Bath for dependent patients: theorizing aspects of nursing care in rehabilitation

Baño del paciente dependiente: aspectos teorizantes de la atención de Enfermería en rehabilitación

ABSTRACT

Objective:

to produce a reflective essay on what has been produced in relation to bath as a procedure related to nursing care and diagnosis for dependent patients undergoing mediate and immediate rehabilitation processes after a traumatic event.

Method:

discursive, reflective study supported by classical content analysis consisting of the following stages: a) reading of the texts in their most comprehensive form; b) emphasizing the relevant elements produced about bathing; c) reflection on texts and what is produced about bathing.

Results:

the texts point out to three categories for nursing practice and reflection: Meaning to patients on the purposes of bathing; Representation for nurses in the work process; Representation for nurses in the management of care and nursing care planning.

Conclusion:

the reflection points out understandings on bathing as a care focused on the autonomy of nursing rehabilitation patients, requiring further investigations.

Descriptors:
Rehabilitation Nursing; Nursing Care; Self Care; Baths; Skin Care

RESUMEN

Objetivo:

Analizar en la perspectiva de un ensayo reflexivo sobre lo que está siendo producido acerca del baño, como procedimiento de atención y diagnóstico de enfermería para pacientes dependientes, en proceso de rehabilitación mediato e inmediato, posterior a evento traumático.

Método:

Discursivo, reflexivo, respaldado por análisis de contenido clásico, incluyendo las etapas: a) lectura integral de los textos; b) énfasis en elementos relevantes producidos sobre el baño; c) reflexión sobre los textos y sobre la producción sobre el baño.

Resultados:

Los textos determinaron tres categorías para reflexión y práctica de enfermería: Significado para el paciente de la práctica de enfermería; Representación para enfermeros en el proceso de trabajo; representación para enfermeros en la gestión del cuidado y planificación de atención de enfermería.

Conclusión:

La reflexión refiere una comprensión del baño como cuidado enfocado en la autonomía del paciente de enfermería de rehabilitación, y carece de investigaciones futuras.

Descriptores:
Enfermería en Rehabilitación; Atención de Enfermería; Autocuidado; Baños; Cuidados de la Piel

RESUMO

Objetivo:

versar na perspectiva de um ensaio reflexivo do que vem sendo produzido sobre o banho, como um procedimento do cuidado e do diagnóstico de enfermagem para clientes dependentes, em processo de reabilitação mediata e imediata, após evento traumático.

Método:

discursivo reflexivo, apoiado pelo método de análise de conteúdo clássica, constituída pelas seguintes etapas: a) leitura dos textos em sua forma mais abrangente; b) destaque para os elementos relevantes produzidos sobre o banho; c) reflexão sobre os textos e o que é produzido sobre o banho.

Resultados:

os textos apontam três categorias para reflexão e prática de enfermagem: Significado para o cliente nos propósitos desta; representação para enfermeiros no processo de trabalho; representação para estes na gestão do cuidado e planejamento da assistência de enfermagem.

Conclusão:

a reflexão aponta entendimentos do banho como cuidado focado na autonomia dos clientes da enfermagem de reabilitação e carece de futuras investigações.

Descritores:
Enfermagem em Reabilitação; Cuidados de Enfermagem; Autocuidado; Banhos; Higiene da Pele

INTRODUCTION

Traditionally performed by the nursing team worldwide, bed baths (aspersion, immersion, ablution) performed with totally dependent patients or supporting individuals with lower levels of functional dependence currently needs to be better understood. The practice of bathing developed by nurses is often performed only as a psychomotor-related procedure in accordance with a script, without any reflection on what is involved in this action (which is also a scientific action) and without considering aspects that go beyond the routine.

These ways of doing-thinking baths, including baths performed as a body hygiene and care and comfort procedure, baths for dependent patients performed in the shower or bath tub, or by spilling small volumes of water over the body, should be performed with serenity, gentle movements, careful observation to physical, sensory, and emotional responses, gathering a detailed list of nursing records for identification of nursing therapeutic procedures and diagnoses^(1-3).

Dependence in relation to bath-related body care appears essentially associated with altered mobility presented by individuals with pathologies⁽¹⁾, that is, individuals’ musculoskeletal incapacity to be independent in their activities of daily living. Reflecting on the essence of what constitutes a bath, it is possible to affirm that it is a complex care procedure that goes beyond the replacement of a patient presenting no strength, willingness, or knowledge to do it⁽³⁾.

