw sheet as close to patient's side as possible
Position the stretcher next to the bed and parallel to it. Lock brakes on the bed and stretcher. Remove pillow from the bed and place it on the stretcher

Transfer by using draw sheet:
a) The 1st staff should kneel on the side of bed away from the stretcher. Position one knee at the upper torso (trunk) closer to the patient than the other knee. Grasp the draw sheet securely
b) The 2nd staff should stand on the side where the stretcher is and reach across stretcher to grasp the draw sheet at the head and chest areas of the patient
c) The 3rd staff (stands on the same side as 2nd staff) should reach across the stretcher and grasp the draw sheet at the patient's waist and thigh area
d) At a signal given by the 1st staff, the 2nd and 3rd staff pull and press the body against the stretcher while the 1st nurse lifts the patient from the bed to the stretcher

Transfer by using a transfer board (patslide)
a) The 1st staff stands on the side of bed away from the stretcher, while the 2nd and 3rd staff stand on the far side of bed next to stretcher after assisting the 1st staff to turn patient onto his side with the back facing the stretcher
b) The 1st staff continues to support patient in the lateral position
c) The 2nd and 3rd staff position the transfer board lengthwise and midway between the bed and stretcher (with smooth side of board facing upward)
d) Return patient to his back with a draw sheet between patient and the board. Place patient's arms across his chest
e) On the count of three, grasp the sheet as close to patient as possible and slide across the transfer board onto the stretcher with one firm and coordinated movement
f) Roll patient slightly over one side, and pull transfer board out from under his back, if necessary

Center patient on stretcher and secure him until side rails are raised
Assist patient to a comfortable position. Place blanket over patient and adjust head of stretcher accordingly to patient's limitations
Leave draw sheet in place for transfer back to bed later
Perform hand hygiene

Transferring a patient from bed to chair/wheelchair

Planning
Collect the necessary equipment:
- wheelchair or chair with arm support
- non-skid slippers or shoes
Remove obstacles from the area used for the transfer
Obtain sufficient assistance to complete the procedure with ease

Implementation (two persons)
Perform hand hygiene
Identify patient and explain the procedure
Offer bedpan/urinal or provide perineal care before transferring, if necessary
Move furniture as required to make room for the procedure
Bring the chair close to the side of the bed
Place it at a 45 degree angle to the bed if patient experienced difficulty in walking or place the wheelchair parallel to the bed if the patient is able to walk a few steps. If the patient has a weaker side, place the chair on the patient's stronger side. Lift up the foot pedals and lock brakes for wheelchair
Place the bed to the lowest position, and raise head of bed as far as patient can tolerate. Lower side rails
Assist patient to side-lying position, facing the side of bed he will sit on
Two staff stand on the same side as the chair. The first staff stands near the head of the bed place arm around patient's shoulders ( to support head and neck) and place the other hand on the bed surface to provide support and balance. The staff shift weight to back leg and lifts patient
The second staff stands near the foot of the bed swinging patient's lower legs off the bed in one single and coordinated motion. Keep back straight, avoid twisting
Support patient in a sitting position at the side of the bed with his legs dangling for a few minutes, and assess for signs and symptoms of orthostatic hypotension (do not leave patient unattended during dangling)
Help patient to put on robe and non-slip footwear as necessary
Assist patient to move as close to the edge of bed as possible until feet are firmly on the floor and slightly apart
Two staff stand on each side of the patient, with the hand closest to the patient places just below but not directly under the axilla. Using a wide stance, flex knees and assist the patient to a standing position
Standing close to the patient. Pivot or take a few steps until the patient's back is toward the chair/wheelchair
Instruct patient place hands on the arm supports of chair to gain balance and judge the distance to seat
Flex hips and knees while lowering patient into a sitting position
Assist patient to maintain proper body alignment. Support weak side of the body with pillows in order to prevent slumping (sudden fall) in the chair/wheelchair if needed
Make sure tubes and lines, arms and hands are not pinched or caught between the patient and the chair
Cover patient and supply a seat belt if needed
Place the foot pedals back to the wheelchair or offer footrest (chair) as necessary
Position call bell for easy reach
Perform hand hygiene

