Caring for someone’s skin is one of the most intimate tasks of a caregiver. On the one hand, skin care is straightforward: Keep the skin clean, moisturize if it’s dry, and reposition your loved one to prevent pressure sores.
On the other hand, caring for someone’s skin may mean touching the person in a different way than you have done before. For example, now that you are a caregiver, you may be bathing your parent or sibling or friend for the first time in your life. This type of intimacy may take some adjustment for both of you.
“It can be a difficult issue,” says Don Rehwaldt, RN, case manager for Enclara Health. “It’s an intimacy that’s not common in our culture. We have to overcome our sense of personal space and our aversion to touching our loved one in places where we normally would not touch them under other circumstances. It can be difficult not only for the caregiver but for the patient also.”
For some people, the intimacy of bathing and other skin care feels awkward at first, especially if their relationship did not involve much touching before. But it can also be a meaningful source of comfort and an opportunity to develop a greater sense of closeness. Skin care that’s provided with sensitivity is an emotional gift as well as a physical service.
Basic Skin Care
The most important guideline for good basic skin care is to keep your loved one clean — especially to keep the skin clean of sweat, urine, feces, and any fluid draining from a wound. These substances irritate the skin because they are wet. But they can also cause chemical damage to the skin if left there.
“The skin is a protectant,” says Rehwaldt. “It covers our body and our organ systems. If there’s any type of access through a cut or wound, bacteria will take advantage of it.” Good cleaning helps keep the skin intact and reduce bacterial growth to prevent infection as well as odors. Think of bathing as an opportunity for inspecting the health of your loved one’s skin.
“Part of what you’re doing when you’re cleaning the skin is observing,” Rehwaldt says—looking for redness, abrasions, or other signs of a problem.
Along with bacteria, fungal infections are a risk. They like to grow in warm, moist areas, including the folds of skin, and can take weeks or months to treat and get rid of. “Your goal is to prevent a fungal infection,” says Rehwaldt. “Once it occurs, the patient will be uncomfortable for sure. There will be itching and scaling, and then we tend to scratch. Then there’s risk for a secondary bacterial infection” to get in through the open skin.
Bathing
Bathing should be pretty simple if your loved one is mobile and only needs a little help getting into the shower each day. But if he’s bed bound, your care will be more intensive, and even more so if he’s incontinent. Some people need help with cleaning several times a day.
A certified nursing assistant or home health worker can be a great help with bathing, says Rehwaldt. One advantage of hospice is that it typically gives you access to such professional helpers.
If, for example, an aide comes every other day to provide a thorough bath, you may only need to do a light washing—such as wiping the face, hands, back, chest, and armpits—on the days with no aide, says Rehwaldt.
You may also want to use specialty foaming bath products, he adds, that don’t require rinsing afterward. This helps simplify bathing. Ask your loved one’s medical team for advice about this option and which products may be useful. In any case, Rehwaldt suggests avoiding products that are more likely to trigger an allergic reaction, such as anything with scents, colors, or dyes.
Besides general cleaning, talk with your loved one to make sure you know about her specific needs. “Be aware of skin issues the patient has had in the past,” says Rehwaldt. “Many of us have eczema or dandruff, for example, and we’ve been using some type of cream or shampoo for it. Continue to utilize those if they are appropriate.”
Here are some other basic guidelines for maintaining skin health.
For Dry Skin
- Use warm water when bathing, rather than hot water, which dries the skin more.
- Wash gently with a soft cloth, instead of scrubbing hard. Rinse soap off well.
- Gently pat the skin dry with a soft towel.
- Gently apply a water-soluble lotion or cream after bathing and any time you notice dry skin. (Avoid alcohol-based or heavily perfumed products.)
- Don’t overbathe, because washing takes away natural oils that seal moisture in the skin.
- Encourage your loved one to drink more fluid, such as water, juice, broth, and other beverages that contain no caffeine or alcohol.
- Remember that the lips are also skin, says Rehwaldt. Use a lip balm to keep them moisturized.
- If the eyes feel dry or scratchy or seem blurry, ask the medical provider about using eye drops to moisturize them.
- Call the medical provider about any flaky, red, or rashlike area that doesn’t clear up within a few days.
For Itching
- Discourage scratching, which usually makes itching worse.
- Avoid tight clothes or fabrics that irritate. Cotton fabrics will be more soothing than synthetics.
- Give a bath in cool water sprinkled with baking soda or oatmeal. This can soothe irritation.
- Ask the medical provider about using anti-itch cream, like calamine lotion or cortisone cream, or an over-the-counter antihistamine.
For Excess Moisture
- Apply a light dusting of cornstarch or other gentle powder over the body after bathing and drying, especially in areas where skin folds can trap unwanted moisture.
- For incontinence, use absorbent bed pads or adult diapers to pull moisture away from the skin and make it easier to clean up quickly and thoroughly.
For Patients on Supplemental Oxygen
- Where the supply tubes run over her ears and into her nose, apply a protective ointment to prevent dryness and irritation. Ask the medical provider what to use.
- Many oxygen-supply systems have a reservoir for water to humidify the oxygen before the patient breathes it. Follow the manufacturer’s directions for keeping the reservoir full.
Preventing and Caring For Pressure Sores
Anyone with limited mobility is at risk for getting pressure sores. Also called bedsores or decubitus ulcers, pressure sores develop when blood cannot get to a patch of skin. As a result, that skin begins to die. Usually, this happens because of prolonged pressure against the skin, such as from lying in bed or sitting in a wheelchair without moving much. Pressure sores typically develop near a bony area, like the head, shoulder blades, elbows, tailbone, hipbones, and heels. They can be very painful. They are slow to heal and provide an opening for infections to enter the body.