Nurses need to understand their important role in teaching about bed baths to home caregivers, as well as in relation to other procedures regarding bathing functional dependent individuals out of institutional environments. Nursing guidance allows the clarification of doubts about the appropriate posture of the caregiver and the minimization of several negative feelings presented by patients in face of new experiences, making them more relaxed and promoting quality of life⁽²⁾.

Baths provided to self-care deficit individuals are seen by nurses as an action that confers a certain type of knowledge of an institutionalized profession that is legally regulated⁽³⁾ and involves intense physical strength to mobilize patients and change the bedding, often leading to complaints of fatigue and musculoskeletal injuries that may results in absences⁽⁴⁾.

It is known that individuals with spinal cord injury lose tactile and thermal sensitivity and control of urinary and fecal sphincters, thus presenting a higher inclination to intestinal constipation, urinary infections, and pressure ulcers^(5-6). Baths for these individuals should be an opportunity for rehabilitation nurse to contribute to improve the health indicators of this population segment, reducing the incidence and recurrence of bladder infection and pressure ulcers, and leading to an improvement in the levels of satisfaction of rehabilitation service users.

Providing care for family members or other significant people with disabling neurological injury and total dependence, including bed baths or shower baths, may represent a major challenge for nurses⁽⁵⁾ as it mobilizes the affective, emotional, and physical dimensions of both professionals and patients. Due to the affective involvement with patients, nurses seek to reconcile bathing with the patient’s predisposition, and often need to break with routine care standards of the institution so the bath does not represent an invasion of privacy or a discomfort to the patient⁽⁷⁾.

It is important to consider that rehabilitation nurses should suggest to home caregivers of individuals with severe neurological injury that the daily bath is also used for bowel and urinary eliminations and for the sequential care: assessment of skin integrity and other procedures aiming at the adequacy of the guidance on home accessibility^(5-6). These procedures contribute so that the bath does not cause physical, mental, or emotional overload for both professionals and patients, fulfilling its basic purposes in accordance with what was defined in their initial assessment, planning, intervention, and assessment of results.

Figure 1
Etiology of the need to bathe patients: therapeutic intervention

Body hygiene or bed bath has been pointed out by nursing as a potential factor for the work overload of the team⁽⁵⁾. Even though it represents one of the most important needs for individuals and significantly contributes to the recovery of patients in hospitals or rehabilitation centers, health professionals often do not give due importance to the theme.

Nursing students should be prepared to bathe patients in various practical situations, especially defining the most appropriate manner to their level of dependence and self-care deficit. In the acute stage of the hospital treatment of individuals with disabling neurological injury, for example, until the patient reaches more balance to sit in the shower chair, nurses should opt for the bed bath, remaining attentive to the responses of the patient’s body, understanding them as determining factors for the planning of long-term care actions^(4-5).

In the air-conditioned environments of high complexity treatment hospitals it is important to take into account the influence of the several conditions to which patients are exposed during the bath, and the need for thermal equilibrium, oxyhemodynamic balance, microbiologic aspects, and patient satisfaction, which may lead to different effects⁽⁸⁾.

Body hygiene of quadriplegic patients is more complex and requires nurses to preserve some basic essential principles to detect problems related to postural, motor, and sensitivity deficit⁽⁶⁾ resulting from spinal cord injury.

Incidentally, the absence of postural control, characterized by the deficit or absence of head, neck, and truck control, makes these individuals need external support to remain sit, including the use of accessories such as belts, head restraints, and side supports to promote stability, safety, and comfort. These accessories should also provide an appropriate posture for the caregiver during bath⁽⁹⁾.

As potential users of physical rehabilitation programs, as soon as individuals with severe neurological injury show signs of postural balance, they should be referred to aspersion baths, a convenient moment to assess the level of spasticity, tactile and thermal sensitivity, sphincter control, and motor coordination strength for support and transferences, activities of daily living, and self-care⁽⁵⁾.

In the literature there are several studies assessing the perception of patients in relation to bed baths, with prevalence of considerations on how they are unpleasant, embarrassing, difficult, uncomfortable, dry, cold, incomplete, inhuman, time consuming, and unsatisfactory^(4-5,7). This perception is aggravated when individuals enter physical rehabilitation public programs, considering that the number of dependent patients is significantly higher than the availability of hygiene chairs, leading to a high turnover of use associated with discomfort, malaise, and insecurity for patients as these accessories are often delivered wet and with remains of foam or gauze left by the previous user⁽⁵⁾.

