BEDSIDE CARE AND MANNER

As a Yogi-Doula you may or may not be involved much with hands-on care and with Guest hygiene. But we think it is an important skill to have and be familiar with in the case that you are in a situation when someone needs your help.

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 the Guest 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 a Guest, 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, as they can be uncomfortable and be cause for skin injury.

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

Step-by-step:

1. Wash your hands thoroughly with soap and warm water or use hand sanitizer. Put on your gloves. Place the patient/guest comfortably on their back if they are not already.

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 operate on a flat surface and at a height where you’re comfortable and your back is not leaning too far forward, it is important to protect your back.

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 Guest’s 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 your Guest 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 on Guests.

7. Fully open a fresh brief, lie 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 your Guest 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. As the Guest 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 with the Guest 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 bed bound can be a challenge; their position will need to be changed frequently (every 2-3 hours).

Hazards of being bed bound and with little movement include: pressure sores (pressure ulcers), cramps, 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, arms, and keep boney areas from touching.
Rolled washcloths placed in hands will absorb sweat and prevent nails from digging into their hand.
For Guests 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 is 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 that has little muscle, poor skin turgor, poor nutrition can cause injury. In some cancer patients with metastasization to the bone, the bones are brittle and can break/fracture easily.

Wet or Dry Death

It is better to die dry than wet. At least that is the gist of traditional thinking in hospice and palliative care, where parenteral (IV or subcutaneous) fluids are often avoided at the very end of life to prevent fluid buildup in the lungs and other organs. During the normal death process, people will lose their hunger and thirst. Additionally, they may not be sufficiently alert to swallow safely. This is a sign that the body’s systems are beginning to malfunction. At this period, death can occur anytime. While hydrating the mouth may make the patient feel more comfortable, this is done to alleviate dry mouth, not to quench thirst. (See Module 7.2 Stages of Dying for more information on this topic.)

Transferring a Guest

Be as certain as you can that the Guest has the ability to stand, support their weight and take steps. The Guest 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 the Guest 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 the Guests equipment present and in place (i.e. have the walker or wheelchair close to the Guest’s starting point). Place breaks on the wheelchair and consider the height of the chair or bed the Guest is 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 the Guest to sit for a few moments, in case they feel dizzy when first sitting up.

Then complete the following steps:

Place the Guest’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, the Guest should place their hands by their sides and help push off the bed, supporting their weight during the transfer.
Pivot towards the wheelchair, moving your feet so your back is aligned with your hips.
Once the Guest'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 Guest into the seat, with the Guest 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 Guests 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 the Guest 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, such as beer, apple juice, even wine.
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 guest/patient 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 an oral solution can be ordered that will clear it quickly.

Injury Prevention

Everything is important but nothing is urgent. Don't rush. Explain procedures with the Guest before you begin. Always speak to them directly regardless if they can respond, establish eye contact and be present with the Guest.

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 Guests.
Maintain good posture and bend at the hips and knees.
Lift with leg muscles. Not back or arm muscles.
Avoid twisting motion.
Do not lift a load higher than the waist.
Keep the load close to the 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, eyes on where you and the Guest are walking.
Immediately clean up spills and standing water.
Have proper footwear; 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 Guest’s personal hygiene; baths, showers, shaves, washing hair. Hospice also provides DME (durable medical equipment) to aid the guest such as, bedside commode (BSC), shower chairs, bedside tables. However, you will be called upon to aid in the Guest’s personal hygiene and ADLs (Activities of Daily Living). You will have Guests at different stages of ability and an eventual decline in ability to complete ADLs on their own. Keep in mind this may be embarrassing for the Guest to ask for assistance. Ask permission to assist and assure the Guest of your willingness to be of help. Some ways you may be called upon to assist the Guest are as follows:

Turning and repositioning them in bed. Using pillows or other soft items to protect pressure points.
Transferring to a chair.
Ambulating to and from bed, chair, toilet.
Assisting Guest 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 Guest’s activities and status while you are with them.

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

When we’re involved in the day-to-day caring for Guests and Clients, 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 with Guests is important to pick up cues on their needs, agitation, pain, respiratory changes, level of consciousness, and mood. Also, the energy you show up with affects the Guests 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 are four steps to help you show up contemplatively in a Guest’s sacred space.

Recognize when you are 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; the ability to do a thing without focusing on it and without being present in the moment and noticing what is happening. When you realize you’re distracted - that is the moment to choose to refocus. We’ve all experienced the morning drive to work where you’re going over the day’s agenda, squeezing in your personal errands. Before you know it, you have arrived at work and wondered “How did I even get here!?”

Come back to breath.

The breath is the gateway back into the moment, event, or action you're currently doing. It’s not about doing anything special with your breath, just notice it, breath is part of the feeling of things. If you notice your breath, you'll notice the feel of what you're doing in the present, or you’ll notice the colors, smells, 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. At ABODE, we want you to catch the moment your focus begins to wane and redirect your energy to the importance of each sacred moment serving our Guests.

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”). 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, 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 the breath.

The thought of a mistake, 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…

I’m counting my 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