BEDSIDE CARE AND MANNER

As a yogi doula, you may or may not be involved much with hands-on care and with your clients’ hygiene. But we think it is an important skill to have and be familiar with in the case you are in a situation when someone needs your help. Remember that you always have the right to set contemplative boundaries around what you will and will not do as a yogi doula – if you are open to the below, though, we think you’ll be able to offer a more well-rounded service to your clients.

For hands-on training, there’s nothing better than to volunteer at ABODE and learn directly from our Navigators.

Changing Briefs

A clean and dry brief is important in reducing skin breakdown and infection. It can be tricky at first – and the first time you do it, don’t be surprised if it doesn’t look anything like the one you took off!!

Before changing someone, gather up the items you’ll need. Ideally, they’ll be stored near your client in their room.

Gloves
Wipes
Barrier cream
Chux
Brief (proper size)
Small trash liner to remove soiled items and dispose of them immediately

As you’re changing someone, you can reduce friction and skin tears by using the draw sheet to move and turn them. You will want to straighten the chux and the linen underneath them so that they aren’t lying on creases, which can be uncomfortable and be cause for skin injury.

Changing the briefs of someone who is bedbound can be done on your own – but having an extra set of hands is always helpful. Keep in mind you may be educating family members how to do so safely. Once you’ve learned to do it, keep practicing – and practice how you’d teach others.

Step By Step Instruction

1. Wash your hands thoroughly with soap and warm water or use hand sanitizer. Put on your gloves. Place your client comfortably on their back.

2. If the bed is adjustable, raise the entire bed to a comfortable height, slightly lower than your hips. Lower the head as far down to horizontal as they can tolerate. You want to protect your back by operating on a flat surface and at a height where you’re comfortable and your back is not leaning too far forward.

3. Unfasten the tabs on the soiled brief, attaching the sticky tabs to the brief so they don’t catch on anything when removing. Tuck the side that is away from you under their hip.

4. Cross the ankles with the top ankle being the direction you intend to roll them. With one hand on the hip and the other on the shoulder, roll the person away from you onto their side. If you tucked the diaper far enough under the hip, you should be able to pull the diaper out from under them.

5. Roll the soiled diaper inward as you remove it to contain any waste. Place the soiled diaper into the trash liner. Using wipes, thoroughly clean the bottom, both the front and the back. Remember to wipe in the correct direction – away from any orifices. Do not apply too much pressure as skin may be fragile. Here is your opportunity to check the status of wounds or development of any new tears or bed sores. Remember to document and report any changes you observe.

6. Once dry, apply barrier cream as needed on troubled areas. Apply barrier cream in a thin layer like you are buttering bread, not frosting a cake. You can wipe excess barrier cream from your gloved hand onto the inside of a fresh brief. See the below section for instructions on performing peri care.

7. Fully open a fresh brief, place it tab side down on the bed and tuck the opposite side from you under the hip. Flatten and position the rest of the diaper on the bed. You can pull it up to make sure it is centered on their bottom. Next, roll the person back toward you onto the brief. Hopefully they’ve landed square on the brief – if not, make adjustments. You can now pull the brief up between their legs.

8. Remove any wrinkles and fasten the tabs. If the person is bedbound, you do not have to fasten the brief tightly. You can leave some gap to let the skin breathe.

9. Remove your gloves and place them in the trash liner. Tie and discard the trash liner. Wash your hands.

10. Use this time to check body alignment, position, assess pain level and cover them. Remember to lower the bed back to a position closer to the ground.

11. Make sure they have their call bell near them or whatever device they use to call for assistance.

Body Alignment/Repositioning

Keeping someone comfortable while bedbound can be a challenge; their position will need to be changed frequently (every 2-3 hours).

Hazards of being bedbound and with little movement include: pressure sores (pressure ulcers), cramps and contractures. Pressure causes a local area of tissue injury. Pressure points include back of head, lower back/sacrum, upper buttock, elbows and heels.

Repositioning Onto Side

When repositioning onto their side, check shoulder alignment and make sure you pull the shoulder out and that it isn’t trapped beneath them.
Document time and position.
If they complain of lower back pain, place a small towel under lumbar spine for comfort.
While they are positioned on their back or side, use pillows to elevate knees and arms, and keep boney areas from touching.
Rolled washcloths placed in hands will absorb sweat and prevent nails from digging into their skin.
For those who are actively dying and asleep, we prefer to minimize disturbances, so holding off on repositioning is advised.