Figure 2
Nursing semiotechnics for bathing patients with motor and self-care deficit

Summarily it is possible to verify that although bathing is part of the knowledge in nursing, a reflection in relation to the development of the specific knowledge of nurses is required.

Baths have a strong routine-centered representation⁽¹⁾, although they are also referred to as a moment of interaction with patients^(1,6,10). Lastly, the therapeutic vision is associated with the technique, intentionality, and principles to which they are intended, such as anxiety⁽¹⁰⁾.

The questions that guided this reflection were: Based on practice, which theorizations are we building to substantiate baths as a scientific technique? How are we teaching and performing baths? What is the importance given to baths if they are being relegated to other individuals in the hospital environment?

METHOD

• Moment 1: selection of texts about bathing;

• Moment 2: reading, highlighting the themes that emerged and indicated aspects of reflection;

• Moment 3: characterization of the terms and reflection on them based on the practice.

RESULTS

Data produced from the used methodology are shown in Chart 1.

Chart 1
Themes found about bathing

Authors	Emerging themes
Figueiredo, Carvalho and Tyrrell, 2006.	What nurses report about bathing • Action that involves self-knowledge (&) • Institutionalized profession (@) • Regulated by law (@) • Physical strength to mobilize (@) • Change of beddings (@) • Occupational fatigue (@) • Absenteeism (@) •
Machado and Scramin, 2010.	Functional dependence on home caregiver • Improvement of health indicators ( &) • Reduction of incidence and recurrence of bladder infection (&) • Minimization of the incidence of pressure ulcers (&) • Satisfaction of users (&) • Postural, motor, and sensitivity deficit (&) • Spinal cord injury (&) •
Lima and Lacerda, 2010.	Bath in critical hospitalized adult patients: review • Thermal regulation ( &) • Oxyhemodynamic equilibrium (&) • Microbiology (&) • Patient satisfaction (&) •
Dutra and Gouvinhas, 2010.	Development of shower chair prototype – spastic quadriplegia During aspersion bath keep attentive to: • Absence of postural control ( &) • Head and trunk control deficit (&) • Use of accessories (&) • Promotion of stability (&) • Safety and comfort (&) • Appropriate posture for caregivers (&) •
Penaforte and Martins, 2011.	In shift records of nurses • Altered mobility ( &) • Some pathologies (&) • Musculoskeletal disability (&) • Complex care (&) • Willingness or knowledge to perform (&) •
Lopes, Nogueira-Martins, Andrade and Barros, 2011.	Perception of patients about shower and bed bath • Ease suffering (#) • Unpleasant (#) • Embarrassing (#) • Important (#) • Difficult (#) • Uncomfortable (#) • Does not clean (#) • Dry (#) • Cold (#) • Incomplete Inhuman (#) • Unsatisfactory (#) • Time consuming (#) • Dependent (#) • Health professionals do not care (#) •
Lopes, Nogueira-Martins, Barbosa and Barros, 2013.	In informative manuals on bathing • Functional dependents ( &) • Institutional environments (&) • Minimization of negative feelings (&) • New experiences and feelings (&) • Promotion of quality of life (&) •
Figueiredo, Machado and Porto, 2014.	Field diary records • Providing care for significant people ( &) • Disabling neurological injury (&) • Total dependence (&) • Postural balance (&) • Spasticity assessment (&) • Tactile and thermal sensitivity assessment (&) • Motor coordination and strength (&) • Body responses (&) • Major challenge (@) • Mobilizing affective, physical, and emotional dimensions (&) • Affective involvement with patients (&) • Reconciling bath with the predisposition of the patient (@) • Breaking with the routine care standards of the institution (@) • Work overload (@) • Invasion of privacy (#) • Self-care (&) • Basic technical scientific deployment procedure (&) • Professors should emphasize the importance of observation during bath (&) • Providing support for care planning (&) • Technical aspect (&) • Minor activity appearance (&) • Bath is not important from the scientific perspective (&) • Bed bath until the patient reaches balance to sit (&) • Being attentive to the responses of the patient's body (&) • Meeting the determinants for planning care actions (&) •
Moller and Magalhães, 2015.	Work overload and safety of patients • Intense physical strength (@) • Bath is not important from the scientific perspective (&) • Unpleasant (#) • Embarrassing (#) • Inhuman (#) • Time consuming and unsatisfactory (#) • Mobilizing patients (@) • Changing the beddings (@) • Complaints of fatigue (@) • Musculoskeletal injuries (@) • Absences at work (@) • Nurses delegate it to nursing aides and technicians Omission of records (&) • Resistance by students in relation to learning to bathe (&) • Nurses rarely perform the procedure (&) •
Lopes, Barbosa, Nogueira-Martins, Barros, (2015)	• Anxiety (#) • Opportunity to train (&) • Promotion of well-being (&) • Provide care to individuals @

