m224 – ABC’s of Personal Care 2017-12-31T07:13:29+00:00

WORDS YOU SHOULD KNOW

Some of the terms used in this module may not be familiar to you. Outlined below is a description of some words you will find in this module:

Indwelling urinary catheter – A tube that stays in the bladder for some time. It is used to withdraw urine.

Dementia – A mental disorder that causes confusion. The confusion becomes worse over time. It affects memory, thinking, judgment, and impulses.

Genitalia – The sex or reproductive organs that can be seen on the outside of the body (e.g. the penis). Also called the genitals.

Incontinent – Loss of bladder (or bowel) control.

Lesion – A local area of damage to the tissues of the skin (e.g. a wound, sore, rash, or boil).

Range of motion exercises – Movement of joints through their normal range.

Sebum – An oily substance secreted from sweat glands.

Self-care (hygiene) – Ability to provide own personal hygiene needs.

LESSON TWO

BENEFITS OF ASSISTING WITH PERSONAL HYGIENE

Healthcare workers
The time you spend in bathing and cleansing activities is a very intimate period between you and your client. Talk with your client and help build a trusting relationship. This is also a time in which you can focus on the immediate and future concerns of your client. For example, your client may want to talk about concerns that are emotional, social, or health-related. Give each client your full attention. Be supportive.

Use this time to observe and assess your client. Note any redness, swelling, lesions, broken areas, or anything else that looks unusual. Also look for drainage and the presence of pain. Make sure you report any unusual findings or any findings you are unsure of.

Clients
Feeling clean promotes a strong feeling of well-being for your clients.

  • Cleansing the skin removes perspiration, bacteria, dead skin cells, and sebum. Removing these substances from the skin will lessen the chance of irritation or infection.
  • While washing your client’s skin, you are also gently massaging the body. This massaging action will actually help to enhance circulation (blood flow) through the body.
  • While providing care, you are gently moving the client’s limbs. These movements provide range of motion exercises for the client. Range of motion exercises assist the client to maintain joint function.
  • Our bodies secrete many substances that can cause unpleasant odors if left on the skin for a period of time. Areas of concern are the axilla (armpit) and the perineal areas. Bathing can get rid of odors in these sites.
  • We feel more comfortable when we are clean. Assisting a client with this process promotes relaxation and a feeling of overall well-being. Care of the hair and teeth can enhance appearance and improve the client’s self-image.

CONSIDER FOR A MOMENT ...

Can you identify any other benefits of assisting with personal hygiene? For staff? For clients?

THE SKIN

The skin, the largest organ of the body, surrounds and protects us. Intact (unbroken) skin has many functions, all of which are very important. These functions include:

Defense against infection
The skin is an important line of defense against infection.

Sensation
Sensors in the skin make us aware of touch, pain, heat, cold, and pressure.

Body temperature control
Because of the action of the skin, our internal body temperature changes very little.

Excretion and secretion
Glands in the skin produce sweat to help control body temperature. The skin also secretes sebum to help prevent drying of the skin and hair.

The skin becomes more dry and fragile with age. It tears easily so ensure that you remove your watch and any rings prior to providing personal care. As well, keep your nails trimmed. Once torn, the skin of an older person takes longer to heal.

There are other differences for older clients. As we age, we tend to sweat less so that our bodies do not cope well with temperature increases. Monitor your older client carefully when the weather is very hot.

As you provide care to your clients, observe the skin for signs of present or potential problems. These include broken or reddened areas, unusual color changes, swelling or lumps, moles that have changed color, size or appearance, dry skin, bruises, rashes, and areas where the skin is broken. If you notice any reddened areas, do not massage them. Report anything unusual or anything you are unsure about.

You should be aware that there are differences in the skin, mucus membranes, and hair among people of different ethnic backgrounds. These differences may affect your findings. For example, some rashes may be difficult to see in persons who are dark-skinned.

LESSON THREE

BATHING THE CLIENT

When deciding how to bathe your client, consider issues such as: Can the client assist with the bath? Is the client confused? Does the client have any skin conditions that you should be aware of? How does the client wish to bathe?

The clients you care for may have many different practices with respect to bathing and grooming. Some clients prefer to have their bath in the morning, whereas others prefer the evening. Some clients wash daily; others bathe once a week. Some clients feel more comfortable accepting help with their bath from family members rather than from staff.

