It's a wash: safeguarding the resident and yourself during the bathing process.

Editor's Note: The following information is provided to describe the various kinds of bathing equipment and transfer devices commonly used in the long term healthcare environment, as well as typical methods used to effectively and safely use them. Neither the author, the publisher or Invacare Corp. intend this information to be used, in whole or in part, as mandatory policy or procedures in your facility. It is provided solely as an overview of the type of equipment you are likely to encounter. Your individual facility will provide you with recommended procedures to be used in conjunction with bathing and transfer equipment.

Bathing equipment and transfer devices have come a long way from the days of cast iron tubs and steam kettles. The nurses and CNAs of a hundred years ago would scarcely recognize the modern equipment available to us today: Whirlpool jets for hydrotherapy, side access doors, onboard disinfecting systems and battery operated lifts all provide for a more pleasurable and effective means of bathing today's resident.

But many of the same safety precautions and considerations that were important "back then" are just as relevant today--even when applied toward today's more sophisticated equipment.

For the most part, bathing equipment can be divided into four basic groups: Showers, ShowerTrolleys, SitTubs and SupineTubs. In this article, we will only address Showers, Sit Tubs and Supine Tubs. [ShowerTrolleys, though still in use in some facilities for bathing, are more often found in Emergency Room and Triage units. If your facility does use shower trolleys, ask your D.O.N. or supervisor for specific information as to their use.]

Tools of the trade

Showers--Probably the most familiar unit, since nearly all of us have one in our home. Institutional showers are typically made of ceramic tile over a concrete block wall, with a cement floor, or are pre-molded out of fiberglass (sometimes called FRP in England and other areas) or acrylic. Older facilities are more likely to find tile and concrete showers, where newer facilities usually have fiberglass or acrylic units. The tile and concrete showers often have a "half high" wall that allows the caregiver to be on one side of the wall, while the resident is seated on the opposite side. Typical showers also feature a standard pressure balancing mix valve to adjust the water temperature and a "telephone" style shower wand on the end of a flexible shower hose.

SitTubs--Now almost universally made of fiberglass, these units are intended for use with the resident in a seated position. In the case of a side opening door unit, it may be used with or without a lift or transfer device. Solid units without doors require the use of a lift. The resident is situated on the seat of the lift and then elevated and maneuvered up, over and down into the tub.

Common accessories would be an anti-scald or "thermoscopic" mix valve to dispense water to the tub fill and the shower wand, a hand-held shower wand with flexible hose, whirlpool jets or air jets for hydrotherapy, and possibly some means of automatically disinfecting the system.

Almost all manufacturers of Sit Tubs market a lift designed to be used with their particular tub. [Lifts and transfer equipment will be discussed elsewhere.]

SupineTubs--Again, usually made of fiberglass, a supine tub bathes the resident in a prone or semi-prone position. A supine tub requires use of a lift and most often is of the "stretcher" type. The resident is typically transferred onto the stretcher while still in his or her room and transported to the bathing facility, bathed and then returned to the room having never left the stretcher.

Some tub manufacturers produce a "High-Low" version of their Supine tub. The High-Low feature allows the caregiver to raise the tub and bathe the resident without having to bend over. This greatly reduces the occurrence of MSDs (Musculoskeletal Disorders) among the care staff.

Playing it safe

Each resident is different in his or her degree of ambulatory ability, physical strength, motor skills and cognizance. A physical assessment of the resident will reveal his or her strengths and weaknesses and will play a major part in determining what special precautions, if any, need to be taken.

Just as important are the individual preferences of the resident. Some folks have spent a lifetime taking baths and dislike showers; while others are used to taking a shower and prefer not to sit in a tub. Dialoging with the resident will reveal these preferences and, to the extent possible, these requests might be met. If Helen is used to taking a bath before going to bed, it might be possible to implement that into her schedule. Harry, however, always liked to get up in the morning and take a shower. Do you have to give Martha a shampoo today, or did she just get her hair done yesterday and she wants to look nice? Whenever possible, meeting these needs goes a long way toward promoting a sense of familiarity and well being in their new environment.

Once the type of bathing and means of transfer have been decided upon, the caregiver(s) assigned to that resident should be made aware of his or her special needs and interact accordingly.

Transfers from wheelchairs--One of the most common types of transfers is that of getting a resident out of the wheelchair and onto a shower chair or lift of some kind. Here, it's important to take every safety precaution with the resident. But as a caregiver, it's just as important to look after your safety as well. Use proper body alignment at all times. "Body mechanics" is all-important. Wear shoes that grip, so you don't lose your footing while lifting and moving the resident. Plant your feet firmly. Lift with your legs and not your back. Assume a low or "squatting" position as you move.

If you are transferring from a wheelchair to a shower chair, bring the wheelchair into position beside and 90 degrees to the shower chair, with the opening of both chairs pointing toward you. In this way, you only need to raise the resident out of the wheelchair, and with very little pivoting, lower the resident onto the shower chair.

