MDS Alert

Published on Tue Jan 22, 2008 PDF

A combo of strategies can make a big difference in resident behavioral and satisfaction outcomes.

Bathing can become a source of dread for residents with dementia who fear the bath -- or for any resident who finds the experience too institutional and undignified. Yet simple changes in assessment and care planning can turn around even the fiercest resistance to this necessary part of care.

Overcome this obstacle: Nursing home staff "get stuck on doing the skin assessment during the bath or shower" and think residents therefore "need to be naked" for that purpose, says Joanne Rader, MSN, RN, a Silverton, Colo.-based consultant and pioneer in research on bathing without a battle.

Yet people "prefer to be warm and covered when they are bathed." And there are ways to assess a resident's skin while keeping the person covered, Rader adds.

And "if you can't completely visualize the person's buttock area during the bath," take advantage of other opportunities during toileting and dressing, Rader suggests.

Assessment is more than skin deep: A caregiver can collect a wealth of other information during the bath for care planning. For example, you can determine if the person can follow directions, has pain, range of motion deficits ��" and his tolerance level for having things done to him, says Rader.

These additional strategies can help people better enjoy the bath:

• Replicate familiar routines. When assessing customary routines and preferences at admission, ask about the person's usual bathing routine with a goal of replicating it as much as possible. All residents can benefit by having their familiar shampoos, colognes and liquid soaps available during bathing, grooming and hygiene, says Reta Underwood, principal of Consultants for Long Term Care in Buckner, Ky.

• Provide spa touches. Some facilities give everyone their own spa robes with their name embroidered on it to wear to the tub room, Underwood notes.

Another perk: "Residents can wear these customized spa robes to breakfast," if they wish, she adds, which saves "precious staff time" and allows the resident to sleep in a little longer and get dressed for the day once they've had their coffee.

Some facilities go the full spa route, including offering aromatherapy. But if that is too much for your facility, providing simple decorative touches in the bathing area, such as hanging pictures and towels on the walls, can help make it seem more home-like, notes Cheryl Boldt, RN, a consultant with Maun-Lemke in Omaha, Neb.

If a resident with dementia dislikes the bath, try to provide hygiene care when the person seems most agreeable to it, such as when he first gets up before dressing, suggests Rader. Also break down the bath into smaller components to accomplish hygiene goals, she adds.

For example, "provide a basin of warm water to help the person wash his hands and face, or use the basin to wash the person's legs and feet," Rader advises.

"Many elders in facilities today used to take what they called 'spit baths' where they washed out of a basin," says Boldt. So that may seem familiar to them, she adds.

Very important: Assign a constant caregiver who listens to and respects the resident's choices. If you do, the resident who resists bathing will probably eventually allow the caregiver to bathe him or even take him to the shower, says Rader. "Sometimes it takes up to three months," she says. But "we have all heard stories about that happening or seen it happen."

Tip: Primary assignments pay off for all residents, regardless of their cognitive status. A CNA who is familiar with a resident will be able to detect changes in the person's status during the bath, such as pain or limitation in the range of motion, notes Jennifer Gross, BSN, RN, RAC-CT, a healthcare specialist with PointRight in Lexington, Mass.

Don't sacrifice trust for routine: If caregivers develop rapport with a resident by honoring his preferences, and then push personal care on him, they'll destroy whatever trust they've built up with the person, Rader cautions. And that can cause the person to resist care the next time.

Rader sees "a tendency to think we have to bathe someone right at this moment" rather than looking more at the bigger picture. "Sticking to the bathing schedule is not more important than the effect on the resident and his behavior."

Teach staff to resist the temptation to do more for any resident during the bath than needed, which can undermine his opportunity to increase range of motion, activity levels, and self-esteem. "Washing your own face is more powerful than having it done for you," says Sheryl Rosenfield, RN, BC, a consultant with Zimmet Healthcare Services Group in Morganville, N.J.

Look for opportunities to provide restorative care in the area of bathing. For example, staff could provide verbal cues to help the person wash and dry and dress, says Cheryl Field, RN, MSN, CRRN, a consultant with PointRight Inc. And they could provide a program of upper body exercises to strengthen residents' abilities to perform more of their own bathing skills in the future, she adds.

Tip: Even if the person doesn't receive restorative, look to see if he would benefit from task segmentation (G7) for bathing. This approach can help people with dementia succeed at the ADL -- and it can help residents who tire easily during the bath due to COPD or congestive heart failure, as examples.

Editor's note: Is your bathing coding in Section G as pristine as it could be? For more info, see the next MDS Alert.