November 2005

Intimate Assistance

By Danielle Cohen

Approaching bathing and toileting issues requires creativity and compassion from therapists

Battery-powered equipment such as this bath lift can assist individuals with their bathing skills by adjusting their positioning in a tub.

While there are numerous aids for daily living (ADLs) available for individuals with various needs, none may be as personal or intimidating to those using them as the ones for bathing and toileting.

Besides the physical issues related to bathing and toileting, therapists must address the patient's psychological issues as well. Since the mere thought of needing an ADL for bathing and/or toileting can be overwhelming for patients, therapists have to present the need in as positive a manner as possible, focusing on the fact that the equipment will maximize the patient's independence and safety.

The patients who are assisted by bathing and toileting ADLs vary as much as the equipment itself, and include those who are paraplegic or tetraplegic, poststroke, or polio survivors, or have total joint replacements, spina bifida, cerebral palsy, muscular dystrophy, multiple sclerosis, traumatic brain injuries, spinal cord injuries, amyotrophic lateral sclerosis, or other neurological conditions.

Aids to daily living, including transfer systems and handheld showers, assist individuals with their hygiene skills, keeping them more independent.

EVALUATING THE NEEDS
Determining which ADLs to use usually begins with therapists assessing patients' problem areas, functional mobility, ability to transfer, and standing and sitting balance. Therapists also take into consideration any restrictions placed on patients due to disease diagnoses, disorders, injuries, or surgeries.

"Often, patients aren't really good at self-reporting and telling you where they're having problems. You have to be a good interviewer. You're getting people who are very independent and don't want to admit that something as personal as bathing or dressing is a problem," says Maria Cole, OTR/L, advanced clinician at Spaulding-Framingham, an outpatient facility in Framingham, Mass, that is part of the Spaulding Rehabilitation Hospital Network.

Patients and/or their families or caregivers are interviewed about the bathing and toileting routines and bathroom setups at home, including whether they already have any adaptive equipment or other ADLs. The interview helps therapists simulate home environments in the rehab environment, and determine what ADLs are needed and where they should be placed.

Patients or their families are also encouraged to take pictures to give a snapshot of what the home looks like and to help evaluate existing needs. Cole also uses an equipment catalog and advises patients to go to a medical supply company to help them visualize the ADLs and feel less intimidated by the equipment.

If needed and when possible, therapists conduct home visits to observe the environment, discover the patients' bathing and toileting routines, and make any suggestions for adaptations.

For patients who require assistance with sitting and/or transfers, bath/commode transfer systems such as this one eliminate the need for heavy lifting or awkward transfers.

TRAINING PATIENTS, CAREGIVERS
Before training patients about how to use the various ADLs, the therapists work on standing, sitting, and transfer skills.

The therapists say it makes a difference in the training whether there will be someone to assist the patients at home with bathing and toileting. The therapists try to involve family members as much as possible so that they feel comfortable taking the patients home. Family members and/or other caregivers are often key to helping patients be as independent as possible and, if need be, to assisting the patients and training others to do the same.

"A lot of [people] do take pride in their appearance, so they want to be clean. It's important to be comfortable when they're going through their bathing and toileting. For hygiene purposes, it's much easier for them to use some of these specialized chairs and [other items]; it makes it easier to clean themselves," says Heidi Guess, OTR/L, with Good Shepherd Home at Conrad W. Raker Center, Allentown, Pa, which provides inpatient and outpatient rehabilitation. Repetition helps ingrain the proper procedures for patients.

Bathing and toileting ADLs range from simple to complex to custom-made. Bathing ADLs include grab bars; long-handled sponges; tub/shower benches and chairs; handheld showerheads; rubber mats; adapted washcloths; shampoo or soap dispensers; adapted holders for electric shavers; and shower trolleys, stretcher-like products for those who are unable to sit for long periods of time while bathing—patients are wheeled into a shower and a drain on the trolley removes water.

Toileting ADLs include elevated toilet seats with locking devices to keep them in place—some with cutouts that make it easier to wipe; adapted wiping tools; commodes; ring reducers—small foam seat inserts for the top of the toilet so that individuals do not fall through the toilet; bars that latch onto the toilet to assist with standing; and catheters.

"The part about toileting that's really hard for some people is wiping," says Kathleen Putzier, OTR, with Salina Regional Health Center, a nonprofit hospital in Salina, Kan, that provides rehabilitation services for inpatients, outpatients, and home health, skilled nursing, and rehab unit patients. "Sometimes, after back surgery, people just don't have the flexibility to reach around and wipe, so we'll have to recommend long toilet tongs. With the population getting heavier and heavier, it's harder for these heavy patients a lot of times if they've had any kind of surgery or they're weak to reach around and be able to wipe themselves, so another thing we have to look at is hygiene."

There are also toileting ADLs such as suppositories and digital stimulation to facilitate bowel movements, which are especially helpful for patients with spinal cord injuries. "The individual with a new spinal cord injury often needs to have a bowel program established, such as the digital stimulation or a suppository, to help regulate their system," says Teresa Foy, OTR/L, therapy manager on the spinal cord injury unit at the Shepherd Center, an Atlanta-based catastrophic care hospital. "Someone with a spinal cord injury, depending on the level and whether the nature of the injury is complete or incomplete, needs a predictable pattern of elimination."

The therapists say the increasing number of bariatric patients can pose problems in finding appropriate ADLs, although manufacturers have begun to address the needs of that patient population by creating sturdier shower/tub benches and lifts, for example.

While many of the ADLs that exist for bathing and toileting have been around for awhile, there have been some more recent additions, including a variety of showering and toileting chairs that can accommodate abnormal tone and postures; showering equipment that comes with different types of padding to help prevent sores; and bedside commodes with front, side, and back cutouts for easier access. Much of the equipment today is also more aesthetically pleasing: long-handled combs and brushes are now more ergonomically correct and come in different colors; shower chairs have a more updated look and are more comfortable; raised toilet seats are more functional, allowing men to raise them to urinate; and grab bars come in different colors.

There are those times when a custom-made item is the only solution. When that occurs, the staff at Good Shepherd turn to adaptive equipment specialist Donna Miller.

With regard to bathing and toileting, the ability for people to tilt is always a big issue, Miller says. She recalls having to create something for a patient who could not sit on any commercially available device. "[The patient] was extremely spastic and couldn't really sit at a 90° angle," she says. She eventually took a frame from an old shower chair, and welded, padded, and covered it for the patient to use. The project took months to complete from design to creation.

Danielle Cohen is associate editor of Rehab Management.

LOOKING FOR EXPERT ADVICE? Experts here are available to answer all your questions! Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER Interactive Media  Archives  · December 2008  · November 2008  · October 2008  · August/September 2008  · Fall 2008 Product Directory  · July 2008  · June 2008  · May 2008  · April 2008  · March 2008  · All Archives  Newsletter  · Rehab Today Resources Classifieds Calendar Consumer Resources Media Kit Advertiser Index EAB Reprints Submit an Article