These differences may stem from personal values. They may also be due to cultural beliefs that are different from your own. Talk to your clients. Ask about their normal routine. Inquire about their comfort level. Explain what you are doing and why. Make adjustments in your routine where possible.

Clients who are totally dependent for all aspects of care may require a complete bed bath. Many clients, especially older clients, do not need a complete bath every day. Remember, older clients have dry and fragile skin. Providing a complete bath each day can increase the dryness and make the skin more prone to breakdown.

CONSIDER FOR A MOMENT ...

Consider your own normal bathing routine. Now imagine that you were told that, beginning tomorrow, you could only bathe at a specific time each day and in a manner that was different from your usual routine. Would you be disturbed? Clients often find themselves in this type of situation when they enter a healthcare facility.

COMPLETE BED BATH

The bathing process will be more efficient if you gather all equipment and supplies before you begin. Make sure that the room is warm before you remove the client’s clothing. Close any windows and shut the doors and/or pull any screens. Keep the client covered and expose only the body part you are washing. You will need the assistance of a colleague for bathing some clients.

When bathing a client, remember to use good body mechanics. Keep your feet shoulder width apart and stand firmly. Bend your knees and keep your back straight.

Side rails are often used for safety reasons. They may also be used to make the client more stable in the bed or to assist with moving around in bed. Always use them for unconscious clients to prevent them from falling out of bed.

It is important to know that side rails may be considered a restraint when they restrict a person’s movement. Check with facility’s policy and your client’s care plan for direction on the use of side rails prior to beginning personal care.

EQUIPMENT REQUIRED
Several washcloths
Bath blanket or sheet
Basin of warm water
Lotion
Disposable gloves
Several towels
Liquid soap or soap and soap dish
Deodorant
Clean clothes
Bag or container for soiled laundry

Procedure

1. Assist the client to empty the bladder if needed.
2. Wash your hands.
3. Explain the procedure to the client.
4. Place a basin of warm water at the bedside.
5. Provide privacy.
6. Put on gloves.
7. Remove regular bed linen and cover your client with a bath blanket.
8. Ensure client is in a comfortable position.
9. Raise the bed to a comfortable position for you to provide this care.
10. Place a towel under the client’s head and one over the chest.
11. Wash eyes, bathing from inner to outer areas. Use a clean area of the cloth for each eye. This will prevent the spread of germs from one eye to another. Dry gently.
12. Wash the face with a cloth and plain water. Continue to wash the remainder of the face and ears without using soap. Soap can cause drying of the skin on the face; however, a client may request use of a soap or an alternate face cleanser. Respect your client’s wishes.
13. Place a towel under the arm. Apply soap to washcloth and wash arm using long, firm strokes from fingers to underarm. Ensure underarm is cleansed, rinsed, and dried completely. This will help to reduce body odor that can be present in this area.
14. Repeat this step with the other arm. Apply deodorant if appropriate.
15. Bathe chest using long, firm strokes. Ensure skin under the female’s breasts is rinsed and dried well. You may have to lift each breast to wash well underneath. Look for any soreness or redness as you do so. Excess moisture can cause bacterial growth and irritation.
16. Bathe, rinse, and dry the abdomen. Take special care with the umbilicus (navel) and skin folds of the abdomen and groin.
17. Expose the client’s leg and place a towel underneath. Wash, rinse, and dry the leg using long, firm strokes from ankle to knee and then knee to thigh. Hold the heel to give greater support when flexing the knee. Wash feet and toes. Rinse and dry area well, especially between the toes.
18. Repeat with the other leg. Lotion can be applied if the skin appears dry. Your facility may have a specific lotion for this purpose or your client may have one that he/she prefers to use. The lotion should not have a drying effect.
19. Change the water.
20. If perineal care is to be provided see the following section entitled Perineal Care.
21. Assist client to a side lying position.
22. Place towel lengthwise along the back.
23. Wash, rinse, and dry the back from neck to buttocks using long firm strokes.
24. If skin appears dry, apply lotion. You can also use lotion to provide your client with a back rub. A back rub can be very comforting and relaxing.
25. Help the client to dress or to put on pajamas.
26. Ensure client is as comfortable as possible.
27. If side rails are used, put the bed in the lowest position.
28. Put away all equipment and supplies and wash hands.
29. Record the procedure in the appropriate area.