Moving Side-to-Side or Up in Bed

Use the shoulder and hips to lift and move.
It’s best to use a drawsheet to move them side to side or up in bed. A drawsheet prevents friction injuries and skin tears.
Handling someone who has little muscle, poor skin turgor and/or poor nutrition can cause injury. In some cancer patients with metastasization to the bone, the bones are brittle and can break/fracture easily.

Transferring a Client

Be as certain as you can that your client has the ability to stand, support their weight and take steps. Your client may be an unreliable narrator regarding this, and certain that they still have it in them. Have a plan in mind of your movements and remember you’re not going to catch them if they fall, but create a controlled fall to reduce injury for you and them.

Non-skid socks or shoes are preferred to bare feet or slippery slippers. Have your client’s equipment present and in place (i.e. have the walker or wheelchair close to their starting point). Place breaks on the wheelchair and consider the height of the chair or bed they’re moving to and from, and try to have them the same height.

Reminder: Always explain what you are doing or what is going to occur. Allow time in the process for your client to sit for a few moments, in case they feel dizzy when first sitting up.

Then complete the following steps:

Place your client’s outside leg (the one farthest from the wheelchair) between your knees for support. Bend your knees and keep your back straight.
Do a “three” count aloud and on “three” slowly stand up. Use your legs to lift and shift your weight from your front leg to your back leg.
At the same time, your client should place their hands by their sides and help push off the bed, supporting their weight during the transfer.
Pivot toward the wheelchair, moving your feet so your back is aligned with your hips.
Once the client’s legs are touching the seat of the wheelchair, bend your knees and move your weight from your back to your front leg to lower the client into the seat, with them simultaneously reaching for the arm rests.

Oral Care Tips

Provide mouth care routinely. If they can take sips, sit them up to at least 45 degrees and allow them to take small sips with a straw. Eventually most clients become too weak to suck on a straw, so you may want to trap liquid in the straw with your finger (or a syringe) and drip it in their mouth. It’s amazing how this brings such comfort.
Once your client can no longer swallow safely, you can use oral sponges to keep the mouth moist. Oral sponges can also be used to soak up their beverage of choice.
They will often bite down on the sponge. At first this may be startling because they won’t let go. Just wait, pull back on the sponge little by little, and they will eventually let go.
Apply chapstick to dry lips often.
You may have a client with dentures. Remove dentures or partials at night, and soak them in a cleaning solution. Rinse dentures thoroughly before putting them back in the mouth.
A common infection you may see is oral thrush (candidiasis), which is a frequently occurring fungal infection for people living with a weakened immune system. It is painful and looks like thick white patches coating the tongue and mouth. The tongue and oral mucosa will look beefy red. Let hospice know and they’ll order a oral solution that will clear it quickly.

Injury Prevention

Everything is important but nothing is urgent. Don’t rush. Explain procedures with your client before you begin. Always speak to them directly regardless if they can respond. Establish eye contact and be present with your client.

To Avoid Back Injury

Always raise the bed to the level necessary to save your back. Remember to return the bed to the low position for safety when you are done.
Use proper techniques and body mechanics for lifting and transferring clients.
Maintain good posture and bend at the hips and knees.
Lift with leg muscles – not back or arm muscles.
Avoid twisting motion.s
Do not lift a load higher than your waist.
Keep the load close to your body.
Do not attempt to lift or move something that seems too much to handle safely. Ask for help. Two people are always better than one.

Slips and Falls

Keep pathways free of obstacles / tripping hazards, rooms free of clutter and eyes on where you and the client are walking.
Immediately clean up spills and standing water.
Have proper footwear such as non-skid, closed-toe shoes.
Have enough lighting, non-skid mats and grab bars in the restroom.

Environmental Hazards

Know how to operate O2 and become familiar with O2 tanks.
Know where fire extinguishers are.
Know electrical safety.
Again, monitor spills, chemical and water hazards.

Comfort Care

A hospice CNA is responsible for your client’s personal hygiene including baths, showers, shampoos and shaves. Hospice also provides (Durable Medical Equipment (DME) to aid your client – such as Bedside Commode (BSC), shower chairs and bedside tables. However, you may be called upon to aid in your client’s personal hygiene and Activities of Daily Living (ADLs). You will have clients at different stages of ability, and an eventual decline in ability to complete ADLs on their own. Keep in mind that it may be embarrassing for the client to ask for assistance. Ask permission to assist and assure the client of your willingness to be of help.

