Which actions should the nurse take when assisting the patient with toileting?

Falls are a leading cause of injury among older adults, and a significant number occur during bathroom transfers. As a healthcare professional, understanding Which actions should the nurse take when assisting the patient with toileting? is crucial for ensuring patient safety and preserving dignity.

Quick Summary

A nurse assisting a patient with toileting should first perform a patient-centered assessment, maintain strict infection control, use proper body mechanics for safe transfers, ensure patient privacy and dignity throughout the process, and document all pertinent observations.

Key Points

• Pre-Assessment is Crucial: Before assisting, evaluate the patient's mobility, cognition, and fall risk to determine the safest approach and required level of assistance.

• Prioritize Privacy and Dignity: Use respectful language, provide a private environment, and maintain the patient's modesty throughout the toileting process.

• Practice Safe Transfer Techniques: Utilize proper body mechanics, assistive devices like transfer belts, and clear communication to ensure a safe transfer and prevent injury.

• Maintain Strict Infection Control: Always wear gloves, wipe from front to back, and perform thorough hand hygiene and equipment cleaning to prevent the spread of germs.

• Provide Thorough Post-Care: After toileting, ensure proper hygiene, observe and document patient output, and reposition the patient safely and comfortably.

• Document and Report Observations: Accurately chart the procedure and report any unusual findings, such as pain, discomfort, or abnormal output, to the appropriate medical personnel.

Comprehensive Patient Assessment

Before beginning any assistance, a thorough assessment is fundamental to providing safe and effective care. This initial evaluation helps the nurse understand the patient's specific needs, limitations, and preferences.

Assess Patient Mobility and Fall Risk

Evaluate the patient's ability to move, including their strength, balance, and endurance. Is the patient able to bear weight on one or both legs? Do they have a history of falls or feel dizzy upon standing? The nurse must also consider any medical conditions that affect mobility, such as arthritis, stroke-related weakness, or neurological disorders. This assessment informs the choice of assistive devices and the level of assistance required.

Understand Cognitive and Communication Status

Assess the patient's cognitive function and ability to follow instructions. For patients with cognitive impairments like dementia, the nurse should look for non-verbal cues that indicate the need to toilet, such as fidgeting, pulling at clothing, or agitation. Clear, simple language should be used to communicate each step of the process, ensuring the patient feels involved and respected.

Evaluate the Environment

Conduct a safety check of the immediate area. Ensure a clear and well-lit path to the bathroom or commode. Remove any tripping hazards like loose rugs, cords, or misplaced equipment. Confirm that grab bars, raised toilet seats, and other assistive devices are properly secured and functional.

Ensuring Privacy and Dignity

Toileting is a very personal and private act. The nurse's approach should always prioritize the patient's dignity and modesty, which helps foster trust and reduce embarrassment.

• Provide a Private Space: Close the room door and pull the curtain to create a private environment. Respect the patient's preference regarding leaving or staying in the room if they can be safely left alone.
• Maintain Modesty: Drape a towel or blanket to cover as much of the patient as possible while providing care. Avoid using language that infantilizes the patient, such as referring to briefs as 'diapers.'
• Communicate Respectfully: Explain what you are doing before you do it, and do not rush the patient. A calm, patient demeanor is essential, and humor, if appropriate, can help ease tension.

Safe Transfer and Positioning

Using proper body mechanics and assistive devices is critical for preventing injury to both the patient and the nurse.

Assisting with Toilet Transfer

• Prepare the Patient: Position the patient to a sitting position on the side of the bed. Ensure they have on non-slip footwear.
• Position Yourself: Stand in front of the patient, with your feet apart for a stable base. Keep your knees bent and back straight, and keep the patient close to your body.
• Use a Transfer Belt: If the patient requires moderate assistance, use a gait or transfer belt to provide a secure hold around their waist. Never lift by their arms.
• Pivot, Don't Twist: Guide the patient to stand and slowly pivot toward the toilet. Lock the wheels on any device, such as a wheelchair or commode, before beginning the transfer.

Using a Bedpan or Commode

For patients unable to transfer to the toilet, the nurse must properly place and remove bedpans or use a bedside commode. Use a fracture pan for patients with hip injuries to reduce strain. When positioning a bedpan, roll the patient onto their side, place the pan, and then roll them back into position.

