Chapter 8: Washing, Dressing and Personal Care

A Common Situation

A woman in her forties has started to help her father with his morning routine since his balance became unsteady. He has always been a private, rather formal man, and she can see that he feels embarrassed when she comes into the bathroom. Some mornings he says he will wash later, and then the day passes without a wash. Getting dressed takes him a long time, especially the buttons on his shirt, and when she tries to speed things up by doing it for him, he becomes quiet and unhappy. She wants him to be clean, comfortable and safe, but she also wants him to keep his pride, and she is not sure how to do both.

Personal care means the everyday tasks of looking after the body: washing, bathing, caring for the skin, the hair, the nails and the teeth, shaving, and getting dressed and undressed. These are some of the most private things a person does, so helping with them asks for special care and tact. In this chapter I will explain how care textbooks approach personal care with privacy and dignity, how to let the person do each step that is still possible, how to make bathing and showering safe, and how to protect the skin, including the basics of preventing pressure sores. We will finish with hair, nails, shaving and clothes, and with a simple rule for dressing when one side of the body is weaker than the other.

Privacy, Dignity and Doing It Together

Most of us learned to wash and dress ourselves as small children, and since then nobody has seen us do it. When an adult begins to need help with these tasks, it can feel like losing a piece of adulthood. Feelings of shame, embarrassment or irritation are very common and very understandable. A person who refuses a wash is often not being difficult; the person may be protecting privacy, may be afraid of falling, may feel cold, or may simply not want to be told what to do. Understanding these feelings is the first step towards care that the person can accept. It also helps to remember that the carer may feel awkward too, especially a son helping his mother or a daughter helping her father. Such feelings are normal, and they usually ease as a calm, respectful routine develops.

Care textbooks give several practical ways to protect privacy. Close the door and the curtains before you begin. Knock before entering the bathroom or bedroom, even in your own family home. Keep the parts of the body that are not being washed covered with a towel, so that the person is never more exposed than necessary. Explain what you are about to do before you do it, in a calm and ordinary voice, and wait for the person's agreement. Talk about something other than the task if that helps, or keep quiet if the person prefers. When someone else must be present, such as a second helper, explain why and keep the number of people as small as possible.

Chapter 1 introduced a key idea in care: support what the person can still do, instead of doing everything for the person. In personal care this means breaking each task into small steps and helping only with the steps that are truly difficult. A man who cannot bend to wash his feet may still wash his face, chest and arms himself if the basin, soap and towel are within reach. A woman who cannot manage buttons may still choose her clothes, put her arms into the sleeves and pull up a skirt with an elastic waist. Handing over the flannel, holding a mirror, or simply waiting a little longer can be more helpful than taking over. Each step the person does alone keeps strength, skill and confidence.

Choice is another part of dignity. The person you care for can decide, as far as possible, when to wash, whether to have a bath, a shower or a wash at the basin, which soap to use, what to wear and how to wear the hair. If the person has always bathed in the evening, a morning shower may feel wrong, however practical it is for you. Some people prefer to be helped by a family member of the same sex, or by a professional rather than by a son or daughter, and these wishes deserve respect when it is possible. In some cultures there are customs about washing, modesty or clothing that matter deeply to the person, and it is worth asking about them.

A common moment is when the person refuses help again and again. It helps not to force the matter and not to turn it into a contest. Try again at a different time of day, offer a different kind of wash, make the room warmer, or let another person you both trust offer the help. Sometimes a reason, such as "we are going out to see your sister", makes washing feel worthwhile. A full bath or shower every day is not necessary for most older people; a daily wash of the face, the hands and the private areas, with a bath or shower on some days, keeps a person clean and comfortable. If refusals continue and you are worried about the person's hygiene or skin, talk to the doctor or nurse.

Bathing and Showering Safely

The bathroom is one of the places in the home where falls happen most easily, because floors are wet, surfaces are hard and the person may feel tired or light-headed in warm water. Chapter 5 describes the bathroom as part of making the whole home safe. Here we look at the moment of washing itself. Good preparation is the most important safety step. Before the person comes into the bathroom, gather everything you will need: soap, flannels, towels, clean clothes, a comb and anything else the person uses. Then neither of you will need to leave the bathroom halfway through, and the person will not be left standing on a wet floor while you look for a towel.

