Palliative Care Guidelines
Jimmy S Bilimoria Foundation

CARE OF THE BEDBOUND PATIENT

INTRODUCTION

Bedbound patients are those who are confined to their bed due to illness or infirmity more than 90% of the time (some may be wheeled to the toilet or for showering). This can lead to further weakness and inability to move. Bedbound patients could be conscious or unconscious. Care of conscious and unconscious patients remain the same except in the area of nutrition/feeding and care of the skin, bowel and bladder.

The most common complications/problems of bedbound patients are:

  • Dry skin
  • Pressure injuries
  • Muscle wasting/atrophy
  • Contractures/deformity of joints and bones
  • Osteoporosis
  • Atelectasis
  • Respiratory tract infections
  • Venous thrombosis
  • Constipation
  • Urinary tract infections especially those on indwelling urinary catheters
  • Risk of falls
  • Depression

Care provided to a bedbound patient aims to assist in rehabilitation, cure or comfort, and prevention of problems and/or complications.

ASSESSMENT

  • Assessment must determine the underlying aetiology of confinement to the bed, effectiveness of treatment of the underlying condition, especially if it is still reversible or can prevent or slow down progression of the underlying condition and improve the quality of life for the patient and their family
  • Assessment must also include evaluating the patient for problems and/or complications secondary to being confined to bed (refer to the Guideline – Symptom Assessment)

RECOMMENDATIONS

  • Universal precautions are a must when providing hygiene
  • Care should be individualised based on the patient’s performance status, preferences and comfort
  • Medicines for relief of symptoms should be administered before providing hygiene
  • The presence of anxiety or fear related to the care being provided must also be assessed and addressed
  • If the patient is able, the patient should be permitted to perform personal hygiene independently
  • The patient/caregiver should be educated, trained and demonstrated in methods to perform personal hygiene
  • A multi-disciplinary approach is recommended in the care of the bed ridden patient
  • Safety of the bed bound patient should always be considered. Measures to improve and enhance safety, such as the use of bed rails, should be applied.

MANAGEMENT

Care of the bedbound patient includes the following:

  • HYGIENE
  • COMFORT
  • NUTRITION and HYDRATION
  • PHYSICAL REHABILITATION

HYGIENE

According to the World Health Organization (WHO), “hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases”. Personal hygiene refers to maintaining the body’s cleanliness and includes:

Eye care

Eye care is performed to prevent the development of dry eye, clear the eye of secretions and debris, relieve any irritation of the eye, and to prevent corneal damage and infections

  • Assessment – Assess for corneal dryness, ability of the patient to keep the eyes closed completely, cleanliness of the eye and eyelids, discharges, crusts, discolouration, signs of infection, eye care interventions, and effectiveness of eye care interventions
  • Management
    • Cleaning of the eye
      • Prior to the procedure, advise the patient to close the eyelids to prevent any damage to the cornea or sclera
      • Use a gauze swab soaked in 0.9% saline or normal water and gently wipe from the medial corner of the eye outwards to the lateral corner of the eye
      • Discard the used gauze swab and repeat the procedure with a new gauze swab each time until the eye is clear of discharges and crusts
      • Do not use soaps or other irritants to clean the eyes
    • Lubrication of the eye – Use eye lubricants, e.g. Carboxymethylcellulose Sodium Lubricant Eye Drops 0.5% w/v, 1 – 2 drops q6h and prn, to keep the eyes moist
    • Eyelid closure – Tape the eyelids closed with transparent tape when the eyelids cannot be closed at all by the patient
    • Ophthalmology consultation – When above measures do not achieve the desired result

Ear care

  • Assess for deafness, tinnitus, pain, itching, ear infections, wax, partial or complete occlusion of the auditory canal, inflammation or perforation of the tympanic membrane, discharges and skin lesions
  • Management
    • Cleaning of the ear
      • Clean the outer ear with a damp cloth or tissue
      • Do not insert cotton swabs or sharp objects, such as fingernails, car keys, bobby pins or matchsticks into the
      • When ear wax with occlusion is present, an earwax softener be used for easier removal
      • Clean earrings and earlobes with rubbing alcohol in patients with pierced ears
    • ENT Consultation

Nose care

  • Assessment – Assess for cleanliness of the nares, discharges, crusts, discolouration, signs of infection
  • Management
    • Advise the patient to blow gently into a soft tissue to remove secretions
    • Advise the patient to avoid harsh blowing as it can cause damage to the nose, ear and throat
    • Use a gauze, swab or a cotton tipped applicator soaked in 0.9% saline or normal water
    • Never insert the applicator into the nose beyond the cotton tip
    • When a patient is on a nasogastric tube or nasal cannula to deliver oxygen, the nares should be cleaned three times daily with a cotton tipped applicator soaked in 0.9% saline
    • Lubricants such as coconut oil can be applied in the nares to prevent abrasion by the nasogastric tube or nasal prongs

