Implementing Bathing and Toileting Aids in the Homecare Setting

When a patient is discharged to home from a rehabilitation hospital, it is common practice for an occupational therapist (OT) to perform a home evaluation. This evaluation is meant to assist the patient and family return to a safe and accessible environment. Recommendations from the OT are based on the patient’s current level of functional mobility. When addressing adaptive equipment needs for the bathroom, adaptive bathing and toileting equipment should be considered. Patient safety concerns include fall risk, reaching limitations, spinal precautions, hip precautions, activity tolerance and pain management. When determining an individual’s level of bathing independence, it is common practice to refer to a guideline such as the Functional Independence Measure (FIM) to consider the number of parts of the body the person can safely wash independently. FIM considers 10 body parts: the chest, abdomen, perineal area, buttocks, right arm, left arm, right thigh, left thigh, right lower leg/foot, left lower leg/foot. The head/hair and back should also be included. An individual with bending and twisting limitations would struggle to safely wash both lower feet and their buttocks. If the person attempted this activity from a standing position, he or she might need help to wash the front and back of their upper legs to avoid excessive bending and twisting. Thus, without adaptive equipment, this individual needs help with bathing 50 percent of their body. If we added any other physical limitations such as limited range of motion with either or both shoulders, the amount of help required could go above 75 percent. In such a situation, adaptive equipment such as a sponge bathing stick could make a significant change. Using a sponge bathing stick, the individual would be able to wash both of their lower legs, feet and buttocks. They would also most likely be able to wash their upper legs front and back. This would score the individual as being 100 percent independent, but requiring adaptive equipment (modified independence). Few of us would accept a splash of water on the hands as proper hand hygiene, yet a splash of water in a shower is sometimes acceptable. Thus, when choosing adaptive equipment for bathing, a few considerations should be made: Does the equipment facilitate appropriate hygiene techniques? Can the patient exchange or clean the adaptive equipment between body parts or do they use the same cleaning sponge for all body parts? Is he or she able to clean the adaptive sponge between bathings or does he or she use the same sponge repeatedly? Is the equipment user-friendly? Can the equipment be used by the patient independently and can a caregiver use it to provide help if needed? Is the equipment affordable, durable and safe? Toileting is a very personal activity, and it can frequently determine the overall safety and independence of an individual in a home setting. Using a toileting aid is common for individuals with bending or twisting restrictions or those with reduced reaching ability. Often the individuals can stand with one-handed support and use the other hand for aid use. Individuals that need more help from a caregiver can use a two-handed support on a walker while the caregiver uses the toileting aid. The toileting aid is useful in maintaining a dignity gap in personal space between the caregiver and individual. When determining toileting functional skills, three questions are equally scored. Can the individual pull down his or her clothing? Can the individual wipe and perform hygiene? Can the individual pull up his or her clothing? If patients cannot perform their own hygiene, they are considered to require over 30 percent help with toileting. Pulling up the pants may present additional difficulty secondary to bending over to grasp the pants. A compensatory technique such as squatting to grasp the pants is possible, or the patient may use adaptive equipment such as a reacher. Adaptive equipment could raise the individual's functional level to modified independent. Many toileting aids are intended to help increase the reach of the individual and reduce the amount of bending. However, few of these products address the twisting motion that frequently escalates the pain or the lateral bending of the spine when wiping from a sitting position. An aid may have a bulky head that fits poorly between the cheeks of the buttocks. Almost all toileting aids encourage a back to front wipe. Some aids have a weak grasp on wiping material providing a less than suitable cleaning experience. When choosing a toileting aid, one should consider patient safety precautions, bending and twisting precautions, possible fall risks, the effectiveness of the product and its promotion of safety and proper hygiene, the equipment's ability to work with multiple wiping materials including washcloths, the ease of cleaning and sanitizing the product, safety and dignity for patient and caregiver, portability and ease of transport in public, affordability, durability and safety. When considering bathing and toileting aids, many choose equipment based on availability or routine. In doing this, we fit the patient to the equipment and not the equipment to the patient’s needs. Being familiar with the range of adaptive equipment that is available and understanding the proper use can be pivotal in facilitating patient independence and safety.