Some ways you may be called upon to assist:

Turning and repositioning them in bed. Using pillows or other soft items to protect pressure points.
Transferring to a chair.
Ambulating to and from the bed, chair and toilet.
Assistance in using a BSC, toilet, catheter, hand held urinal and providing peri care.
Emptying a catheter bag or other types of urinary bags.
Mouth care – moisturizing lips, tongue, teeth and thus using mouth swabs, chapstick. Placement, removal and care of dentures.
Helping to dress or undress being aware of wounds, constrictions, weak or immobile limbs.
Incontinence care – changing briefs and pull ups.
Assistance walking with use of cane, walker or wheelchair.
Assistance feeding or drinking.
Changing bed linen.
Documentation of their activities and status while you are with them.

You can also visit The Hospice Care Plan’s site (thehospicecareplan.com) for video demonstrations on bedside care topics, or visit their YouTube channel (youtube.com/@TheHospiceCarePlan).

ADDITIONAL Thoughts on Contemplative Care

When we’re involved in the day-to-day caring for someone, it can be easy to fall into a routine of performing our care services “by rote.” Perhaps we find ourselves gradually ebbing away from being present with our folks – from being contemplative.

Being present is important to pick up cues on their needs, agitation, pain, respiratory changes, level of consciousness and mood. Also, the energy we show up with affects our clients and each other. We should be aware that what we do in each moment sets up the next moment.

How can we get in the moment and be present; i.e. how can we be contemplative?

We return to our breath. And why is it always said to return to breath? The reason is, you can’t feel your breath anywhere else except in the present moment.

Equally important is awareness – the giving of attention to the present moment. Yet, it's difficult to be aware if we don't even know when we are distracted.

The following steps can help you show up contemplatively in your client’s sacred space:

Recognize When You’re Distracted

Distraction is when you’re not giving your full attention because your attention is being pulled to something else. Autopilot is similar to distraction – do your best to avoid doing something without focusing on it and without being present in the moment. Notice what is happening. When you realize you’re distracted is the best moment to choose to refocus. We’ve all experienced the morning drive to work when we’re going over the day’s agenda and thinking of so many other things. Before we know it, we have arrived at work and wondered “How did I even get here!?”

Come Back to Breath

Our breath is the gateway back into the moment, event or action we’re currently doing. It’s not about doing anything special with our breath – just notice it. Breath is part of the feeling of things. If we notice our breath, we’ll notice the feel of what we’re doing in the present, or we’ll notice the colors, smells and sounds. Breath is the anchor to now.

We do any number of mundane tasks daily – or almost daily. The more repetitive and familiar things become, the easier it is to disconnect from being grounded in the present moment. Catch the moment your focus begins to wane and redirect your energy to the importance of each sacred moment serving our clients.

To recognize you’re distracted is to take note of your triggers and patterns that lead to distractions. These could include lack of energy, making careless mistakes, forgetting what you were doing or what just occurred – or anxiety.

Keep a Practice of Uncertainty

Now that you’re back in the present moment, rather than trying to get the job done, explore the task and detach from a perfect result – be OK with the uncertainty or things (the “don’t know mind” philosophy we’re learning about from Frank Ostaseski). Do the work to the best of your ability, but don’t be so attached to the results. Understand that practice does involve failure, and know that mistakes can be learning opportunities. Explore the task, and notice the smells or the texture of the broom you’re sweeping with or the texture of the hand you’re holding.

Come Back to Breath (Again...and Again!)

The thought of a mistake or doing a bad job can follow you into the next time you try the task, causing you to be racked with nerves. This is when you can gently pivot into counting your breaths:

…one breath (inbreath/outbreath)…I am here in the present...

…two breaths…I am in awareness…

…three…four…five breaths…I’m continuing to count breaths...

…man, I could use a coffee!...

…oh, and I also need to put gas in my car…

…wait…where was I?!?...

…and that's OK. This is an exercise of counting, getting distracted and coming back. The goal is not to get to 10, but the practice of coming back. It’s building those pathways to make the coming back easier over time.

RETURN TO MODULE TWO