Bedfast Care
Problems | creativity | changing an occupied bed | preventing problems | positioning | skin care | bathing | range of motion exercises
(This section is incomplete, but there is enough here to be helpful)
At some point in advanced cancer, neuromuscular disease, chronic lung disease, and other illnesses, most patients become bedfast. The inability to leave the bed results in at least the risk for a number of problems, which are discussed below. Problems of immobility are most likely to occur when a person has been bedfast for an extended time, such as with Alzheimer's disease; when the person is completely immobile; or when there is widespread disease, such as advanced cancer or AIDS. Bedfast care focuses in large part on preventing problems.
Skin breakdown: Prevention of skin breakdown is a major issue in caring for people who are bedfast. See the section on skin problems, especially the material on preventing decubitus ulcers or bedsores.
Cardiovascular Problems: The heart must actually work harder to circulate blood when a person stays unmoving in bed. Blood becomes thicker and thus coagulates more easily. This may lead to development of deep vein thrombosis, especially when the person is positioned in such a way that circulation is cut off. Phlebitis (inflamed vein) may be an early warning of thrombosis. A blood clot may break loose (thromboembolism) and travel elsewhere in the body, most commonly to the lungs where part of the blood supply to the lungs is blocked (pulmonary embolism). Manifestations of pulmonary embolism include sudden onset of difficulty breathing, rapid breathing, rapid heart rate, cough, chest pain, and blood in sputum. A pulmonary embolism is an emergency situation (911). Decreased blood pressure on arising (orthostatic hypotension) also occurs. People who have been in bed for a long period of time are subject to a sudden drop in blood pressure on arising. Therefore, getting up should be done in stages if there are signs of decreased blood pressure (dizziness, blacking out, weakness). Edema or pooling of body fluids is common in bedfast patients. Edema is usually thought of as occurring in the ankles and feet, but in a person who lies unmoving in bed, edema occurs in whatever part of the body is lowest, e.g., lower back or elsewhere. Edema can also occur from pathological processes, e.g., edema around a wound. See the section on respiratory and cardiovascular problems.
Respiratory problems: The lungs become less efficient and capacity decreases. Mucous increases in quantity and becomes thicker, while the ability to cough up secretions decreases. There is increasing risk of pneumonia. And secretions thicken and increase, and expectoration decreases, with a net result of increased risk for pneumonia. Manifestations of pneumonia include difficulty breathing, fever, purulent sputum (but not always present), and decreased breath sounds. There may also be pleural effusion present. See the section on respiratory and cardiovascular problems.
Musculoskeletal problems, especially decreased range of motion and strength: Disuse leads to loss of function. This is a loss in and of itself, and also has other consequences. Loss of musculoskeletal function does not result in flaccidity, but rigidity. When range of motion decreases, the body, especially arms, hands, legs, and feet may develop contractures or become frozen in a flexed position. This leads to increased opportunities for skin breakdown, pain, and difficulty moving. Osteoporosis also occurs or, if already present, advances more rapidly. There is also an increased chance of stress or pathological fractures.
Metabolic imbalances: Electrolyte imbalances may occur, especially imbalances of nitrogen and calcium.
Urinary Problems: Because of bladder distention and urinary stasis, urinary tract infections are more likely to occur in a person who is bedfast. Other problems include perineal infections and kidney stones. See the section on genitourinary problems.
Gastrointestinal problems: Lying immobile, especially when malnourished and dehydrated, increases the likelihood of constipation and impaction. See the section on gastrointestinal problems.
Basics of Bedfast Care
Each person and each family are different. For some, the best response to advanced illness is to do the expected: The patient stays in the bedroom in a hospital bed. For others, it may be better to set up the patient in the living room, den, or wherever feels best for the patient and family. There are no rules in where or even how one does this work.
Unless the caregiver is young and strong, it is wise in almost every case to have the patient in a hospital bed that can be raised and lowered as a whole and at head and feet. A hospital bed that can be raised and lowered is nearly always the best choice - but not always. The primary issue in bed choice is the ability of caregivers to give assistance without injuring themselves. Changing linens with the patient in the bed is an essential skill. There will be times when linens have to be changed several times in a day and it will have to be done without help. And it will have to be done well; without hurting the person in the bed; without hurting yourself; and without wrinkles.
Preventing problems centers around maintaining mobility, hygiene, and adequate nutrition and fluids. The person who is ill should be encouraged to participate in care as much as possible, including exercising and changing position, staying clean, and taking food and fluids. Accomplishing these is dependent, in large part, on managing symptoms such as pain, nausea, and depression. Any of these and other problems lead to lying immobile and not participating in the care. The person who cannot move or participate in care requires total patient care, and thus greater stress on everyone - including the person receiving the care.
One of the most important problems to prevent is injury or strain to the caregiver. The caregiver's problems always become the patient's problems.
Every position has advantages and disadvantages. Maintaining any one position creates problems.
As much as possible, skin should be clean and dry. Please see the section on skin problems for further discussion of skin problems.
A person who is partially mobile should bathe in the shower for as long as possible. The bedside commode chair or an inexpensive lawn chair can be set in the shower so that the person can sit while bathing. Assistive bars can be installed (sometimes paid for by insurance). A person who is confused may need a protective belt to keep from falling out of the chair. One caregiver should not attempt to help a person bathe who is too weak to sit in a chair.
Bathing a bedfast person can be difficult if attempted without some degree of knowledge and planning. The best way to learn how to give a bedbath is to watch someone who is skilled. Note that such a person does not waste time: quick and thorough is the key - and the patient appreciates that.
Passive range of motion sometimes seems futile to families who associate exercise with rehabilitation. In this case, however, the purpose is not rehabilitation, but prevention of contractures and their sequelae of further decreased range of motion, pain, and skin breakdown. Maintaining range of motion also affects cardiovascular status, muscular strength, and skeletal strength - thus decreasing the likelihood of stress or pathological fracture and further decreased mobility.