Nurses in our local intensive care

In 1981, Armstrong Esther wrote “The daily bed bath, often described as a ‘cat’s lick’ is not given on the basis of patient need or habit but as a part of ritualised care. ” Gooch (1989) admits that despite the documentation of the effects of soap and water on the skin, “the routine blanket bath remains one of the most frequently performed, and least often omitted, nursing task. ” The aim of this paper is to alert nurses in our local intensive care unit (ICU) to practice their work rationally and not on a ritualistic routine approach.

The aspects of bathing from different perspectives is going to be discussed, the primary aim being to demonstrate both its benefits and dangers to patients’ health, focused mainly on critically ill patients. Such aspects include sleep-wake patterns, subjective opinions, skin integument, and physiological changes. Many are the procedures that need to be carried out on patients requiring intensive care; some of them are invasive and inevitable, others include basic nursing care that, although important, could be co-ordinated and delayed according to the circumstances or priorities.

One such basic procedure is bathing. Webster and Thompson (1988) describe how bathing has been, throughout history, associated with physical, emotional, and social well being; and how today, society seems to regard hygiene as a high priority. Henderson and Nite (1978) consider that cleanliness is essential to a normal physical and mental state and point out that many diseases inhibit physiological functions such as lacrimation, salivation, and sweating, that, in a sense, cleanse the body so that “cleansing processes inadequate in health may have to be modified in sickness.

” Nightingale (1859) considered that leaving a patient unwashed was interfering injuriously with the natural process of health just as effectively as if she were to give the patient poison. During their time of study in nursing, the majority of nurses, if not all, have come across literature supporting the importance and necessity of bathing as indicated above. In the classroom, the student learnt the procedure both theoretically and practically.

In the clinical setting the student was conditioned to bathe patients in the early morning. However the co-ordination of this procedure with others has hardly ever been emphasised. The result is that bathing became and still is a ritual in each and every corner of our hospital. The intensive care unit whom the author works in is no exception and since its inauguration, this procedure has been ritualised to the fullest.

Nurses bathe patients between seven and eight in the morning irrespective of whether they (the patients) are still asleep, they had a ‘rough’ night, they do not feel like to, or their degree of sickness is so grave; such as in haemodynamic instability; that the minimum of procedures further compromise their condition. Moreover most of the nurses do not seem to perceive rest and sleep as an essential necessity. “The patient has the right to have knowledge and information, and the right to be fully involved in planning care” (Walsh and Ford 1992).

Unfortunately this does not often apply to patients receiving care in an intensive care unit whom the majority of them are either sedated or worse still, are muscle relaxed too. Their critical condition prohibits them from participating in their care therefore leaving the nurses in a position to plan the nursing care according to the patients’ needs alone. Such planning demands careful attention for timed procedures, a broad knowledge base of intensive care nursing and common sense. Are nurses practising in this manner?

Walsh and Ford (1992) argue how “common sense is highly preferable to ritualistic action” and admit that “traditional nursing is based on many unsubstantiated beliefs, but not so many facts”. Fabijan and Gosselin (1982) suggest that patients in ICUs show signs and symptoms of sleep deprivation within 48 hours of admission and although the majority of nurses are aware of the importance of sleep, they do not differentiate between essential and non-essential nursing tasks and often disturb patients unnecessarily (Morgan and White 1983).

Hilton (1976) admits that due to the critical nature of the patient’s illness in the ICU and the essential need for continuous monitoring and care, the normal sleep patterns and cycles are highly susceptible to interruptions and changes. From his study Hilton (1976) concludes that personal care (which includes bathing amongst others) scored 18. 5% when compared to other possible sleep disturbance factors. These results are considerably high and should be seriously considered so that awareness for the promotion of adequate sleep periods is ensured from all nursing professions.

Many studies have confirmed that there is a huge body of evidence which supports the hypothesis that sleep aids healing. Although not concrete, Torrance (1990) argues that there is evidence that many cycles, such as protein synthesis, cell proliferation, metabolism of plasma amino acids, and growth hormone secretion, are entrained to the sleep-wake cycle; and that wakefulness is marked by enhanced catabolism, while sleep appears to be the time of maximum anabolic activity.

The findings suggest that disturbing patients’ sleep interferes with anabolic body functions and thus increasing the time of recovery in critically ill patients. These findings urged the author to ask, is bathing an essential or a non-essential task in an ICU environment? A study conducted by Webster et al (1988) on patients’ and nurses’ opinions about bathing shows how patients and nurses have different views on the importance of this task when compared to others. Patients perceive bathing as a non-essential task (86%), while nurses think that it is essential (90%).

In this same study Webster et al (1988) observed that most bathing was carried out in the morning and that two thirds of the nurses in the study disagreed that such a practice is best for patients. The researchers conclude by admitting that such practices appear to continue as a result of ward tradition and routine. Although this study was done on a small scale (22 nurses and 22 patients) it seems to represent the true picture of the current situation concerning bathing in many hospitals.

It also shows that patients and nurses often have rather opposite views of what is important. However the study has shown too that both nurses and patients disagree that it is essential for all patients to have a daily bath while in hospital. Walsh and Ford (1992) suggest that a good starting point, in the context of bathing, would be to consider whether the patient needs or wants a bed bath and argue that “like all aspects of care, this should be individualised to meet the patient’s needs.

” They also recommend the evaluation of various routine tasks and ask if they really are necessary. The literature demonstrates different views of bathing tasks and studies have been performed to show the effects of bathing both from a quantitative and a qualitative perspective. Weissman et al (1984) performed a study on the effects of routine intensive care interactions on metabolic rate in a group of 23 mechanically ventilated critically ill patients and demonstrates how the various routine daily activities can significantly alter metabolic rate.

The comparison of percent change of oxygen consumption, carbon dioxide production, heart rate, and systolic blood pressure between rest and bathing in the above study show that: 1. There are significant increases (about 20%) in both oxygen consumption and carbon dioxide production above the resting levels. 2. There are significant increases (about 10%) in both heart rate and systolic blood pressure above the resting levels.

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