Nursing Diagnosis: Bathing/hygiene Self-care deficit

Linda S. Williams
NANDA Definition: Impaired ability to perform or complete bathing/hygiene activities for oneself

Defining Characteristics: Inability to: wash body or body parts; obtain or get to water source;
regulate temperature or flow of bath water; get bath supplies; dry body; get in and out of bathroom

Impaired physical mobility-functional level classification:

0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance, supervision, or teaching
3 Requires help from another person and equipment or device
4 Dependentdoes not participate in activity

Related Factors: Decreased or lack of motivation; weakness and tiredness; severe anxiety; inability
to perceive body part or spatial relationship; perceptual or cognitive impairment; pain; neuromuscular
impairment; musculoskeletal impairment; environmental barriers

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Self-Care: Activities of Daily Living (ADLs)

Self-Care: Bathing

Self-Care: Hygiene

Client Outcomes

Remains free of body odor and maintains intact skin

States satisfaction with ability to use adaptive devices to bathe

Bathes with assistance of caregiver as needed without anxiety

Explains and uses methods to bathe safely and with minimal difficulty

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Bathing

Self-Care Assistance: Bathing/Hygiene

Nursing Interventions and Rationales

Assess client's ability to bathe self through direct observation (in usual bathing setting
only) and from client/caregiver report, noting specific deficits and their causes. Use of
observation of function and report of function provide complementary assessment data for
goal and intervention planning (Reuben et al, 1992).
 If in a typical bathing setting for the client, assess via direct observation using physical
performance tests for ADLs. Observation of bathing performed in an atypical bathing
setting may result in false data for which use of a physical performance test compensates
to provide more accurate ability data (Guralnik, 1994).

Ask client for input on bathing habits and cultural bathing preferences. Creating
opportunities for guiding personal care honors long-standing routines, increases control,
prevents learned helplessness, and preserves self-esteem (Miller, 1997). Cultural
preferences are respected (Freeman, 1997).

Develop a bathing care plan based on client's own history of bathing practices that
addresses skin needs, self-care needs, client response to bathing and equipment needs.
Bathing is a healing rite and should not be routinely scheduled with a task focus. It should
be a comforting experience for the client that enhances health. (Rader, Hoeffer, McKenzie,
1996).

Individualize bathing by identifying function of bath (e.g., odor or urine removal),

frequency required to achieve function, and best bathing form (e.g., towel bathing, tub, or
shower) to meet client preferences, preserve client dignity, make bathing a soothing
experience, and reduce client aggression. Individualized bathing produces a more positive
bathing experience and preserves client dignity. Client aggression is increased with shower
(especially) and tub bathing. Towel bathing increases privacy and eliminates need to move
client to central bathing area; therefore it is a more soothing experience than either
showering or tub bathing (Rader, Hoeffer, McKenzie 1996; Hoeffer et al, 1997; Miller,
1997).

Request referrals for occupational and physical therapy. Collaboration and correlation
of activities with interdisciplinary team members increases the client's mastery of self-care
tasks (Schemm, Gitlin, 1998).

Plan activities to prevent fatigue during bathing and seat client with feet supported.
Energy conservation increases activity tolerance and promotes self-care.

Provide medication for pain 45 minutes before bathing if needed. Pain relief promotes
participation in self-care.

Consider environmental and human factors that may limit bathing ability, such as
bending to get into tub, reaching required for bathing items, grasping force needed for
faucets, and lifting of self. Adapt environment by placing items within easy reach, lowering
faucets, and using a handheld shower. Environmental factors affect task performance.
Function can be improved based on engineering principles that adapt environmental
factors to the meet the client's capabilities (Rogers et al, 1998).

Use any necessary adaptive bathing equipment (e.g., long-handled brushes, soap-on-
a-rope, washcloth mitt, wall bars, tub bench, shower chair, commode chair without pan in
shower). Adaptive devices extend the client's reach, increase speed and safety, and
decrease exertion.

Provide privacy: have only one caregiver providing bathing assistance, encourage a
traffic-free bathing area, and post privacy signs. The client perceives less privacy if more
than one caregiver participates or if bathing takes place in a central bathing area in a high-
traffic location that allows staff to enter freely during care (Miller, 1994).
 Keep client warmly covered. Clients, especially elderly clients, who are prone to
hypothermia may experience evaporative cooling during and after bathing, which produces
an unpleasant cold sensation (Miller, 1994).