Positioning a patient in bed

Assessment
Assess patient's body alignment and comfort level in current position
Check patient's record and physician's order. Determine if any condition that influence patient's physical ability to move or to be positioned (e.g. muscle strength, fractures and presence of paralysis)
Note the presence of tubes, IV lines, incisions or equipment that may interfere with the positioning procedure
Assess patient's level of consciousness and ability to understand instructions in positioning
Assess patient's weight and your strength. Determine if additional assistance is needed

Planning
Collect the necessary equipment: pillows for positioning; draw or lifting sheet
Obtain sufficient assistance to complete the procedure with ease

Implementation (2 persons)
Perform hand hygiene
Identify patient and explain the procedure
Adjust the head of bed to flat position or as low as the patient can tolerate
Elevate the bed to a comfortable working height
Remove pillow and place it at the head of bed to prevent striking patient's head during lifting
Coordinate the movement between two staff. One staff is responsible for stating when to move patient, "on count of three"

For partially dependent patients:
a) Position one staff on each side of the patient
b) Each staff place one arm under the patient's shoulders and one arm under the patient's thighs. This supports the heaviest part of the body
c) Assume broad base of support; position front foot facing head of bed, body slightly turned toward head of bed
d) Ask patient to flex knees with feet flat on bed
e) Instruct patient to flex neck, tilting chin toward chest
f) Instruct patient to assist moving by pushing with feet on bed surface
g) Staff flex knees and hips, bringing forearms closer to the level of bed
h) Instruct patient to push with heels and elevate trunk while breathing out, thus moving toward head of bed on count of three

For totally dependent clients:
a) Position one staff on each side of bed
b) Place lifting sheet under patient's body extending from shoulder to the thighs
c) Position patient in a supine position
d) Roll up sides of lifting sheet as close as possible to the sides of patient
e) Assist patient to flex knees and fold arms across the chest, if not contraindicated
f) Each staff firmly grasp sheet at level of patient's upper back with one hand and at level of buttocks with the other hand, placing weight on back foot
g) Place feet apart with forward-backward stand. Flex knees and hips

Shift weight back and forth from the back leg to front leg, and on count of three, lifts patient toward head of the bed with a firm, coordinated and rocking movement
Repeat if necessary
Ensure patient is in correct body alignment, replace pillows and arrange bedding as necessary
Position drains, tubes and IV to accommodate a new position in order to prevent accidental dislodgement and discomfort from movement
Maintain patient safety. Raise the side rails and resume the bed to lowest position. Place cell bell within patient's reach
Perform hand hygiene

Position patient in side-lying position
Perform hand hygiene
Identify patient and note any mobility restrictions
Lower head of bed as flat as patient can tolerate if not contraindicated
Elevate the bed to a comfortable working height
Position one staff on each side of the bed and lowers the side rails
Using draw sheet. Roll up the sheet as close as possible to the patient's body and grasp firmly. Staff pull the patient with draw sheet to the opposite side of the bed that he will be turned
On the side that patient will be turned, abduct patient's arm slightly away from his body. On the other side, position patient's arm across the chest and flex the knee before turning
Place one hand on the patient's hip and the other hand on the shoulder
Staff assumes a broad stance with knees slightly flexed. Gently roll patient over onto the desired side by using the draw sheet
Observe patient's skin condition after turning
Maintain patient's body alignment
Place pillows under head and behind back to provide additional support to the spine
Bring shoulder blade forward and out from under patient (?)
Position both arms in slightly flexed position. Support patient's upper arm with pillow level with shoulder, if necessary
Place pillow lengthwise between patient's legs from thighs to foot. Shoulder and hips should be aligned
Raise the side rails and adjust the bed position as necessary. Place call bell within patient's reach
Perform hand hygiene

Evaluation
Patient's tolerance and response of procedure
The skin condition of patient
Patient's position in alignment and comfortable
Level of assistance received from patient