Other Bathing Options
A partial bed bath involves bathing a part of the body, usually areas that are likely to cause odors if left unwashed. Many clients, mainly older clients, will receive a partial bed bath every day and a more complete bath (bed bath, tub, or shower) once or twice a week.

The equipment used for a bed bath includes a washbasin. Washbasins that are not cleaned and completely dried, however, may harbor germs that can lead to illness. Another option is to use a bag bath. A bag bath involves the use of a package of wet washcloths. The washcloths have been pre-moistened with water, a cleanser, and a lotion. The bag is warmed in a microwave and a different cloth used for cleansing various parts of the body. Rinsing and drying are not required.

CONSIDER FOR A MOMENT ...

What is the usual procedure for cleaning washbasins at your facility? Do you feel that it is adequate? If not, notify your supervisor.

Many clients prefer to bathe in the tub or shower. A tub bath provides a more thorough cleansing, but safety must be taken into account. Clients must be able to get into and out of the bathtub. Strength, mobility, and mental functioning must be assessed to ensure the client can use a bathtub safely. Special tubs and chairs are also available to assist with bathing clients in the tub or shower. If you do use special equipment, ensure that you know how to use it safely.

LESSON FOUR

FOOT CARE

Assist clients to keep their feet clean and dry. Older people, in particular, tend to have conditions of the feet that cause pain and make it difficult for them to get around. Corns, calluses, and deformities are not at all uncommon.

Learn how to give good foot and nail care. Remember to dry well between the toes after bathing. Cut the nails straight across. Apply lotion if the feet are dry. Advise older clients to wear properly fitted shoes.

Some clients, especially older clients, may not have good circulation to their feet. They may also have a decreased ability to sense hot or cold. You must be very careful not to use water that is so hot that it can harm them.

Clients with diabetes are at particular risk for infection if their skin is torn. If your client has diabetes, a trained professional should provide foot care. As well, clients with diabetes should not have their feet soaked as this may increase the risk of infection. Some agencies have policies that state that only professionals with special training in foot care may cut the nails of an older client. In still others, a doctor’s order is required for nail cutting. Find out about the policies in your agency regarding nail and foot care and follow them.

CLIENTS WITH SPECIAL NEEDS

Clients with dementia have special needs. These clients may become very upset when a caregiver provides personal care. Confused clients may strike out and resist bathing, posing a safety risk for themselves and others. A variety of techniques can help reduce the stress for the client as well as the care provider. These include using warm towels to dry the client off, using a heat lamp, playing soft, soothing music, and maintaining a quiet area. Another option is the towel bath.

A towel bath is a gentler way of bathing. It involves placing washcloths and towels in a plastic bag. The number of cloths used will depend on the extent of the body to be washed. A no-rinse body shampoo is then added to a pitcher of warm water and poured into the plastic bag. The towels and washcloths are applied to the individual’s body using a massage-like action. It is best to start at the feet and work your way up the client’s body. The upper body and the hands are bathed last. A towel bath provides warmth, comfort, and relaxation in a way that is not too invasive. The process can be changed somewhat to meet the needs of individual clients. This system is similar to the bag bath mentioned earlier in the module.

CONSIDER FOR A MOMENT ...

Would any of your clients benefit from a towel bath? If so, discuss your ideas with your supervisor.

HAIR CARE

Keep your client’s hair neat and clean. Hair washing improves blood flow to the scalp area. Proper hair care helps prevent breakdown of the hair or scalp. Clean hair also improves appearance. It helps to improve your client’s feelings about him/herself.

Shampooing a Client in Bed
Shampooing a client in bed may be a necessary part of providing care for your client. If a client is unable to sit upright or transfer to a washroom or tub room, the shampoo may be provided with the person in bed.

EQUIPMENT NEEDED
Towels
Washcloths
Water pitcher
Wash basin/pail to catch water
Waterproof pad
Hair dryer (optional)
Cotton balls (optional)
Shampoo
Conditioner (optional)
Bath blanket
Clean comb or brush
Plastic or inflatable shampoo trough
Several containers of warm water
Bag or container for soiled laundry

Procedure

Before beginning the hair wash, check the care plan to ensure that it is safe to wash the client’s hair in bed. Conditions such as neck injuries, spinal cord injuries, or even arthritis may require another means of cleansing. If you are not sure, check with your supervisor. Also check your client’s care plan to find out about the need for a special shampoo.