Allow client to participate as able in bathing. Smile and provide praise for
accomplishments in a relaxed manner. The client's expenditure of energy provides the
caregiver the opportunity to convey respect for a well-done task, which increases the
client's self-esteem. Smiling and being relaxed are associated with a calm, functional client
response (Maxfield et al, 1996).

Inspect skin condition during bathing. Observation of skin allows detection of skin
problems.

Use or encourage caregiver to use an unhurried, caring touch. The basic human need
of touch offers reassurance and comfort.

If client is bathing alone, place assistance call light within reach. A readily available
signaling device promotes safety and provides reassurance for the client.
Geriatric

Provide same type of bathrobe and bathing articles, such as scented dusting powder
and bath oil, that client used previously. Use of sensory channels to stimulate memory
may help foster understanding of bathing and self-care (Danner et al, 1993).

Assess for grieving resulting from loss of function. Grief resulting from loss of function
can inhibit relearning of self-care.

Arrange bathing environment to promote sensory comfort: reduce noise of voices and
water and decrease glare from tiles, white walls, and artificial lights. Noise discomfort can
result from high-echo tiled walls, loud voices, and running water. Glare can cause visual
discomfort, especially in clients with visual changes or cataracts (Miller, 1994).

When bathing a cognitively impaired client, have all bathing items ready for client's
needs before bathing begins. Injury often occurs when cognitively impaired client is left
alone to obtain forgotten items (Sloane et al, 1995).

Bathe elderly clients before bedtime to improve sleep. An evening bath helps elderly
clients sleep better (Kanda, Tochihara, Ohnaka, 1999).

Bathe cognitively impaired clients before bedtime. Bathing a cognitively impaired

client in the evening helps improve symptoms of dementia (Deguchi et al, 1999).

Limit bathing to once or twice a week; provide a partial bath at other times. Frequent
bathing promotes skin dryness. Reducing frequency of bathing decreases aggressive
behavior in cognitively impaired clients (Hoeffer et al, 1997).

Allow client or caregiver adequate time to complete the bathing activity. Significant
aging increases the time required to complete a task; therefore elderly individuals with a
self-care deficit require more time to complete a task.
 Avoid soap or use only mild soap on genital and axillary areas; rinse well. Soap can
alter skin pH and thus skin defenses, and it may increase skin dryness that results from
decreased oil and perspiration production in the elderly (Skewes, 1997).

Use tepid water: test water temperature before use with a thermometer. Hot water
promotes skin dryness and may burn a client with decreased sensation.

Use a gentle touch when bathing; avoid vigorous scrubbing motions. Aging skin is
thinner, more fragile, and less able to withstand mechanical friction than younger skin.

Add hydrating bath oils to tub bath water 15 minutes after client immerses in water.
Client's skin is coated with oil rather than being hydrated if bath oil is placed in water
before client's skin is moistened with water (Skewes, 1997).

Home Care Interventions

Based on functional assessment and rehabilitation capacity, refer for home health aide
services to assist with bathing and hygiene. Support by home health aides preserves the
energy of the client and provides respite for caregivers.

Cue cognitively impaired clients in steps of hygiene. Cognitively impaired clients can
successfully participate in many activities with cueing, and participation in self-care can
enhance their self-esteem.

Respect the preference of terminally ill clients to refuse or limit hygiene care.
Maintaining hygiene, even with assistance, may require excessive energy demands from
terminally ill clients. Pain on touch or movement may be intractable and not resolved by
medication.

If a terminally ill client requests hygiene care, make an extra effort to meet request
and provide care when client and family will most benefit (e.g., before visitors, at bedtime,
in the early morning). When desired, improved hygiene greatly boosts the morale of
terminally ill clients.

Maintain temperature of home at a comfortable level when providing hygiene care to

terminally ill clients. Terminally ill clients may have difficulty with thermoregulation, which
will add to the energy demand or decrease comfort during hygiene care.

Client/Family Teaching

Teach client and family how to use adaptive devices for bathing, and teach bathing
techniques that promote safety (e.g., getting into tub before filling it with water, emptying
water before getting out, using an antislip mat, wall-grab bars, tub bench). Adaptive
devices can provide independence, safety, and speed (Schemm, Gitlin, 1998).

Teach client and family an individualized bathing routine that includes a schedule,
privacy, skin inspection, soap or lubricant, and chill prevention. Teaching methods to meet
client's needs increases the client's satisfaction with the bathing experience.