• Note:
• ^#
  what the bath means to patients in the purposes of nursing;
• ^@
  what the bath represents for nurses in their work and health process;
• ^&
  what the bath represents for nurses in the management and planning of nursing care.

DISCUSSION

A lot of time has been dedicated to reflection activities with students in nursing undergraduate and graduate programs focusing on the knowledge produced about bath in its several technical aspects, scientific practice, or procedures to provide care to dependent patients⁽⁵⁾. These incursions seek to conceptualize bath in a way that it is possible to affirm that it is a “care technology”, taking into account that its development requires scientific knowledge of anatomy, biology, physiology, psychology, and a significant level of subjectivity. Also, sensitivity (intuitive) is also necessary to perform a diagnosis on the needs for nursing interventions.

In light technology bathing is conceived in the group of technologies of relationships, access, embracement, bonding, meetings of subjectivities that encourage individuals with disabling neurological injuries to believe in their own potentials, essential to the functional gains that lead them towards self-care. It involves an act or effect of becoming autonomous⁽⁵⁾, considering the nursing scientific perspective based on the self-care deficit.

Incidentally, touching to care within the physical rehabilitation service represents a decisive factor so that patients are stimulated to a deeper dedication to reach functional gains and become more independent in relation to self-care and coordinated performance of activities of daily living. Touching in the bath enhances the exchange of energies, emotions, and actions between the individual performing the therapeutic procedure and the patient being bathed. It transcends the very technique of bathing patients and is established as the primordial basis of a nursing therapeutic action, becoming something beyond a simple technique action to perform body hygiene⁽³⁾.

In Intensive Care Units or in reserved institutional rehabilitation environments where basic care procedures are developed for individuals with disabling neurological injury, even techniques developed without major difficulties in stable patients, such as bathing, become complex in relation to critical patients⁽⁵⁾. Those are nursing actions that require an appropriate planning and qualified team to perform them, guided by a set of specific knowledge aimed at providing damage-free care, bio-functional improvement, and satisfaction and comfort to patients⁽⁸⁾.

Study limitations

Believing that the scientificity of bathing stands in the physical-chemical and biological responses resulting from touching, the harmonization of the environment, the exhaled body odors, and other subjective signs, although not representing measurable parameters from the quantitative perspective, represents a major challenge for all of us and objects that require further academic investigations in the area of nursing. The empirical affirmation that care heals and comforts is a result of our work in the practice of providing care to a number of patients in various situations, in which bathing causes sensations of well-being or malaise.

Contributions to the area of nursing, health, or public policies

It is known that bathing is one of the most frequently performed activities in the daily routine of the population in general, representing one of the most intimate and private moments, when individuals have contact with their own body⁽²⁾. Currently, in the routine of nursing, there is a concern related to compliance with standards and routines that lead to a fragmented care centered in the execution of tasks. Nursing professionals often disregard the fact the when they are bathing a patient, they are handling their body, invading their privacy and intimacy, causing dissatisfaction and anxiety⁽⁷⁾.

CONCLUSION

Being a theoretical-practical reflection, in accordance with the proposal of this study, it is important to highlight that the texts read and listed in Table 1 approach themes of particular interest for nursing, focusing on what bathing means to patients in the purposes of this area of knowledge. The major challenge in these texts is the fact that they show personal experiences of the several authors, in which the bathing procedure is found to be an object of scientific research when it is affirmed that it is within the field of light technologies. The procedure involves patients and nursing professionals in a ritual of acceptance and embracement in a meeting of subjectivities that encourage autonomy for self-care.

In relation to what the bath represents for nurses in the work and health process of workers, the association with the idea of work overload, physical exhaustion, and consequent occupational diseases reiterate that the procedure has not been performed in accordance with the principles of body dynamics and organization of nursing work processes. Informed, unsystematic, automated procedures conditioned to bathing are found to be adverse to care management and nursing care planning.