1. Wash your hands.
2. Explain the procedure to your client.
3. Position your client on the back with head and shoulders close to the top of the bed.
4. Raise the bed to a high position to decrease stress on your back.
5. Place waterproof pad under head, neck, and shoulders.
6. Position the basin or pail on the floor or on a chair. Place a towel underneath to catch spills.
7. Inspect the client’s hair for knots and lice. Lice are tiny black insects that live on the hair and scalp. If knots are present, gently comb out. If lice are present, report to your supervisor as this will require a special treatment.
8. Put the bath blanket on the client, and fold back the regular bed linen. Keep the client covered at all times.
9. Cotton balls can be placed in the client’s ears to keep water out if the client wishes.
10. Position the shampoo trough under the client’s head. Have the open edge pointing toward the basin or pail to enable the water to drain.
11. Check the client’s clothing to ensure it is not in a position to get wet.
12. Provide your client with a washcloth to protect the eyes.
13. Ensure that the temperature of the water is not too hot or too cold.
14. Gently pour water over the client’s head with a cup or pitcher. Repeat until the hair is completely wet.
15. Apply shampoo to hair.
16. Wash hair and gently massage the scalp using both hands. Be careful not to use fingernails as this may scratch the scalp.
17. Rinse the shampoo out of the hair using the same procedure you used to wet the hair. Ensure all shampoo is rinsed from the hair. Shampoo left in the hair can cause dryness and itching.
18. Apply conditioner and rinse well.
19. Dry the client’s head, neck, and shoulders.
20. Remove the cotton if it was applied.
21. Raise the head of the client. Dry hair as much as possible with a towel.
22. Comb or brush the hair and dry with a hair dryer if the client wishes. Use on warm setting rather than hot.
23. Remove all equipment from the bedside.
24. Ensure the client is as comfortable as possible.
25. If side rails are used, put the bed in the lowest position.
26. Clean all equipment and wash your hands.
27. Record the procedure in the appropriate place.

LESSON FIVE

PERINEAL CARE

Perineal care (also called peri-care) involves cleansing of the external genitalia, perineum, and the surrounding skin. This care can be provided with the routine bath or as needed. Clients who are incontinent of urine or feces should have perineal cleansing provided after each soiling.

Encourage clients to provide perineal care for themselves if they are able to do so. Providing this care to clients can be embarrassing for both the client and the healthcare provider; however, embarrassment should not cause this care to be overlooked. Many clients prefer to have perineal care provided by a member of the same sex. This request should be met if at all possible.

CONSIDER FOR A MOMENT ...

Think about situations in the past where you have provided peri-care to clients. Did you use any particular techniques to help make the client feel more at ease during the procedure? If so, what were they? Would you feel comfortable sharing them with your colleagues and/or supervisor?

Challenges

Providing peri-care to some clients presents special challenges. The following clients need special attention to the perineal area:

  • Clients who have indwelling urinary catheters
  • Males who have not been circumcised
  • Female clients who are menstruating or who have recently given birth
  • Clients recovering from surgery involving the rectum or genitals
  • Clients who are incontinent need extra perineal care to prevent irritation, skin breakdown, or infection.

Equipment Required
Washbasin
Two or three washcloths
Bath blanket
Toilet tissue
Warm water
Bag or container for soiled laundry
Liquid soap or soap and soap dish
Bath towel
Waterproof pad
Disposable gloves
Cotton balls/gauze (may be required)

Procedure (Part 1)

  1. Gather all equipment at the bedside and explain the procedure before you begin.
  2. Pull the curtain or close the room door to provide privacy.
  3. Wash your hands.
  4. Raise the bed to a comfortable position.
  5. Assess the perineal area for signs of inflammation and skin breakdown.
  6. Assist client to a side lying position and place a towel along the client’s side.
  7. Keep the client covered with the bath blanket as much as possible throughout the procedure to ensure privacy.
  8. Apply gloves.
  9. If the client is wearing an incontinence product, remove and discard in appropriate garbage container. Remove any excess feces with the toilet tissue.
  10. Place a waterproof pad under the client.
  11. Apply soap to the washcloth. Never place the soap, especially bar type, in the basin of water. This will cause the water to become soapy and create difficulty with rinsing.
  12. Cleanse buttocks and anus washing from front to back. Germs can be transferred from the anus to the genital area. Ensuring you wash from front to back will decrease the chances of this occurring. If the cloth becomes soiled with feces, continue with a clean washcloth.
  13. Cleanse, rinse, and dry thoroughly.
  14. Remove underpad and replace with a clean one.
  15. Remove gloves and wash hands.