Types of Toileting Aids Compared

Aid	Best For	Key Feature	Safety Precaution
Bedside Commode	Patients with limited mobility who can't walk to the bathroom.	Portable toilet, often with height adjustment.	Lock wheels and ensure the patient is stable before sitting or standing.
Raised Toilet Seat	Patients recovering from hip or knee surgery; limited flexibility.	Increases toilet height, reducing bending.	Ensure it is properly clamped to the toilet for stability.
Bedpan (Standard)	Bedridden patients with good hip mobility.	Curved shape conforms to patient's body.	Support the lower back during placement to prevent discomfort.
Bedpan (Fracture)	Patients with hip fractures, limited movement.	Smaller with a flatter end for easier placement.	Position with the flat end toward the foot of the bed.

Infection Control and Hygiene

Maintaining strict hygiene standards is non-negotiable during and after assisting with toileting. This prevents the spread of bacteria and reduces the risk of urinary tract infections (UTIs) and skin irritation.

1. Wear Gloves: Put on clean, disposable gloves before any contact with the patient's intimate areas or bodily fluids.
2. Proper Wiping Technique: Always wipe from front to back to prevent the spread of bacteria from the anus to the urethra. Use fresh toilet paper or wipes with each wipe.
3. Perineal Care: After a bowel movement, use warm, soapy water and a fresh washcloth to clean the area thoroughly. Dry the area gently to prevent skin breakdown.
4. Hand Hygiene: After removing soiled gloves, always perform hand hygiene with soap and water or an alcohol-based hand sanitizer. The patient should also wash their hands if they are able.
5. Clean Equipment: Thoroughly clean and disinfect all toileting equipment, such as bedpans or commodes, after each use to prevent cross-contamination.

Post-Procedure Actions and Documentation

After the patient has finished and is safely back in bed or a chair, the nurse's responsibilities continue.

• Empty and Clean: Dispose of the waste, clean all equipment, and return the area to a clean, safe state.
• Monitor and Report: Observe the patient's output for color, consistency, odor, and amount. Note any signs of discomfort or pain. Report any abnormalities to the charge nurse or physician. For example, the presence of blood, cloudy urine, or very hard stool should be promptly documented and communicated.
• Document Care: Accurately record the time, type of assistance provided, patient's tolerance of the procedure, and any observations in the electronic health record.
• Patient Education: Take the opportunity to educate the patient on maintaining regular toileting routines, proper fluid intake, and potential signs of issues like constipation or UTIs. An authoritative source on falls prevention provides further context for patient safety. World Health Organization.

Conclusion

Assisting a patient with toileting is a critical nursing skill that goes beyond the physical act. It requires a holistic approach encompassing respectful communication, thorough patient assessment, adherence to safety protocols, and diligent infection control. By prioritizing patient dignity and safety throughout the process, the nurse ensures a positive and secure experience, contributing significantly to the patient's overall well-being and recovery.

Frequently Asked Questions

What is the first step a nurse should take when a patient needs to use the toilet?

The nurse should first perform a quick but thorough assessment of the patient's mobility, cognitive status, and the immediate environment to identify any potential risks, especially for falls.

How can a nurse maintain a patient's dignity during toileting?

Maintaining dignity involves closing doors or curtains for privacy, using respectful language, explaining each step of the process, and ensuring the patient's body is covered as much as possible to maintain modesty.

What are safe transfer techniques for getting a patient to the toilet?

Safe transfers include using a transfer belt, locking the brakes on all equipment, using proper body mechanics (bending knees, keeping back straight), and pivoting rather than twisting. The nurse should always encourage the patient to help as much as they safely can.

How should a nurse assist a patient who needs to use a bedpan?

To assist with a bedpan, the nurse should roll the patient onto their side, position the pan correctly, and then gently roll the patient back onto it. Raising the head of the bed slightly can help facilitate elimination. The nurse should use proper lifting and rolling techniques to protect their back and the patient's safety.

What infection control measures are necessary during and after toileting?

Infection control requires wearing disposable gloves during assistance, practicing proper front-to-back wiping, and performing meticulous hand hygiene with soap and water after removing gloves. All soiled equipment should be cleaned and disinfected promptly.

What should a nurse look for and document after a patient uses the toilet?

After toileting, the nurse should observe and document the characteristics of the patient's urine and stool, noting color, consistency, odor, and volume. The nurse should also assess the patient's skin for any irritation and document the patient's tolerance of the procedure.

How can a nurse prevent falls when a patient is using the toilet?

Fall prevention involves ensuring the path to the toilet is clear, using appropriate assistive devices like grab bars or raised seats, never leaving the patient unsupervised if they are a fall risk, and ensuring they have non-slip footwear. A proper pre-assessment is key to identifying potential hazards.