ASSESSMENT OF NURSES’ PRACTICES REGARDING BED-BATH OF CRITICALLY ILL PATIENTS IN TERTIARY CARE HOSPITAL LAHORE

Introduction: Every day bed-bath are normally accommodated most basically sick patients to improve their cleanliness, advance solace and improve wellbeing results. Fundamentally sick patients are at more serious hazard for skin colonization and contamination with multidrug-resistance pathogenic organisms. Hence, it is imperative to furnish basically sick patient with powerful close to home cleanliness particularly bed-bath as poor cleanliness may expand the danger of contamination. Methodology: quantitative observational descriptive study design was used to assess the nurses’ practices regarding bed-bath of critically ill patients. In order to assess nurses practiced, data was collected through the standardized checklist regarding bed bath. The check consists of 51 items. Results: The findings of this study revealed that there is poor practices of nurses regarding bed bath of critically ill patients. Conclusion: This study has described an important basic nursing care that is bed-bath practice in critically ill patient. Although, bed-bath is a routine nursing procedure, critical care nurses in the current study had poor skills and practices regarding it. This study has implications for clinical practice and nursing research. Bed-bath is a routine nursing care; many nurses understand that bathing is just for cleaning. Therefore, Inservice training program should be conducted

Hence, there is evidence that management and care of patient with critical illness need a unique body of knowledge and skills from a responsible multidisciplinary team member especially the nurse, and specific bed-bathing guidelines should be developed for preventing infections especially the health of the patient. The actual need to do the study is to assess the practice of nurses regarding bed-bathing patient. In the context of above mention research problem, the answer will give for bellow mentioned questions through this study.
Purpose of the study: the purpose of the study is to assess the nurses' practice for bed-bathing in critically ill patients in tertiary care hospital Lahore

Research questions:
• What are the practices of nurses regarding bed bathing among critically ill patient at tertiary care hospital Lahore Pakistan? Hypothesis Alternative hypothesis: • There are positive nurses' practices regarding bed bathing among critically ill patients Null hypotheses: • There are negative nurses' practices regarding bed bathing among critically ill patients Conceptual definition Practices: "The application of rules and knowledge that leads to action" (Badran, 1995) Bed bathing: Giving a bed bath means washing someone who is in bed. A bed bath cleans the skin and helps keep the skin free of infection. It helps to relax the person being bathed and help him feel better. Let the person wash himself as much as possible (Dias, Souza, Azevedo, Andrade, & Nery, 2016). Operational definition Practices: standard guidelines and personal protective equipment follow/use by nurses working in burn unit of tertiary care hospital Lahore. Bed bathing: bed bath is washing the critically ill patients, who is in bed and cleans the skin and helps keep the skin free of infection. It helps to relax the patients admitted in tertiary care hospital Lahore.

Variables of Study:
Significance of the study Patient who admitted in critical units usually are unable to clean themselves and highly susceptible to infection. Thus, the application of universal precautions protected the patients and environment from infection and restricted uses of standard guidelines regarding bed bathing to promote patient safety, wellness and decrease risk of complications.
Nurse: subsequently, assessment level of nurses' practice about bed bathing is vital action to promote health status in the critically ill patients. In this way nurses will understand their weakness and tried to adopt standard guide line in results their knowledge and skills will be improved.

Organization:
The Finding of the examination may be useful for the association to build up the methodologies to control superfluous malpractices through instructional meeting, workshop, and class, this will improve the workplace and nature of care. It will be appropriate for the administration to find a way to locate the powerless components. In results the quality of care will be improved.
Policy maker: This mindfulness will help the strategy creator to plan methodologies and set in motion to improve the workplace.

Future researcher:
The aftereffect of this investigation will provide guidance to the future analyst to use this examination as a writing and direction. Moreover, study will assist them with identifying the investigation hole. The discoveries of the examination can be utilized as optional information for future research researchers.

