Lecture # 403:
The Everyday Angel's Cram Course in Essential Nursing Skills

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

The type of people who are willing to care for someone at home usually manage quite well. Hospice nurses who visit the dying in their homes observe that "people have power to overcome obstacles and perform tasks they never thought they could do." Usually, nurses in the hospital are patient and family teachers. This is an intregal part of their job. They give the family the necessary information they need to understand medications, treatments, and changes in health condition. And this is an on-going education for the person who is caring for someone at home. Such education gives the caregiver confidence and skill. This is what we want to do for the families of our clients.

Meditate Word By Word On These Verses:
Hebrews 12:9-13.

There are about nine daily nursing skills that are necessary for the sick person whether he is recovering from illness or dying.

The first of these is hydration. Most people don't drink nearly enough water, which is the basic substance of our bodies. Our bodies 90% fluid and we need to replace the fluid we lose every day through urine, feces, perspiration and respiration. This amount is approximately 2.5 liters per day.

Seriously ill patients are prone to dehydration for two reasons: Common symptoms of diarrhea and vomiting deplete the body of water, but also the sick and nauseous person is reluctant to drink. So the problem is that there is excessive output of fluids and insufficient intake.

Conditions that lead to dehydration are: nausea/vomiting, diarrhea, profuse perspiration due to fever, and neurological disorders that leave the person confused, forgetful, and unable to feed himself. Sometimes medications can cause frequent urination and loss of fluids (diuresis). An unpleasant taste in the mouth or dry mouth due to radiation therapy or medications makes people reluctant to drink fluids. A stroke can make swallowing difficult thus fluid intake is decreased. Alcohol is a diuretic and causing dehydration thus the drinkers in our community are at risk.

Question 1: What are some of the reasons sick people do not drink fluids?
(One or more of the following answers may be correct.)
Sometimes medications cause frequent urination.
Diarrhea and vomiting deplete the body of water.
Sick people may be afraid to drink because it will make them vomit.
Radiation therapy may leave a bad taste in the person's mouth.

 

 

Dehydration can lead to fluid and electrolyte imbalance in the blood and other body fluids, uremia, urinary tract infections, bedsores, respiratory tract infection, and constipation. We can easily check for dehydration by pinching a fleshy area on the person's body and if the skin stays raised, this is evidence of severe dehydration.

Question 2: What are the consequences of dehydration?

 

 

If you want to know for sure if there is a fluid deficit, do a 24-hour calculation of urine output. This requires a urinal or a bedpan, but you can be sure of the results you get. Someone who is dehydrated will expel significantly less than 1440ccs. If the low urine output persists over two days or more, it can cause other problems such as acidosis, abdominal pain, cardiac arrhythmias, and diminished reflexes.

There are some ways to help the sick person drink. Handing a sick person a glass of water and telling him to drink is like asking a healthy person to drink a fish-tank of water. It is much easier for someone to sip fluids gradually throughout the day. Giving the person a half glass full at a time is not so intimidating to him. Water is the best fluid, but there are some alternatives such as: frozen fruit pops, jello, non-fat soups and broths, juices and nectars diluted with a little water. Flavors of juice that are easiest to digest are grape, apple, and cranberry. Nectars that are easy to digest are apricot, mango, and peach. If drinks are offered with straws and spoons, they may be more interesting. Beverages containing caffeine are diuretics that cause even more fluid loss. Try giving caffeine-free teas and broths.

Question 3: How can you make drinking fluids more interesting for a sick person?

 

 

The key is to try and encourage a person to drink what he can and what he can tolerate. Here is a simple recipe for replacement of fluids that marathon runners use. It is also cheap to make.

The second skill is prevention of infection. Sickness weakens the barriers of skin and body chemistry to infection. Just being immobile increases susceptibility to infection. A major function of urine, stool, saliva, and mucous is to eliminate infectious agents. If a person is debilitated and confined to bed, he is prone to constipation, his mouth can dry out, it is difficult to raise phlegm from the throat, it is difficult to urinate and thus the body begins to act as an incubator for bacteria and other microbial agents to grow, multiply and eventually injure cells. If a person is dehydrated and malnourished, the immune system does not have the resources to fight for the body.

Question 4: Why is a sick person more susceptible to infections?

 

 

The two most prevalent infections are bacterial and viral. Bacterial infections produce disease-causing toxins and may be more dangerous than viral infections. Bacteria usually respond to antibiotics, but few viruses can be tamed medicinally. The common cold comes from a virus and there is no medication that can prevent it from running its course, only agents to control fever and other symptoms.

Other infections such as thrush grow slowly and are harder to treat. They are rarely deadly except for the person who suppressed immune system. Protozoal infections include several infections like pneumocystis carinii pneumonia that is is frequently seen in AIDS, as well as intestinal abcesses and life threatening diarrhea from common amoebas.

Since direct contact is the way most infections are spread, we need to be careful of hand washing. Remember that it is flushing your hands under water that rids them of microbes - not the temperature of the water. You are aware of sterile technique and covering of cuts and sores.