Currently, it is possible to affirm that the works produced partially met our objectives, as the postulated questions investigated in these literatures were not able to answer all questions, which is essential in a reflection text so that new inspirations may be forwarded to new investigations.

REFERENCES

• ¹
  Penaforte MHO, Martins MMFPS. The visibility of hygiene self-care in nurse-to-nurse shift change reports. Rev Latino-Am Enfermagem [Internet]. 2011 [cited 2016 Apr 20];19(1):131-39. Available from: http://www.scielo.br/pdf/rlae/v19n1/18.pdf
  » http://www.scielo.br/pdf/rlae/v19n1/18.pdf
• ²
  Lopes JL, Nogueira-Martins LA, Barbosa DA, Barros ALBL. Development and validation of an informative booklet on bed bath. Acta Paul de Enferm [Internet]. 2013[cited 2016 Apr 17]; 26(6): 554-60. Available from: http://www.scielo.br/pdf/ape/v26n6/en_08.pdf
  » http://www.scielo.br/pdf/ape/v26n6/en_08.pdf
• ³
  Figueiredo NMA, Carvalho V, Thyrrel MAR. (Re)lembrando Elvira de Felic: gestos e falas de enfermeiras sobre o banho no leito, uma técnica/tecnologia de enfermagem. Esc Anna Nery Rev Enferm[Internet]. 2006[cited 2016 Apr 16];10(1):18-28. Available from: http://www.scielo.br/pdf/ean/v10n1/v10n1a03.pdf
  » http://www.scielo.br/pdf/ean/v10n1/v10n1a03.pdf
• ⁴
  Moller G, Magalhães AMM. Bed baths: nursing staff workload and patient safety. Texto Contexto Enferm [Internet]. 2015[cited 2016 Apr 21]:24(4):1044-52. Available from: http://www.scielo.br/pdf/tce/v24n4/0104-0707-tce-24-04-01044.pdf
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• ⁵
  Figueiredo NMA, Machado WCA, Porto IS. Bastidores do Cuidado: a arte de cuidar em reabilitação. São Caetano do Sul: Yends; 2014.
• ⁶
  Machado WCA, Scramin AP. Functional (in)dependence in the dependent relationship of quadriplegic men with their (un)replaceable parents/caregivers. Rev Esc Enferm USP [Internet]. 2010 [cited 2016 Apr 12];44(1):53-60. Available from: http://www.scielo.br/pdf/reeusp/v44n1/en_a08v44n1.pdf
  » http://www.scielo.br/pdf/reeusp/v44n1/en_a08v44n1.pdf
• ⁷
  Lopes JL, Nogueira-Martins LA, Andrade AL, Barros ALBL. Semantic differential scale for assessing perceptions of hospitalized patients about bathing. Acta Paul de Enferm [Internet]. 2011 [cited 2016 Mar 28];24(6):815-20. Available from: http://www.scielo.br/pdf/ape/v24n6/en_a15v24n6.pdf
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• ⁸
  Lima DVM, Lacerda RA. Hemodynamic oxygenation effects during the bathing of hospitalized adult patients critically ill: systematic review. Acta Paul de Enferm [Internet]. 2010 [cited 2016 Mar 28];23(2):278-85. Available from: http://www.scielo.br/pdf/ape/v23n2/en_20.pdf
  » http://www.scielo.br/pdf/ape/v23n2/en_20.pdf
• ⁹
  Dutra FCM, Gouvinhas RP. [Development of a shower chair prototype for tetraplegic sufferers of cerebral palsy]. Prod[Internet]. 2010[cited 2016 Apr 08]:20(3):491-501. Available from: http://www.scielo.br/pdf/prod/v20n3/AOP_200810103.pdf Portuguese
  » http://www.scielo.br/pdf/prod/v20n3/AOP_200810103.pdf
• ¹⁰
  Lopes JL, Barbosa DA, Nogueira-Martins LA, Barros ALBL. Nursing guidance on bed baths to reduce anxiety. Rev Bras Enferm [Internet]. 2015 [cited 2016 Mar 27]:68(3):497-503. Available from: http://www.scielo.br/pdf/reben/v68n3/en_0034-7167-reben-68-03-0497.pdf
  » http://www.scielo.br/pdf/reben/v68n3/en_0034-7167-reben-68-03-0497.pdf

Publication Dates

• Publication in this collection
  Nov-Dec 2017

History

• Received
  17 June 2016
• Accepted
  02 Nov 2016