CHAPTER -III Material and Methods Study Design:
Observational descriptive design was use to assess the nursing practice, Nurses' Practice for bed-bathing in critically ill patients in tertiary care hospital Lahore Study site: The study was conducted in Jinnah hospital located at urban area of Lahore, Pakistan. Study Setting: The study was conducted at critical care units of Jinnah hospital.

Study Duration:
The Study duration was 4 months from February, 2020 to May, 2010.

Study Population:
The study population was all registered nurses working in burn units of selected hospital. Inclusion Criteria: • All registered nurses working in critical care units for at least six months before the start of data collection.
• Willing to participate Exclusion Criteria: Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 • Nurses working in critical care units, who were not involved in direct patient care e.g. Head nurses, Clinical Instructors and Nurse Managers and nurses who have worked for less than six months in the critical care units.

•
Not willing to participate Sampling Technique: Data will be collected by convenient sampling technique from selected sample. Sample Size: Sample size was be calculated by using "Selvin's formula".
The total population is 245. The sample size for this study was 151.

Ethical Consideration;
Written permission was taken from the Ethical committee of University of Lahore. Permission was taken from the Nursing manager of Jinnah hospital to conduct research study. All participants will be informed about the purpose of the study. All information and collected data were kept confidential by principal investigator hard copy in lock. Confidentiality of soft copy was maintained by a coding. The subject was informed that there are no disadvantages or risk on the procedures of the study. Data collection procedure: After approval observe the nurse's practices over a period of 02 months starting from march 2020 to April 2020. The selected critical units were visited on daily basis and nurses were approached during morning, evening and night shifts.

Data Collection Instrument and Tools:
A well-adapted bed-bath check list was used to measure the practices of nurses in this study and it consists of two sections.
Section A: section A consists of demographic data such as gender, age, type of the unit, length of stay (days) and history of hospitalization.
Section B: section "B" consists of 51 items. It was used to assess the practices of nurses regarding bed-bath among critically ill patient.

Data Analysis Method:
The study was analyzing the data by SPSS version 16. Statistical analysis of the study was descriptive. The study sample was characterized by using a measure of central tendency (mean, median, and mode).

CHAPTER -IV Results
This study is conducted at Jinnah hospital to assess the nurses' practices regarding bed-bath of critically ill patients. The result of this study distributed into two sections, first section is statistics of demographic factors and second is frequency and statistics of checklist items. Table 1 shows that the frequency of demographics includes age, experience, department, qualification and duty shift of the participants of 151 nurses and the results revealed that the age of participants was found minimum 21 to highest 60, participant's age group 21-30 years frequency was 42 (27.8%), majority 49 (32.5%) participants were belong to age group 31-40 years and moderately 37 (24.5%) were fall in age group 41-50 years and only 23 (15.2%) were 51-60 year old. Only 23 (15.2%) participants have experience 10-12 years, majority of nurses 46 (30.8%) have 4-6 years job experience and 40 (26.8%) have 1-3 years' experience and 42 (27.2 %) nurses have 7-9 years' experience. Participants' department as expected was only 65 (43%) working in critical care units and majority 86 (57.0 %) working in general wards. The qualification of the participants was found as 35 (23.2%) diploma in midwife, majority 56 (37.1%) diploma in general nursing, 41 (27.2%) were hold a degree of post RN BSN and only 19 (12.6%) were bachelor of science in nursing (Generic). Observation of nurse's practices was performed in three shifts and frequency is as morning, night 50 (33.1%) respectively and evening is 51 (33.8%).  Figure 1 shows that the frequency of demographics includes age the results revealed that the age of participants was found minimum 21 to highest 60, participant's age group 21-30 years frequency was 42 (27.8%), majority 49 (32.5%) participants were belong to age group 31-40 years and moderately 37 (24.5%) were fall in age group 41-50 years and only 23 (15.2%) were 51-60 year old. Figure 2 shows that the frequency of demographics includes department of participants and the results revealed that the Participants' department as expected was only 65 (43%) working in critical care units and majority 86 (57.0 %) working in general wards. Figure 3 shows that the frequency of demographics includes qualification of the participants and results revealed that the qualification of the participants was found as 35 (23.2%) diploma in midwife, majority 56 (37.1%) diploma in general nursing, 41 (27.2%) were hold a degree of bachelor sciences in nursing post RN and only 19 (12.6%) were bachelor of science in nursing (Generic). Figure 4 shows that the frequency of demographics includes duty shift of the participants and results revealed that the Observation of nurse's practices was performed in three shifts and frequency is as morning, night 50 (33.1%) respectively and evening is 51 (33.8%).

