HAND WASHING

HAND WASHING is the rubbing together of all surfaces and crevices of the hands using a soap
or chemical and water. Hand washing is component of all types of isolation precaution and is the
most basic and effective infection control measure that prevents and controls the transmission of
infectious agents.

PURPOSES

 To reduce the number of microorganisms in the hands

 To decrease the risk of transmission t clients
 To prevent the risk of cross contamination among clients
 To reduce the risk of infection among other healthcare workers
 To lower the risk of transmission of the infectious organisms to oneself

ASSESSMENT
1. Assess the environment to establish if facilities are adequate for cleansing the hands.
2. Check hands to determine if they have open cuts, hang nails, broken skin or heavily
soiled areas.

NURSING DIAGNOSIS
Determine related factors that could influence the environment. Appropriate nursing
diagnosis may include:
1. Risk for infection
2. Effective health maintenance

PLANNING
 Determine the equipment to be used
 Wash hands for infection control
 Ensure that aseptic technique is followed
 Obtain materials needed

EQUIPMENT
Soap in a soap dish
Orange wood stick
Clean hand towel
Paper squares
Paper lining
IMPLEMENTATION

STEP RATIONALE
1. Prepare and assess the hands. File the Short nails are less likely to harbor
nail short. microorganisms, scratch a client, or puncture
glove. Long nails are hard to clean.

a. Remove all jewelry. Some prefer to Microorganisms can lodge in the settings of
slide their watch up above the jewelry and under rings. Its removal facilitates
elbows, or pin the watch to the proper cleansing of the hands and arms.
uniform. Otherwise remove it and
place inside the pocket.
b. Check hands for breaks or cuts in Open cuts or wounds can harbor high
the skin and cuticle. Report concentration of microorganisms which can be
condition to your instructor before passed on to clients. The risk of cross infection
beginning one’s work. Anyone who from patient to health workers is also high.
has open wounds may have to
change work assignments otherwise
one wears gloves to avoid contact
with infectious materials.
c. Check hands for heavy soiling. This will require lengthier hand washing
duration.
d. Roll sleeves above the elbows. This facilitates cleaning of the skin including
just above the elbows.
e. Carry equipment to the washing Ensure that you bring all the necessary
area. materials.

2. Turn on the water and adjust its flow or Warm water is more effective in removing
temperature. microorganisms than cold water.

Adjusting the water flow helps in conserving

the precious water without affecting the
purpose of the medical asepsis.
a. Avoid splashing water against one’s Microorganisms travel and grow in moisture
uniform. rapidly.

3. Wet the hands thoroughly by holding

them under the running water. Apply
soap to the hands.

a. Hold hands lower than the elbows Water flows from the least contaminated are.
so the water flows from the arms to The hands are generally considered more
the hands. contaminated then lower the arms.
b. Apply soap, rubbing it firmly and Initially cleanse the hands before soaping the
vigorously creating plenty of lather forearms. Soap cleanses by emulsifying fat and
in the palms, back, wrist and the oil and by lowering the surface tension.
interdigital areas.

4. Thoroughly wash and rinse the hands. Remove soap residue that causes dryness of the
skin.
 a. Repeat (3b) rubbing firmly the Vigorous rubbing the skin enhances
palms and interdigital areas. Use the mechanical loosening and removal of the dirt
orange wood stick to remove the and microorganisms.
dirt in the fingernails. Rinse the
orange wood stick before returning. Interlacing the fingers and thumbs ensure that
all surfaces are cleansed.

Areas under the nails can be highly

contaminated which will increase the risk of
infection for the health worker and the client.
b. In a circular motion soap forearms This ensures removal of gross contaminants on
and elbows. Add more soap as the skin surface.
needed and create plenty of lather.
Do steps (4a) and (b) for about 10-
15 seconds repeatedly interlacing
fingers and rubbing palms and back
of hands with circular motion no
less than 5 times each. Keep
fingertips down to facilitate
removal of microorganism.
c. Rinse forearms, hands, and wrist Rinsing mechanically washes away dirt and
thoroughly, keeping hands down microorganisms.
and elbow up.
d. OPTIONAL: Repeat steps 4a and
b, and extend period of washing if
hands are heavily soiled.

5. Thoroughly dry the hands and arms. Drying from the cleanest (fingertips) to the
least clean (forearms) area avoids
a. Dry hands starting from fingers, to contamination. Drying hands thoroughly
wrist up to the forearms and elbows prevents chapping and roughened skin.
with the wash cloth (or paper
towels).

6. Turn off the water with dry paper It prevents from picking up microorganisms
squares or the paper towel before it is from the faucet handles.
discarded.
Wet paper and hands allow transfer of
pathogens by capillary action.