Indirect transmission is contact with a contaminated substance or object. So never share personal items that could be infected with germs - makeup, razors, blood, toothbrushes, hairbrushes, soap, handkerchiefs. Eat off your own plate, not someone else's. If necessary use a weak bleach solution to clean off doorknobs, toilet seats, bedpans, and faucets every day.

Question 5: What types of household cleaners are good for preventing infections?
(Select the best answer.)
Soap for washing hands, bleach solution for killing germs on surfaces.
Scouring powder for washing pots and pans.
Laundry detergent for washing clothes and sheets.

 

 

Almost every one of us contracts a food-borne disease each year, but for most of us, the symptoms are minimal and may be acute diarrhea or nausea, and perhaps a low grade fever. Many of the people who die from food poisoning are immuno-compromised: cancer patients in chemotherapy, people with AIDS, and transplant recipients. But many of the worst cases of food poisoning are also seen in the elderly who have chronic diseases. Sloppy kitchen habits can place a sick person in mortal danger.

When in a home, look for the following measures and talk about them with the family caretaker:

  1. Wash hands after touching raw meat.
  2. Disinfect cutting boards and counters with a solution of hot water and chlorine bleach.
  3. Wash all fruits and then peel and rinse.
  4. The thermostat in the refrigerator should be set at 4-5 degrees C (38-40F).
  5. Store food in airtight containers.
  6. Never use canned or prepackaged foods that are leaking, bulging, or dented.
  7. Never set food out to thaw at room temperature - thaw in refrigerator or microwave oven.
  8. Cook meat and eggs thoroughly.
  9. Filter and/or boil water.

Preventing airborne transmission of microbes involves keeping rooms well ventilated. We represent a health risk to people who are incapacitated because we transport germs from the outside world. If possible, when we have colds, we need to wear masks when we are with our clients. To decrease the client's feeling of loneliness and isolation when there is an infection present, we can do it nonchalantly such as saying, "I am wearing this mask to protect you from my germs!"

If you are an animal lover, you know what joy they can be to someone. For the person who is immuno-suppressed due to illness, we need to be aware of the disease animals can transmit. Our clients need to wash their hands after handling a pet. If the pet has had inoculations, that is even better for our clients. Cats carry toxoplasma gondii protozoan transmitted through their feces. Psittacosis is a contagious disease common to parrots and other pet birds.

Question 6: Are animals important to sick people? What are the positive and negative aspects of having an animal near a sick person?

 

 

For AIDS patients especially, small cuts, scrapes, and skin irritations can start infections. To avoid this, use an electric shaver if possible, use a soft bristle toothbrush, keep skin moisturized with lotion, refrain from scratching or squeezing pimples and insect bites. We also need to ask visitors if they have been exposed to a contagious disease in the last few weeks. The incubation period may be from 9-21 days for most contagious diseases and a person could be infected but not showing symptoms.

The third skill is personal hygiene for the client. We may not be with a client every day for doing hygiene tasks, but I assume that you will teach the primary caregiver in the home how to wash the client. Changing a diaper or pad on a person is a necessary task. Some of our clients will not be continent, so we must periodically change them. In order to preserve dignity and respect, we ask permission to do this task. This prevents embarrassment and the client knows what you are going to do. If possible privacy while doing this task is important. At times the client will not be embarrassed but simply want to be clean. Explain what you are doing step-by-step. A sense of humor helps when faced with a big clean-up job.

Question 7: Do you need to ask permission to touch someone's body? Why?

 

 

The fourth skill is bathing. This can be a large chore. For the persons who can walk, one of the nice pleasures of life is to sit under a warm shower. Here are some instructions:

To help a person into the tub, do the following:

To help a person out of a tub, do the following:

Question 8: Have you ever bathed a sick person in a tub? What were the results?

 

 

If the person has fragmented memory and limited cognitive function, giving a bath may be more complicated. Brain injured persons may no longer remember how to wash themselves, or they may wash the same spot repeatedly, forgetting they have already washed the spot. Here are some safety tips from the Pittsburgh Alzheimer Disease Research Association:

The fifth object of care is for the skin. This is a necessity because the skin is the body's largest organ and the first barrier against infection. It is of particular concern for older people whose skin secretes less oil and has lost some of its thickness.

Putting moisture back into the surface of the skin restores it and locks in the moisture that was washed away by soap and water. Rubbing in lotion is one way to preserve moisture in the skin. This can double as a massage. Keep the massage light for if the surface layer of the skin is damaged, rubbing hard injures the skin more. This moisturizing is needed for every part of the body. Don't overlook the lips, which can be cracked and dry. Lip balms are adequate. Also Vitamin E capsules can help. Usually, they are just soft gel capsules. Poke a hole in one end of the capsule and apply the gel inside to the person's lips.

Keeping the skin dry especially after incontinence is imperative. Feces, urine, perspiration, and wound drainage are all highly acidic and chemically erode the skin. There are some salves and creams that can be applied to protect the skin after cleanup. If there is incontinence on a regular basis, adult diapers need to be considered. This is because the linings draw the moisture away from the skin.