Oral care (refer to the Guideline – Oral Care)

Hair care

Clean and groomed hair is important as it improves the morale of the patient and prevents the hair from getting matted and tangled

  • Assessment – Assess for cleanliness of the hair and scalp, signs of infection, matting and tangling
  • Management
    • A patient’s hair should be combed at least twice daily
    • A patient’s scalp should be massaged with fingertips daily to improve circulation
    • When combing tangled and matted hair, the ends of the hair should first be combed and then one should move towards the scalp
    • Tangled and matted hair should be held by hand between the scalp and comb to avoid pulling the hair from the scalp when combing the hair
    • Hair should be trimmed regularly with the patient’s approval, if possible
    • Shaving should be done at regular intervals or according to the requirement of the patient
    • Shampooing of the hair should be at regular intervals or according to the requirement of the patient
    • If a person requires shampooing in bed, then the materials necessary are:
      • Mackintosh sheet
      • Sufficient quantity of warm water
      • Bucket
      • Towels
      • Shampoo
      • Pillows
    • Procedure – Shampooing
      • Cover the area with a plastic sheet over the pillows
      • Place a bucket by the side of the bed and position it to catch the water
      • Have the patient lie on the back on a plastic sheet with the head over the side of the bed
      • Ensure that the patient is comfortable by adjusting the pillows
      • Place a towel under the bucket to catch any spilled water
      • Pour water over the hair and let the water flow into the bucket
      • Take an adequate quantity of shampoo into the hand and massage gently into the hair and scalp to lather thoroughly
      • Wash the hair with adequate water to remove the shampoo from the hair and scalp
      • Dry the hair with towel and remove the bucket and the mackintosh
      • Place a fresh towel on the pillow under the head
      • Comb the hair after drying
      • Show the patient a mirror to view himself/herself after if he/she so wishes as this can improve the body image and morale of the patient if done sensitively

Nail care

Clean and trimmed nails improves the morale of the patient and prevents infection

  • Assessment – Assess for cleanliness, change in shape, curvature and thickness of nails, discolouration of the nail and surrounding areas, signs of infection and peripheral vascular disease
  • Management
    • Clipping or cutting should be done after order from a trained nurse
    • Do not cut or clip nails, if there is evidence of inflammation or infection in the skin of the surrounding area
    • Do not clip toe nails
    • Do not cut corns, calluses, bunions or ingrown toenails
    • In patients with peripheral occlusive vascular disease, do not cut nails
    • Massaging the foot with a cream application would improve comfort and aid in moistening the feet and toes
    • If a patient needs nail care in bed, the materials required are:
      • Towels
      • Basin
      • Warm water
      • Nail clippers or scissors (optional)
      • Nail file
      • Gloves
    • Procedure
      • Fill the basin with warm water and check whether temperature of the water is comfortable for the patient
      • Soak the hands and feet in the warm water for 5 – 10 minutes
      • Clean under the nails gently with nail file, without causing injury to the skin
      • Filing must be done to smoothen the rough and sharp edges
      • Dispose soiled supplies
    • Care providers should not wear artificial nails
    • Specialist consultation – Consult a podiatrist, if necessary

Pressure injuries (refer to the Guideline – Wound Care)

Skin care (refer to the Guideline – Wound care)

Perineal care

Perineal area is warm, moist and not well-ventilated; this makes it vulnerable to colonisation of pathogens and can lead to malodour. Urethral meatus, vaginal orifice and anus opens into the perineal area and this could lead to entry of pathogens into the body and cause infection. Cleaning of perineal area is necessary to prevent infections and malodour.

  • Assessment – Assess the perineal area for cleanliness, infections, malodour, vaginal discharge, perineal care and effectiveness of perineal care
  • Management
    • The patient should be in supine position when administering perineal care
    • Place a towel or bedpan under the hips
    • Use soap and warm water or warm water alone to gently wash the perineal area
    • Advice and assist the patient in using a urinal/bedpan to pass urine prior to administering perineal care as application of warm water on the perineal area can stimulate urination
    • Perineal wash should be from front to back
    • In female patients, clean the urethral opening first, followed by the vaginal orifice and finally the anal orifice
    • In male patients, clean from the tip of the penis to anal orifice
    • In uncircumcised male patients, retract the prepuce and start the cleaning from the tip of the penis backwards to clean the glans and ensure to return the prepuce back to the tip of the penis before cleaning from the tip of the penis to the anal orifice
    • Thoroughly wash the perineal area with warm water and pat dry

Bowel Care (refer to the Guidelines – Constipation, Diarrhoea)

Bladder Care (refer to the Guideline – Bladder Care)

Bathing

Bathing can be comforting and help the patient stay clean; but for a bedridden patient, baths have to be done on bed and that could be uncomfortable.