Procedure (Part 2) Female Client

  1. Fill a clean washbasin with warm water.
  2. Wash hands.
  3. Apply gloves.
  4. Assist the client to lie on her back.
  5. Assist her to bend her legs at the knee and to spread her legs.
  6. Keep the client as covered as possible throughout the procedure.
  7. Wash and dry the upper thighs.
  8. Wash the labia majora, which are the outer skin folds of the vagina. Gently pull the labia back from the thigh and wash carefully in the skin folds. Always wipe from front to back, toward the anus. Repeat on the opposite side using separate sections of the washcloth.
  9. Use disposable wipes, cotton balls or gauze for menstruating women and clients with an indwelling catheter.
  10. Rinse and dry area thoroughly.
  11. Separate the labia with one hand to expose the urethral opening and the vaginal opening.
  12. With the other hand, wash area from front to back, from pubic area toward rectum, in one smooth stroke. Use a separate section of the cloth for each stroke.
  13. Cleanse thoroughly around the inner folds, the clitoris, and the vaginal opening.
  14. Rinse the area well. If possible, use a bedpan and rinse by pouring warm water over the perineal area. This will remove soap more effectively than wiping.
  15. Dry area thoroughly.

Procedure (Part 2) Male Client

  1. Fill a clean washbasin with warm water.
  2. Wash hands.
  3. Apply gloves.
  4. Assist the client to lie on his back.
  5. Keep the client covered as much as possible throughout the procedure. Wash and dry the upper thighs.
  6. Gently raise the penis and place a towel underneath.
  7. If the client has an erection, wait 10 or 15 minutes and return to begin again.
  8. If the client is not circumcised, hold the penis and gently pull back the foreskin. This is important as a cheesy-like substance secreted by the glands gathers in this area.
  9. Wash the tip of the penis starting at the urethral opening. Using circular movements, cleanse from the opening outward (cleans from the area of least contamination to the area of most contamination).
  10. Discard washcloth and repeat with clean cloth down the shaft until the penis is clean.
  11. Rinse and dry thoroughly. Return foreskin to the natural position
  12. Instruct the client to open his legs slightly.
  13. Wash the scrotum. Lift and pay particular attention to any skin folds.
  14. Rinse and dry thoroughly.

Procedure (Part 3)

  1. If the client has bladder or bowel incontinence, a barrier cream may be required to protect the skin around the perineum. Your client may be ordered a particular cream for this area. If not, find out if your agency has a specific cream for this purpose.
  2. Replace the incontinent product if necessary.
  3. Remove gloves and wash hands.
  4. Assist client to a comfortable position.
  5. Put away all equipment.
  6. Record the procedure in the appropriate area.

CASE EXAMPLE

Mr. Martin is a 70-year-old man who has recently been admitted to the nursing home in which you work. He experienced a stroke about 3 months ago. The stroke left him unable to walk and incontinent of urine. Mr. Martin’s family were no longer able to provide his care at home. The son and daughter-in-law arranged for placement in your facility.

On admission, Mr. Martin stated he was angry with his son for making him come to the nursing home. He has hardly spoken to anyone since his admission. He keeps to himself and does not wish to participate in activities.

How can you use the bathing experience to help Mr. Martin with this transition?

SUGGESTED ANSWER TO CASE EXAMPLE

The provision of personal care is a very intimate procedure between the client and the healthcare provider. This time can allow for a trusting relationship to develop. While providing care, talk with Mr. Martin. It may help him to express his angry feelings towards his son. You may find he is angrier with himself for being dependent on others. Allowing him to put his feelings into words may assist him in dealing with them.

This time can also be useful for assessment purposes. While assisting Mr. Martin, you are able to assess how much he is able to do for himself. You may be able to make helpful suggestions, such as moving the furniture to allow him more freedom of movement.

THINGS TO REMEMBER

The following is an overview of important points to keep in mind while assisting clients with personal hygiene. Some of these items have been mentioned
earlier in this program but they are important enough
to be repeated again.