Question 9: Are baths or showers necessary for everyone?
yes / no.

 

 

Itching can also be a problem due to reactions to medications, dehydration, allergies, jaundice, radiation treatments, and autoimmune disorders. Our main task is to eliminate the source of irritation, soothe the itching, and prevent breakdown of the skin surface. Of course, the first preventative measure is to keep your client drinking and eating as much as possible. Eliminate irritants to the skin such as deodorants and other personal hygiene products, laundry detergent or laundry softener residue in sheets and clothing. Use cotton sleepwear and sheets. Soothe itchy skin with cool baths that contain baking soda or oatmeal. There are also oral antihistamines that may help for brief periods of time - Benadryl and cortisone creams. These need to be used for as little time as possible.

Pressure sores or bedsores are the breakdown of skin that results from unrelieved pressure over any bony prominence. The areas of the body most prone to ulcers formation are those that bear weight when we are lying down or sitting in a chair. If one remains in the same position in bed for too long, the tiny blood vessels become compressed. Since the vessels are deprived of oxygen and nutrients, the tissue begins to die and a pressure sore begins.

The skin must be examined every day for evidence of emerging pressure sores. We need to be especially vigilant if the person we care for has lost sensation in some part of his body. Because of loss of sensation, they will not feel the pain that signals a pressure sore's onset. Brain injured persons may not be able to process pain or alert us to what they feel. At the first stage of a pressure sore, the skin has not deteriorated, although the area will appear red or purple and may feel warm to touch. Though we cannot see it, the skin underneath is damaged.

Question 10: What causes bedsores?

 

 

To prevent pressure sores, the person must be turned regularly even when they are sleeping. Repositioning a person every two hours is sufficient for persons with no skin damage. By repositioning, that means not rolling persons like logs. Tilt the head, next shift the leg, then lift the right shoulder blade off the mattress and so on. Place pillows or foam wedges strategically will help the person to maintain postures comfortably. Other preventive measures include:

A saline solution may be helpful in flushing bedsores if they occur. Put the saline solution on a piece of gauze and apply to the sore in a wet condition. Cover the wet gauze with another pad and tape them in place. After 6-8 hours, remove the gauze pad and apply a fresh gauze bandage. When you remove the gauze, you look for fresh bleeding around the edges of the sore. This means that there is fresh blood supply forming around the sore and tissue can begin to grow into the edges and finally fill in the sore. Here is a recipe for making the solution:

  1. Boil 4 liters (1 gallon) of water for 5 minutes
  2. Add 8 teaspoons of table salt
  3. Sterilize a spoon by boiling it. Use it to mix the solution until the salt dissolves completely.
  4. Let the solution cool to room temperature before using it.
  5. Store in a tightly sealed sterilized jar.
The solution will keep fresh for one week.

Question 11: What are some folk methods of treating pressure sores? Do they work and why?

 

 

Mouth dryness is a chronic nuisance for many ill people. Diseases such as diabetes, radiation therapy to the head and neck, and many medications can slow down the production of saliva. Since saliva rinses away teeth-decaying germs, its deficiency in the mouth may cause cavities and peridontal disease.

Brush the person's teeth after every meal using a soft bristle brush and a mild flouride toothpaste or a paste of baking soda and water. Many commercial mouthwashes contain excessive sodium and alcohol, which only dry the mouth further. Stir a half-teaspoon of salt and a half-teaspoon of soda in one cup of warm water and have the person rinse his mouth. If person is too nauseated to brush his teeth, the solution of salt, soda, and water may be an alternative to brushing teeth.

Question 12: Is mouth care important in caring for a bedridden person or any sick person?
(Select the best answer.)
Yes, because it keeps bacteria from growing in the mouth.
Yes, because of the smell of bad breath.
No, it's not normal for people to clean their mouth and brush teeth.


 

 

When persons are confined in bed, toileting is always a problem due to unnatural positioning and lack of privacy. Try always to have a person sit up on a bedpan as much as possible so that gravity helps them with elimination. If a person is able to sit at the bedside, a commode lets him sit in a chair-like portable toilet so that he can eliminate bladder and bowels in a more natural position. The caregiver can easily empty the removable holder underneath.

If the person is able to get to the toilet, a small night-light to illuminate the hallway and toilet may minimize a fall. If a person is confused, he may have trouble locating the toilet. Putting a picture of a toilet or writing the word "toilet" and placing it on the door, may lessen confusion. If there is an accident in bed, the linens can be cleaned with bleach to prevent infection and remove stains.

Persons with ostomies require changing of the osteomy bag. The number of times per day it is changed depends on the type of ostomy. An ileostomy from the small bowel and a ureterostomy from the kidney will need changing more frequently than the colostomy. Wearing latex gloves is advised for changing of the bags. The stoma needs to be gently washed because the tissue is tender. Some stomas may bleed easily.

Question 13: Where can ostomy bags and equipment be found in your city?