Warmth matters for comfort and for safety. Older people often feel the cold more and lose body heat more quickly, especially when wet. Warm the bathroom before the wash, close windows, and keep towels ready to wrap around the person straight away. At the same time, water that is too hot can scald older skin quickly, and some older people feel heat less than before. Always check the water temperature before the person touches it. Care textbooks suggest testing it with your own wrist or elbow, which are more sensitive than your hand, or with a bath thermometer. Water should feel comfortably warm, never hot, and should be checked again if more hot water is added.

A safe bathroom floor and safe surfaces protect against falls. A non-slip mat inside the bath or shower and another on the floor outside it, a stable shower chair or bath seat, and grab bars fixed firmly to the wall make standing, sitting and stepping much safer. A towel rail or a basin is not strong enough to take a person's weight, so it should never be used as a handhold. Help the person to sit down for as much of the wash as possible. If the person has a bath, getting in and getting out are the moments when slips happen most, so take these steps slowly. An occupational therapist can advise on equipment that suits the person and the bathroom.

The most important rule is never to leave someone alone in the bath or shower if that person may fall, feel faint or have difficulty getting out. If the doorbell or the phone rings, let it ring; the person's safety comes first. If the person wants privacy and is able to manage safely, you can wait just outside the door, which you leave slightly open, and agree on a way to call you. Signs such as dizziness, sudden weakness or confusion during a wash are a reason to help the person sit down at once and to call for help if they do not pass quickly. If the person falls or becomes very unwell, call the emergency number.

On days when a bath or shower is too tiring, or when the person cannot get into the bathroom, a wash at the basin or in bed keeps the person clean and fresh. Care textbooks describe a bed wash as washing one part of the body at a time, while keeping the rest covered and warm, using fresh warm water, a mild soap and separate flannels for the face and body. Each part is washed, rinsed and dried gently before moving to the next. A nurse or care worker can show you how to do a bed wash safely and comfortably, and watching it done once is often much easier than reading about it. Whatever kind of wash you use, dry the skin carefully, especially in the folds of the skin and between the toes. Damp skin in these places can become sore and is more easily damaged.

Caring for the Skin

Skin changes with age. It becomes thinner, drier and more fragile, it heals more slowly, and it can tear or bruise from small knocks that would not have hurt a younger person. Gentle care keeps it healthy. Use mild soap or a soap substitute, warm rather than hot water, and pat the skin dry instead of rubbing. A plain moisturising cream applied to dry areas, especially the legs, arms and feet, helps keep the skin supple. Watch for rough handling during help with moving and dressing: rings, long nails and watches can scratch fragile skin, and pulling a person by the arm can tear it. Drinking enough and eating well, as Chapter 7 describes, also help the skin stay strong. Small cuts or tears should be cleaned gently and covered, and any wound that does not heal, or that becomes red, swollen or painful, is worth showing to a nurse or doctor.

A pressure sore, sometimes called a pressure ulcer or bedsore, is damage to the skin and the tissue under it caused by pressure that lasts too long. When a person sits or lies in the same position for a long time, the weight of the body presses the skin against the bone underneath. Blood cannot flow freely to that area, and the skin and tissue can become damaged. Rubbing and sliding against the sheets or a chair, and skin that stays damp, make damage more likely. Pressure sores can develop more quickly than many people expect, especially in a person who is thin, very unwell, or not able to move much alone. The good news that care textbooks emphasise is that many pressure sores can be prevented with everyday care.

Pressure sores usually form over bony parts of the body. When a person lies on the back, these are the back of the head, the shoulder blades, the elbows, the base of the spine and the heels. When a person lies on the side, they are the ear, the shoulder, the hip, the knee and the ankle. When a person sits for a long time, the buttocks and the base of the spine carry most of the weight. These are the places to look at when you check the person's skin. Checking once a day, perhaps during washing or dressing, is a good habit, and the person can be invited to tell you about any spot that feels sore, burning or tender.

The most important way to prevent pressure sores is regular change of position. A person who cannot move easily alone needs help to shift weight from time to time, both in bed and in a chair, so that no area carries pressure for too long. How often this is needed depends on the person's skin and health, so ask the nurse to advise you. Encourage small movements too: leaning forward, shifting from side to side, or standing up for a moment if the person can. Chapter 6 explains how to help a person move in bed safely; helping the person to turn and to move up the bed without dragging them across the sheet protects the skin from rubbing. Pressure-relieving cushions and mattresses exist, and the nurse or therapist can say whether one would help the person and how to use it.