Always lock the wheels of both the wheelchair and the shower chair (if so equipped). You do not want either chair skidding away from you in the middle of a transfer. Use your gait belt (transfer belt) around the waist of the resident to help give you additional leverage and to use the resident's own geometry to help in getting up. If you suspect for a moment that you are too small in stature or your resident is too heavy or uncooperative, ask for assistance. It is better to ask a co-worker to help you than to risk injury to you and the resident. Two-person transfers are easier on you and the resident.

During the transfer, maintain eye contact with the resident as much as possible. Make sure the resident has shoes or slippers on his or her feet. Never make a transfer with the resident barefoot if at all possible. Make every effort to avoid abrading the skin. Skin tears happen all too easily with elderly residents. Depending on the protocol at your facility, you may be asked to remove all rings and other jewelry on your hands and wrists. Sharp stones and clasps can cause injury. Make sure the floor is dry. Even in tennis shoes, you can slip on a wet floor and lose your balance. If you start to go down, your resident will go down with you.

If transferring from a wheelchair to a lift, the methods are much the same. Position the lift in such a way that a minimum amount of lifting and pivoting is necessary. Depending on the type of lift and wheelchair, you may be able to bring the lift seat along side the wheelchair and raise or lower the seat to the same height as the wheelchair. Lock the wheels of the chair and the lift. If the arms of the wheelchair come off, you can transfer your resident from chair to lift very easily by making a "sliding transfer" between chair and lift seat. If the arms do not come off, make a 90-degree transfer as described above. Again, a two-person transfer may be easier on you and your resident.

Once you have made the transfer, see that the resident's arms, hands and feet are inside the confines of the chair or lift. Avoid having the extremities come in contact with anything as you transport the individual to the bathing area. If advisable, secure the safety belt around the resident (if so equipped).

Transferring to a Stretcher Lift--Transfers to stretcher lifts are best made from the bed. Depending on the physical capabilities of the resident, there are two basic methods:

1. The rolling transfer, Lower the stretcher, completely flat, onto the mattress along side of and parallel to the resident. Lock the wheels. Situate the resident on their side so they have their back to the stretcher and are nearly touching it. Then, carefully roll the resident onto the stretcher, making sure head, back and legs are equally supported by the stretcher. A two-person transfer is recommended. Raise the stretcher off the mattress before pulling the lift away from the bed. Unlock the wheels. If the resident can tolerate bending at the waist, raise that portion of the stretcher that places the resident in a semi-prone position. If advisable, secure the safety belt around the resident's waist before proceeding, if the lift is so equipped.

2. The sliding transfer. This transfer is best performed with two people. Situate the resident on his or her back, on a sheet or blanket, near the edge of the bed. Bring the stretcher portion of the lift along side of and parallel to the bed. Raise or lower the stretcher until it is at the same height as, and resting against the edge of the mattress. Lock the wheels. With one person at the resident's head, and the other at the feet, grasp the sheet or blanket and begin sliding both sheet and resident onto the stretcher. Once completely supported by the stretcher, the sheet may be removed by rolling the resident toward their side while the sheet is removed. Gently ease me resident back down. If advisable, secure the safety belt around the resident's waist and raise the head end of the stretcher.

Make sure arms, hands and legs are completely inside the confines of the stretcher. You may want to put the resident's hands in his or her lap during transfer to avoid coming in contact with doors or walls. Feet should be covered.

Do diligence

When it comes to safety during the actual bath or shower, you need to be on your guard. A major precaution for your safety is to avoid agitating the resident. Upset residents--especially those with dementia--can injure their caregivers. Extra care must be taken in regards to water temperature, body washing, shampooing, manicuring/pedicuring and even disrobing practices.

Depending on the kind of bathing equipment to be used, follow the manufacturers and your facility's procedures in bringing the resident into the tub. In the case of a supine tub, you will be transporting your resident on a stretcher. With a sit tub, you will be transporting using a sit lift. Bring the lift near the tub and begin raising the stretcher or seat, using whatever method is provided by the equipment used. Look for signs from the resident that the action of lifting is causing alarm. This is especially so of persons with dementia. Take it slow if you suspect any anxiety or fear.

Once the stretcher or seat and resident are well above and directly over the interior of the tub, begin lowering the resident. Continually check the head, hands and feet to make sure they do not contact any parts of the tub.

Continue lowering the resident until, depending on the make of equipment, the stretcher or seat is properly inside the tub. Test and confirm the proper temperature of the water before proceeding. Once the temperature is established, close the drain and turn on the "Tub Fill" valve, depending on the equipment you are using. If you are not intending to give a full emersion bath, you can use the shower wand to both shampoo and bathe the resident.

Follow your facility's procedures for gowning and remove the lift and resident from the bathing area.

Be sure to disinfect the tub, lift and whirlpool system between every bath. Follow the manufacturer's instructions for proper disinfecting.

Bathing can and should be a pleasurable and safe experience for the resident and you. By following these basic steps, using the procedures prescribed by your facility and listening to your resident, you can be assured you are doing everything you can to make bathing what it is designed to be: therapeutic, invigorating and just plain fun.

Brian Amato is bathing/lifting/transferring product specialist for Invacare Corp. As product manager, he has contributed design and engineering input into the various products the company produces.