These empirical findings indicate the extent of both the metabolic and haemodynamic stress that is associated with the various routine daily activities on ICU patients. Such findings should be taken into consideration, especially when patients are haemodynamically unstable and septic, so that the minimum of disturbances are inflicted on them thus minimising their catabolic state during wakefulness while indirectly improving their rate of recovery. Weissman et al (1984) however admit that the measurement of resting energy expenditure is a complex and exacting task which is difficult to achieve.
Another weakness in the study is evident in a way that it was impossible for the authors to measure energy expenditure which is traditionally performed in the ‘basal’ state. This is defined as “the minimal energy expenditure of a subject lying down and resting in a thermoneutral environment having fasted for the previous 12 hours. ” The authors admit that such conditions are extremely rare in the critically ill patient since such a patient is receiving some form of continuous nutrition, whether it is 5 percent dextrose, or enteral or parenteral nutrition.
Contrary to the data presented above, other studies are more in favour of the therapeutic benefits of bathing. Bersevick and Llewellyn (1982) compared the effects of the towel bath and the conventional bed bath on patient anxiety. Anxiety was measured by three methods namely, State-Trait Anxiety Inventory, the Palmar Sweat Index, and the Behavioural Cues Index on 53 patients with unrelieved pain and 52 patients who would be having invasive procedures.
Although results show that there are differences between the two procedures to the levels of anxiety, in general both methods of bathing have anxiety reducing effects. From this study Bersevick and Llewellyn (1982) suggest that bathing should be indicated among the methods used to increase patient comfort. However further studies are needed to determine generalizability of these findings to other patient populations which, in the context of critically ill patients nursed in ICUs, is still lacking.
Heilman (1974) studied bathing from a qualitative perspective and, from the data collected, finalised a hypothesis which says that patients would experience greater relief of stress following the conventional bed bath because of more direct skin-to-skin contact. She also concludes that bathing patients was a desirable nursing action which provides them (nurses) an ideal opportunity to talk with the patients and getting to know them better.
Referring back to the study conducted by Webster et al (1988) on patients’ and nurses’ opinions about bathing, the majority of nurses and patients agree to the fact that bathing provides this opportunity of acquaintance between the two parties. When it comes to the actual procedure of bathing, where the first aim is to clean the skin, literature shows that patients are more often exposed to harm rather than the benefit that many nurses think they are doing while bathing a patient. In the author’s working environment, nurses use communal basins which are moist and stacked one inside the other.
Common soap (supplied by the health authorities) is usually used. A face cloth or washing flannel is usually found hanging to dry from the previous bath, and throughout the procedure the same water is usually used. According to Gooch (1989) any piece of equipment that cannot be dried, such as washing flannels and soap, will be contaminated with gram negative organisms. If water and flannel are unchanged throughout a blanket bath, according to Gooch (1989) the water becomes “a soup of soap and bacteria by the end of the procedure.
” Gooch (1989) also argues that when washing bowls are left moist and stacked one inside the other they will be heavily contaminated. A study conducted by Greaves (1985) shows that microbiologically patients could be dirtier after a bed bath than before it if face cloths are used for washing. Another aspect to be taken into consideration is skin integument. Armstrong Esther (1981) states that in elderly people, the dermis and epidermis are thinner, nail and hair growth is slowed, and sweat and sebaceous secretions are diminished.
The slower renewal rate of the stratum corneum renders the skin more liable to excessive drying after washing. Skin also becomes more permeable to irritants with age. Penbroke (1983) argues that subjecting elderly patients to soap and water several times a day in hospital, when they are only used to wash down once or twice a week at home can cause them to develop asteatotic eczema with its dryness, cracking, and occasional excoriation. Considering that a large proportion of patients admitted to the ICU are elderly people, these facts should not be overlooked and nurses should update their knowledge frequently.
Other facts that Armstrong Esther (1981) brings into attention, which may be surprising to most nurses, is that the use of detergents, soaps, bubble baths, or sodium bicarbonate in baths will aggravate skin dryness, as will water that is too hot. Soap remaining on the skin due to inadequate rinsing (a common habit during bed bathing) intensifies dryness; and the use of soap is not very effective in removing dried faeces. The use of emollients, such as aqueous cream and mineral oils during bathing help in reducing scaliness and make the skin more pliable and may be sufficient enough for cleansing (Armstrong Esther 1981).
Conclusion The arguments brought forward in this paper highlight facts that should urge nurses to stop and think about their practice concerning bathing. The phenomena of ‘let’s get the work done’ without enough reasoning echoes in our unit not just on bathing, but for each and every nursing task. Stereotyping is still dominant over individualised care with possible detriment to the same patients. To change nursing habits that have anchored for a long time demands risk taking and besides a positive approachable attitude, requires time, patience, and perseverance.
According to Plant (1987) change is a five stage process which requires: 1. Recognising the need for change. 2. Mobilising commitment of the critical mass. 3. Building a shared vision. 4. Diagnosing current reality. 5. Getting there. Plant (1987) argues that unless behaviour changes nothing changes. However Walsh and Ford (1992) rightfully state that “while there may be a place for intuition in the art of nursing, there is no place in the science of nursing for rituals and mythology. ”
References
Armstrong Esther C. (1981) Skin introduction. Nursing 1st series, 1115. In Gooch J. (1989) Skin Hygiene. The Professional Nurse Oct. pp. 13-18. Bersevick A. and Llewellyn J. (1982) A comparison of the anxiety-reducing potential of two techniques of bathing. Nursing Research Vol. 31 No. 1 pp. 22-27. Fabijan L. and Gosselin M. (1982) How to recognise sleep deprivation in your ICU patient and what to do about it. The Canadian Nurse 78:4, 20-23. In Closs J. (1988) Patients’ sleep-wake rhythms in hospital. (Occasional Paper) Part 2. Nursing Times Vol 84 No. 2 pp 54-55.