“About 90% of pressure sores occur in the tailbone, or coccyx, area,” says Rehwaldt. “No matter what you do, whether you’re sitting up or lying down, there’s often still pressure in that area.”
The key to preventing pressure sores is to move. Anyone who is seated or in bed should move or be moved at least once every two hours. Even a small shift in position can relieve pressure to some areas. Rearranging pillows for varied support can help, too. But be careful that the patient doesn’t simply settle back into the same position, whether out of weakness or habit.
If she can get up from bed and sit in a chair for a while, or get up from her chair and walk around, she should do that. “Use it or lose it!” says Rehwaldt. A person in a wheelchair or other seated position can do pushups using the armrests to lift up off the seat.
If she must stay in bed, ideally, she should cycle through lying two hours (or less) on the left side, two on the back, and then two on the right, Rehwaldt advises. Regular turning minimizes pressure on the back, especially the tailbone, where so many pressure sores occur.
If movement causes pain for your loved one, she may resist moving, says Rehwaldt. If she says, “Ah, you’re hurting me!” when you try to move her, it’s hard to persevere, he acknowledges. “But in the long run, you’re going to hurt her more if you let pressure sores develop.” The answer, he says, is to give her pain medicine before moving, so she’s able to do it. Ask her medical provider which medicine to give and when to give it so that movement is possible.
Have the patient do as much as she can to move herself. If she needs your help, find out how to do this safely. Ask the medical provider for instructions on how to help her move without injuring yourself. A home health aide or hospice nurse may be able to give you a lesson in person.
“If the patient is able, have her use whatever devices are available to assist you with moving,” Rehwaldt says. “For example, have her hold onto the bedrail while you position pillows to prop her up.”
He points out that “the worst thing you can do is put yourself at risk.” If you get hurt, then you have your own injury and pain to deal with and you’re less able to care for your loved one.
Other Steps for Preventing Pressure Sores
- Make sure bed sheets are clean and dry, and smooth out wrinkles and folds.
- Cushion your loved one’s underside with an egg-crate foam pad or sheepskin pad.
- You can separate the legs with a pillow so they don’t put pressure on each other. Similarly, you can place towels between the arms and the body.
- To keep the heels and ankles off the bed, place a pillow under the calves. (Make sure it’s below the knee, not at the knee.) You can also get elbow and heel pads from a medical supply store to cushion these joints. “The feet are often forgotten,” says Rehwaldt, “especially if the person is bedridden and covered up.” Because the feet are farthest from our heart, they are even more prone to poor circulation. So it’s important to cushion and inspect them.
- Examine your loved one’s body each day for reddish or purplish patches, especially around bony areas prone to pressure sores. This could be a sign that a sore is already developing under the skin. If the discoloration doesn’t clear up after changing positions, let the medical provider know and change your loved one’s position at least every hour.
- Using an oil or lotion, offer a gentle massage each day on bony areas prone to sores. This helps promote circulation and keeps the tissue healthy. If there’s a red or purple patch, massage around it but not on it, because the tissue may already be damaged. If there’s a sore, do not massage around it or on it, because this may damage tissue more and introduce germs.
What to Do When Someone Develops a Pressure Sore
- Have a medical provider evaluate it. Because pressure sores are slow to heal and prone to infection, a prompt assessment from a professional is important.
- Ask the provider for detailed instructions on how to care for the sore. Depending on how severe it is, you may need to follow certain cleaning steps and apply special solutions and dressings to help it heal.
Caring For Special Skin SituationsWhen someone has any wounds, such as from injury or surgery, follow the medical provider’s instructions for cleaning the area and changing the dressings. Some types of wounds need more frequent care than others. Also, different types of wounds need different types of dressings. That’s why it’s important to find out from the medical provider exactly how to care for the wound. If you have any trouble following the provider’s instructions, let the provider know and ask for help.
A stoma is an opening that a surgeon makes in the body to replace a natural opening that has been blocked or removed. For example, “colostomy” is the name of an opening made in the abdomen where waste can exit from the intestines and collect in a bag. Someone whose colon was removed may need a colostomy. A stoma requires special cleaning and care. If your loved one needs a stoma, a nurse or other medical provider will teach you how to care for it. If you have any questions or you are not able to follow the instructions, talk with the medical provider.
When to Call a Medical Provider
Alert a medical provider if you notice any of the following.
- Persistent itching or skin irritation—which might be a sign of infection or might put your loved one at risk for infection if he scratches and breaks the skin.
- A flaky, red, or rashlike area that doesn’t clear up within a few days.
- A persistent reddish or purplish patch that might be from pressure.
- Any signs of an ulcer in the skin, such as an open spot.
- Bleeding from a wound.
- Pus, swelling, redness, or tenderness around a wound.
- Worsening pain from a wound.
- A wound that does not appear to be healing.
Pay Attention to Skin ColorChanges in skin color signal other changes within the body. For instance, a yellowish skin tone may indicate liver problems. A tone that’s bluish, ashen, or paler than normal could mean the body isn’t getting enough oxygen. If you notice a change like this, let the medical provider know. When death is near, the skin may take on a duller, darker tone or appear grayish. This is normal.
Learn more about the changes you may notice when death is near.