  • Assessment – Assess the skin for cleanliness, pressure injuries
  • Management
    • Bed baths should be undertaken gently, slowly, and with dignity
    • If the patient wishes, play some music during the bath
    • Permit the patient to be involved/help in the bathing process if possible
    • When a patient needs a bed bath, the materials required are:
      • A large basin with warm water
      • Mild soap
      • Wash clothes or sponges
      • Towels
      • Suitable change of clothes
      • Skin lotion, cream, powder
      • Perfumes/colognes, deodorants, combs
    • Procedure
      • Wash one part of the body, keeping the rest of the body covered with a large towel or sheet
      • Start from the face and go downward or vice versa; depending on the patient’s choice
      • Place a basin of warm water at the foot of the bed and allow the patient to soak one foot at a time
      • Place the patient in a prone position to clean the back
      • Give a back rub, soft or hard, depending on the patient’s choices
      • Once you have finished washing, pat dry
      • Massage using lotions keeping in mind the patient’s choices
      • Aid the patient to put make-up, perfumes/colognes, deodorants if they wish
      • Aid the patient to put on his clothes

Bed making

  • Bed linen should be changed daily or as and when it becomes soiled
  • Use a firm mattress and place a waterproof cover to protect the mattress
  • Place a cotton mattress pad over the waterproof cover for comfort of the patient
  • Use a cotton bedsheet over the cover mattress pad
  • Place draw sheet over the cotton bed sheet to protect the bedsheet
  • Procedure
    • Place clean pillow cases, bed sheets, draw sheets on a table or chair near the bed for ease of handling
    • When changing bed linen, roll the patient to one side of the bed to make half of the bed
    • Loosen the used/ soiled cotton bedsheet and draw sheet and roll them to the back of the patient, as close as possible
    • Make the half of the bed with clean sheets
    • Now roll the patient back over the centre of the bed where clean and used/ soiled sheets are together
    • Remove the used/soiled sheets from the other side and complete the change of bed linen by making the other half of bed
    • Smoothen the covers as gently as possible to remove the wrinkles

Care of the feeding tubes (refer to the Guideline – Enteral feeding)

COMFORT

  • Bed care
    • Use pillows and cushions to keep the patient comfortable in bed
    • When the patient is lying in lateral position, keep a pillow between the knees and ankles, beneath the arm and behind the back
    • Raise the head of the bed or put the patient in upright position with support when feeding, giving medications or having breathing difficulties
  • Repositioning
    • Use a bed trapeze to improve the upper body strength and repositioning
    • Place a “draw sheet” under the patient extending from above the shoulders and cover the back till half the thighs and reposition the patient using the sheet ends and not the arms and legs of the patient. Two persons, one on each side of the patient should do this
    • When the patient is on a chair or recliner, keep a folded sheet under the patient and pull one end of the sheet gently to reposition
    • Reposition the patient every two hours or as tolerated or at the request of the patient
    • Avoid using electric blankets and heating pads as this could cause burns to the fragile skin
    • Use alternating pressure air mattress for comfort and prevention of pressure injuries
  • Adaptive clothing
    • Use loose clothing that can be put on and easily removed
    • Use suitable slippers (when moving out of the bed)
  • Miscellaneou
    • Gently rubbing the back, shoulders, feet, and/or bony prominences (shoulder blades, elbows, hips, heels) often provides great comfort to the patient

NUTRITION and HYDRATION (refer to the Guideline – Nutrition and Hydration)

PHYSICAL REHABILITATION

  • Principles
    • Physiotherapist should be consulted before initiating passive physiotherapy
    • Physiotherapy should be discontinued if the patient is in discomfort and/ or cannot tolerate the exercise
  • Passive mobilisation
    • Passive mobilisation of as many joints should be done based on the patient’s condition to prevent muscle retraction and decrease of range of movements
  • Active mobilisation
    • Active mobilisation should be done to prevent muscle retraction, muscle wasting and circulatory problems
  • Chest physiotherapy
    • As bedbound patients are at risk of developing respiratory tract infections, all patients should be encouraged to do chest physiotherapy if they are able, to prevent respiratory problems

REFERENCES

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Palliative Care Guidelines

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Created: January 2019
Last updated: August 2019