Figure 4
Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 5 shows that the frequency of demographics includes experience of the participants and results revealed that the Only 23 (15.2%) participants have experience 10-12 years, majority of nurses 46 (30.8%) have 4-6 years job experience and 40 (26.8%) have 1-3 years' experience and 42 (27.2 %) nurses have 7-9 years' experience. Table 2 shows that the frequency of timing of bathing, number of baths per shift and duration of bath and the results revealed that the timing of bathing was 50 (33.1%) in night shift at 6.a.m, 51 (33.8%) in evening at 6.p.m and 50 (33.1%) in morning shift at 1.p.m. Only 1 (0.7%) participants given 2-time bath in a shift, no one 0 (0%) gave three time and majority 150 (99.0%) given 1-time path to the patients in his /her shift. Majority of nurses 79 (52.2 %) take 15-20 min while given path to the admitted patient, 29 (25.8%) take <15 min and only 33 (21.9 %) take <15 min.

Figure 5
Frequency, timing and duration bed-bat  Figure 6 shows that the frequency of number of baths per shift and the results revealed that the timing of bathing was 50 (33.1%) in night shift at 6.a.m, 51 (33.8%) in evening at 6.p.m and 50 (33.1%) in morning shift at 1.p.m.      Table 3 shows the mean, median, mode and standard deviation of demographic variable the highest mean 2.32 for duty shift, then 2.29 for qualification and 2.00 for Frequency of bathing/day and Experience respectively and the Timing of bathing lowest mean was 1.01. The Std. Section 2 consist of checklist regarding bed bathing consisting 51 items. This checklist further divided into 2 parts, and each part consists 26 and 25 items respectively. Table 4 shows the frequency percentage of 26 items of checklist regarding bed-bathing and results revealed that mostly above 50 % nurses have good practices and follow the standard guideline for bed bathing of admitted patient. Further the observation revealed that the nurses, have different level of education and also working in different department such as ward or critical care unit is varying to each other, such as the observation regarding first item of checklist and results revealed that the 75 (49.7 %) were observed as gather necessary equipment and 76 (50.3%) were not observed while giving bed bath to the patients. The observation regarding item two which is "Wash your hands. Put on gloves" and results revealed that majority 83 (55%) were observed and 68 (45%) were not observed. The results of item three was 71 (47%) were observed and majority 80 (53%) not observed as explaining procedure to the patient while going to give bath to the admitted patients. It was also observed that the majority 100 (66.2 %) provide proper privacy to the patient during bed bating but 51 (33.3%) did not provide privacy. 92 (60.9 %) observed and 59 (39.1%) not observed as offering bed pain/urinal during bed-bathing. Observation regarding item six which was "Remove gloves and discard in appropriate container. Wash hands. Put on clean gloves" and results revealed the 81 (53.6%) observed and 70 (46.4%) did not observed. The observation regarding item number seven of checklist which was "Place client in supine position near the side of the bed nearest you" and results revealed that the 79 (52.3 %) were observed and 76 (50.3%) were not observed while giving bed bath to the patients. The observation regarding item eight which is "Un-tuck bed linens" and results revealed that majority 85 (56.3%) were observed and 66 (43.7%) were not observed. The item nine was "Cover top sheet with a large towel. Ask the client to hold the towel in place; if unable, tuck under client's shoulders" and results revealed that 87 (57.6%) were observed and majority 64 (42.4%) not observed. It was also observed that in item ten "Remove top sheet without disturbing the towel and place in laundry basket at bedside" and the majority 93 (61.6 %) observed and 58 (38.4%) did not observed. 