EVALUATION:
 The hand washing was adequate to control topical flora and infectious agents on the
hands.
 The hands were not decontaminated during or shortly after the hand washing.

REFERENCES:

Kozier, B. et al. (2006). Techniques in Clinical Nursing. 4th Ed. Ca: Addison Wesley
Potter,P. & Perry A. (2004). Fundamentals of Nursing. 5th Ed. St. Louis CV Mosby.
Roe, S. (2003). Delmar’s Clinical Nursing Skills and Concept.

HANDWASHING
Performance Checklist
NAME: _____________________________________________ LEVEL: ________
DATE: ___________________

STEP 0 1 1.5 2 N/A COMMENT

ASSESSMENT
1. Assess the environment to establish if facilities are
adequate for cleansing the hands.
2. Assess the hands to determine if they have open
cuts, hang nails, broken skin or heavily soiled areas.
PLANNING
3. Determine what supplies or equipments are needed.
4. Wash hands for infection control.
5. Ensure that the correct technique is followed
6. Obtain the necessary equipments to use.
IMPLEMENTATION
7. Roll sleeves above the elbows.
8. Carry equipment to the washing area.
9. Turn on the water and adjust its flow or
temperature.
10. Wet the hands thoroughly by holding them under
the running water. Apply soap to the hands.
11. Hold hands lower than the elbows so the water
flows from the arms to the hands.

12. Apply soap, rubbing it firmly and vigorously

creating plenty of lather in the palms, back, wrist
and in the interdigital areas.

13. Thoroughly wash and rinse the hands.

14. Repeat (3b) rubbing firmly the palms and

interdigital areas. Use the orange wood stick to
remove dirt in the fingernails. Rinse the orange
wood stick before returning.

15. In a circular motion soap forearms and elbows. Add

more soap as needed and create plenty of lather. Do
steps (4a) and (b) for about 10-15 seconds
repeatedly interlacing fingers and rubbing palms
and back of hands with circular motion no less than
5 times each. Keep fingertips down to facilitate
removal of microorganism.
 16. Rinse forearms, hands, and wrist thoroughly,
keeping hands down and elbows up.

STEP 0 1 1.5 2 N/A COMMENT

17.OPTIONAL: Repeat steps 4a and b, and extend
period of washing if hands are heavily soiled.
18. Thoroughly dry the hands and arms.

19. Dry hands starting from fingers, to wrist up to the

forearms and elbows with the wash cloth (or paper
towels).

20. Turn off the water with dry paper squares or the
paper towel before it is discarded.
EVALUATION
21. The hand washing was adequate to control topical
flora and infectious agents on the hands.

22. The hands were not decontaminated during or

shortly after the hand washing.

ATTITUDE:
1. Purpose
2.Honest and sincere
3.Shows interest and willingness to learn
4.Manifests creativity
5.Shows resourcefulness
6.Possess sense of initiative
7.Shows positive attitude towards supervision
8.Systematic and conserve steps
9.well groomed
10.Applies body mechanics when performing procedure
TOTAL

Rating Scale:

1- Not done, but essentially required

2- Incorrectly done; wrong techniques and findings
1.5- correct measures, but with inadequate description of findings or not systematic in
performance
2- Correctly done, systematic according to standard; with correct findings
N/A- not applicable

REMARKS
 TEPID SPONGE BATH
DEFINITION
A sponge bath given to a patient with fever through the use of lukewarm water and application of
friction to the body’s surface.

PURPOSES:
1. To reduce fever or lower body temperature.
2. To stimulate circulation and aid in elimination.
3. To provide for patient comfort.
4. Sedative effect.

ASSESSMENT:
1. Assess vital signs to obtain baseline data.
2. Avoid unnecessary exposure and chilling.
a. Expose, sponge and dry only a part of the body at one time.
b. Avoid draft.
c. Use appropriate temperature of the water.
3. Do the bath quickly but unhurriedly, and use even, smooth but firm strokes.
4. Use adequate amount and temperature of water and change as frequently as necessary.

NURSING DIAGNOSIS:
Determine the related factors for nursing diagnoses based on the patient’s current status.
10. Risk for Imbalanced Body Temperature
11. Hyperthermia
12. Ineffective thermoregulation
13. Fluid Volume Deficit
14. Knowledge Deficit

OUTCOME IDENTIFICATION:
Expected Outcomes:
a. Temperature decreases or is within normal limit. Other vital signs are WNL.
b. Patient verbalizes increase comfort.
c. Patient verbalizes understanding for the reasons of tepid sponge bath.

PLANNING
A. Determine what supplies and equipment are needed.
B. Wash hands for infection control.
C. Obtain the needed equipment.