Keep the skin clean and dry, especially if the person sweats a lot or has accidents with the bladder or bowels, which Chapter 9 describes. Keep sheets smooth and free of crumbs and wrinkles, and choose soft clothes without thick seams or tight elastic in places where the person sits or lies. Do not rub or massage an area that already looks red, because this can damage the tissue further. Knowing what to tell the nurse about is a vital part of prevention. An area of skin that stays red, or on darker skin looks darker, purple or shiny, after the pressure has been taken off, skin that feels warmer, cooler, harder or softer than the skin around it, a blister, or any broken skin over a bony area are all worth telling a nurse or doctor about soon, so that they can act early.

Hair, Nails, Shaving and Clothes

Looking neat and familiar is part of feeling like oneself. Help with hair can be as simple as placing a comb, a brush and a mirror within reach. Washing the hair can be done in the shower, at the basin with the person sitting, or with a jug and a bowl, and some people enjoy having it done by a hairdresser who visits the home or whom they visit with you. Keep shampoo out of the eyes and take care that the person's neck is not bent back uncomfortably. Many older people take real pleasure in a familiar hairstyle, a little perfume or a favourite lotion, and these small things can lift the whole day.

Nails grow more slowly with age, and toenails often become thicker and harder to cut. Fingernails are easier to trim after a bath or a soak in warm water, when they are softer. Care textbooks advise cutting toenails straight across and not too short, and filing any sharp edges. If the toenails are very thick, if the person's feet have poor feeling or poor circulation, or if the person has a condition that the doctor says affects the feet, a nurse or a foot care professional should look after the nails. Sore spots, cuts that do not heal, or changes in the colour of the feet are worth telling the nurse or doctor about. Comfortable, well-fitting shoes protect the feet as well as helping to prevent falls.

Many men like to keep their usual shaving routine, and it can be an important part of the morning. An electric razor is often safer and easier than a blade, especially for someone with shaky hands or thin skin, or for a carer who shaves another person. If you help with shaving, let the person do as much as possible, use a mirror and good light, and work slowly and gently. Women may also have their own routines for removing facial hair or for make-up, and helping with these quietly and without comment respects the person's sense of self. When memory changes make these routines difficult, doing them side by side, with you showing each step, often helps.

Choosing clothes that are easy to put on can make dressing much less tiring for both of you. Care textbooks suggest loose, comfortable clothes, front openings rather than openings at the back, elastic waists, and large buttons, zips with a ring pull or touch fasteners instead of small buttons. Shoes with a firm sole and a fastening that is simple to close are both easier and safer than slippers that slide off. Lay the clothes out in the order they are put on. Give the person time, and offer a limited choice, such as two shirts, rather than an open wardrobe, if too many choices cause confusion. The person's own taste still matters most; easy clothes do not have to be dull clothes.

When one side of the body is weaker than the other, for example after an illness or an injury, there is a simple textbook rule for dressing: dress the weaker side first, and undress the stronger side first. When putting on a shirt, guide the weaker arm into its sleeve before the stronger one, so the stronger arm, which can bend and reach, goes in last. When taking the shirt off, the stronger arm comes out first, and the sleeve then slides easily off the weaker arm. The same idea works for trousers and other clothes. Sitting down for dressing, in a stable chair with armrests, is safer than standing. A nurse or occupational therapist can show you and the person the easiest way to dress, and the person may learn to manage much of it alone.

Personal care takes time, and on some days there will be little time to spare. It may help to think of it not as a list of tasks to finish but as a daily moment of contact between two people. The touch of a warm towel, a careful hand with a comb, and a few minutes of quiet attention can be as comforting as they are practical. When the person you care for is clean, comfortable, dressed in familiar clothes and treated with respect, the whole day often goes more smoothly for both of you. And if personal care becomes too heavy for you, it is a good moment to ask about outside help, which Chapter 14 describes.

A Question to Think About

Which part of washing, grooming or dressing does the person you care for still do alone, or could do alone with a little more time or a better arrangement? You might watch quietly during the next morning routine, or ask the person directly which steps they would like to keep doing themselves.