  1. Follow the care plan for each client. Sometimes procedures may have to be changed to meet individual client needs.
  2. Follow the policies of your particular agency.
  3. Use the time you spend with your clients to assess their condition and their needs. For example:
    • Observe for redness, swelling, lesions, broken areas, or anything else that looks unusual. Also look for drainage and the presence of pain. 
    • Watch for signs of confusion or for a change in your client’s ability to assist with care.
    • Report any unusual findings or any changes you think may be important. 
    • Encourage clients to assist with their care to the extent of their abilities. Doing so promotes self-care and independence.
  4. Show compassion. Treat your clients like you would want to be treated if you were in a similar situation. For example:
    • Treat your clients with respect.
    • Explain what you are going to do before you begin any procedure.
    • Gather all materials and equipment before you begin care to avoid having to leave the room after you have started a procedure.     
    • Be sensitive to your clients’ feelings. They may feel embarrassed about having someone assist with their personal care. They may also be upset about the fact that they cannot provide this care on their own.
    • Try and anticipate what your clients will need and what may make them feel more comfortable. Offer to help before they need to ask for assistance.
    • Heat the room before you begin a bath and ensure the water temperature is comfortable.
    • Ensure privacy as you assist your client with personal care.
    • Be flexible in your approach as you assist clients with their care.
  5. Follow safe practices. For example:
    • Ensure that you use proper equipment for yourself and your client when assisting with any aspect of care.   
    • Keep the bed in a high position so that you don’t have to bend over as you provide care.
    • Follow safe lifting and moving practices overall. 
    • Follow agency policies and your client’s plan of care with respect to the use of side rails. 
    • Keep the bed in the lowest position when side rails are up to decrease the risk of falls.
    • Find out about client allergies (may be allergic to latex gloves).
    • Be aware that confused clients need careful monitoring. 
    • Ask for the assistance of another staff member if you feel you may need it. Check the water before you begin bathing or shampooing a client. Ensure that it is at a comfortable temperature.
  6. Help prevent the spread of infection.
    • Follow your agency’s guidelines with respect to hand washing.
    • Follow your agency’s guidelines with respect to Standard Precautions, Blood and Body Fluid Precautions, and other methods of infection control.
  7. Document the care you give following agency policies.

IN CONCLUSION

Assisting clients with personal hygiene has benefits for healthcare workers and clients. Healthcare workers get a chance to assess the client, to spend time with them in a personal way, and to build trusting, caring relationships. Clients get their basic care needs met. They build stronger ties with care providers. Their appearance improves and they feel better about themselves.

Attending to a client’s personal needs requires skill, but it also requires a compassionate and sensitive approach. Client safety and proper infection control practices are also important.

CHECK YOUR KNOWLEDGE

What are the functions of the skin?

What equipment would you require to do a total bed bath?

What are the benefits of assisting clients with personal hygiene?

Which client groups might require special attention to the perineal area?

Identify five safety practices to follow while providing personal care to clients.

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133-134.

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http://www.nursingcenter.com/prodev/ce_article.asp?tid=278289.

Como, D. (Ed.). (2002). Mosby’s medical, nursing and allied health dictionary (6th ed.). St. Louis: Mosby.

Elkin, M., Perry, A & Potter, P. (2000). Nursing interventions and clinical skills (2nd ed.).St. Louis: Mosby.

Gray, M., Ratliff, C. & Donovan, A. (2002).  Perineal skin care for the incontinent patient. Advances in Skin and Wound Care, 15(4), 170-175.

Kozier, B., Erb, G., Berman, A. & Burke, K. (2000).  Fundamentals of nursing: concepts, process, and practice, (6th ed.), New Jersey: Prentice-Hall.

Potter, P. (2001). Hygiene. In P. Potter  & A. Perry (Eds.),  Fundamentals of nursing (5th ed.)(pp. 1054-1120). St. Louis: Mosby.

Potter, P., & Perry, A. (2001). Canadian fundamentals of nursing (2nd ed.). Ross-Kerr, J., & Wood, M. J. (Canadian editors). St. Louis: Mosby.

Schindel Martin, S., Morden, P. & McDowell, C. (1999). Using the towel bath to give tender care in dementia: A case example. Perspectives, 23(1), 8-11.

Taylor, R. (2000).  Hygiene. In Harkreader (Ed.), Fundamentals of nursing: caring & clinical judgment (pp. 924-965).  Philadelphia: W.B. Saunders.

Zucker, E. (1996). Being a homemaker/home health aide. (4th ed.). New Jersey: Prentice- Hall.

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