EQUIPMENT:
Pitcher filled with lukewarm water (94°- 98℉). Test by measuring with bath thermometer or by
placing several drops on your inner forearm.
Bath basin Ice bag
Two bath towels Hot water bag
Two washcloths Bed screen (if in ward)
Face towel Linen for changing the beddings
Gown or pajama Rubber sheet
Bath blanket Glooves
Bed pan or urinal Disposable clean gloves
Hand washing materials

IMPLEMENTATION:

STEP RATIONALE
1. Assess patient’s body temperature and Provides baseline for evaluating response to
other vital signs. therapy. Sudden circulatory changes may alter
pulse.

2. Check physician’s order. At times the physician will indicate to perform

TSB as an adjunct therapy for patient’s having
periodic fever.

3. Explain to the patient the purpose of Procedure can be uncomfortable. Anxiety over
sponging with tepid water is to cool procedure can increase body temperature.
body slowly. Briefly describe the steps
of the procedure.

4. Prepare necessary equipment and Facilitates efficiency of the task.

supplies.

5. Perform hand hygiene. Reduces transfer of microorganisms. Infection

are caused by pathogenic microorganisms.

6. Close room door or curtain and Ensures privacy.

windows. If in ward, use bed screen
prn. Avoid chilling the patient by
keeping the surroundings free from
draft.

7. Offer the patient a bedpan or urinal or Prevents interruption of the procedure.

ask whether the patient wishes to use
the toilet or commode.

8. Place waterproof pads under patient Pads prevent soiling of bed linen. Removing
and remove gown. Replace top sheet gown provides access to all skin surfaces.
with bath blanket.

9. Place ice cap to forehead and hot water Ice cap is indicated for headache which is
bag to feet (if desired). common in febrile patients. The HWB is to
 provide warmth while TSB is applied to the
patient.

10. Check water temperature. Tepid water prevents sudden heat loss and
chilling.

11. Place bath towel across patient’s chest. To provide warmth to the patient.

12. Apply wet cloths under each axilla and Axillae and groin contain large superficial
cover groin prn. blood vessels. Application of washcloths
promotes cooler temperature of body’s core by
conduction.

13. Immerse washcloth in water and wring Retains water. A bath mitt prevents . ends of
gently. Make a bath mitt with the washcloth from dragging across the skin.
washcloth.

14. Sponge face gently and then pat dry. Friction stimulates circulation.

15. Gently sponge and apply friction to Prevents sudden temperature fall and
farther arm and hands for 5 minutes. minimizes risk of developing chills.
Use long, even strokes. Cover opposite
extremity. Note patient’s response.

16. Dry extremity and observe patient’s Response to therapy is monitored to prevent
response. sudden temperature change.

17. Continue sponging nearer arm and Prevents sudden temperature fall and
hands, followed by the chest, abdomen, minimizes risk of developing chills.
legs, and thighs, and back for 3-5
minutes each. Change water as
necessary.

NOTE: > When body temperature falls slightly

above normal, discontinue procedure and refer
to physician.
>Do not apply any pressure or friction
on the abdomen. Spread the washcloth
over the areas.

18. Dry extremities and body parts This aids in providing warmth.
thoroughly.

19. Assist patient put on a clean gown.

20. Replace bath blanket with light top Prevents chilling. Excessive heavy covering
sheet. may increase body temperature.

21. Dispose of equipment and change bed Controls transmission of infection.

linen if soiled. Wash hands.
 22. Measure patient’s temperature 30 Temperature indicates response to therapy.
minutes after TSB.

23. Remove hot water bag after 20 minutes. To hinder the effect of rebound phenomenon.
Remove ice bag prn.

24. Record time procedure was started and Recording communicates care provided in
terminated, vital sign changes, patient’s accurate and timely fashion.
response, and health teachings given

EVALUATION:

The expected outcomes are met when patient’s body temperature decreases, and other vital signs
are within acceptable range. Patient will verbalizes increase comfort and understanding for the
reasons of tepid sponge bath.

NURSE’S REMARK SHEET

DATE TIME DIET AND THERAPY NURSE’S REMARK

11/29/05 0800 H Received awake on bed. BP = 90/60 mmHg;
T = 39.5℃, warm to touch; PR = 98 bpm,
strong and regular; RR = 16 cpm, moderate in
depth and without effort. Tepid sponge bath
done for 30 minutes. Verbalized relief.
Tolerated procedure well. Incidental health
teaching given on measures to relieve
fever.________________________________
0830 H Orange juice – 1 glass-- Taken and consumed.___________________
Drop temperature = 38℃._____CM Raga,
SN

Rev: //RGV/Jll//060409