91 (60.3 %) observed and 60 (39.7%) not observed as remove client's gown or pajamas comfortly during bed-bathing. Observation regarding item twelve which was "Fill bath basin 2/3 full of warm water (115o F). Check temperature with inner aspect of arm." and results revealed the 93 (61.6%) observed and 58 (38.4%) did not observed. The observation regarding item number thirteen which was "Place a towel across the client's chest." and results revealed that the 85 (56.3 %) were observed and 66 (43.7%) were not observed while giving bed bath to the patients. The observation regarding item fourteen which is "Wet washcloth and squeeze out excess water. Make a washcloth mitt" and results revealed that majority 84 (55.6%) were observed and 67 (44.4%) were not observed. The item fifteen was "Wash eyes first. Start at inner corner and work out. Use different area of washcloth for each eye. Don't dangle the ends of the washcloth" and results revealed that 86 (57%) were observed and majority 65 (43%) not observed. It was also observed that in item sixteen "Wash, rinse, and dry face, ears, nose, and mouth" and the majority 76 (50.3%) observed and 75 (49.7%) did not observed. 89 (58.9 %) observed and 62 (41.1%) not observed as Wash, rinse, and dry neck during bed-bathing. Observation regarding item eighteen which was "Expose arm farther from you; place towel under arm up to axilla" and results revealed the 84 (55.6%) observed and 67 (44.4%) did not observed. The observation regarding item number nineteen which was "Wash and rinse far shoulder, axilla, arm, and hand" and results revealed that the 104 (68.9 %) were observed and 47 (31.1%) were not observed while giving bed bath to the patients. The observation regarding item twenty which is "Remove the basin and dry the client's arm, shoulder, and hand" and results revealed that majority 91 (60.3%) were observed and 60 (39.7%) were not observed. The item twenty-one was "Repeat steps 21-23 with arm closer to you." and results revealed that 94 (57%) were observed and majority 57 (37.7%) not observed. The observation regarding item number twenty-two which was "The In-Home Aide may perform fingernail care at this time." and results revealed that 94 (57%) were observed and majority 57 (37.7%) not observed while giving bed bath to the patients. The observation regarding item twenty-three which is "Place towel across chest" and results revealed that majority 75 (49.7%) were observed and 76 (50.3%) were not observed. The item twenty-four was "Wash and rinse chest and breasts while lifting towel" and results revealed that 99 (65.6%) were observed and majority 52 (34.4%) not observed. The observation regarding item twenty-five which is "Dry skin thoroughly" and results revealed that majority 93 (61,6%) were observed and 58 (38.4%) were not observed. The item twenty-six was "Keep chest covered with towel." and results revealed that 85 (56.3%) were observed and majority 66 (43.7%) not observed.
Checklist regarding Bed-Bathing (Part 1)  Figure 9 shows that the observation regarding first item of checklist and results revealed that the 75 (49.7 %) were observed as gather necessary equipment and 76 (50.3%) were not observed while giving bed bath to the patients.

Figure 9
Figure 10 shows that the observation regarding item two which is "Wash your hands. Put on gloves" and results revealed that majority 83 (55%) were observed and 68 (45%) were not observed. Figure 11 shows that the results of item three was 71 (47%) were observed and majority 80 (53%) not observed as explaining procedure to the patient while going to give bath to the admitted patients.

Figure 10
Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 12 shows that the frequency of item four and results revealed that the majority 100 (66.2 %) provide proper privacy to the patient during bed bating but 51 (33.3%) did not provide privacy.       Figure 17 shows that the item nine was "Cover top sheet with a large towel. Ask the client to hold the towel in place; if unable, tuck under client's shoulders" and results revealed that 87 (57.6%) were observed and majority 64 (42.4%) not observed.

Figure 16
Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 18 shows that in item ten "Remove top sheet without disturbing the towel and place in laundry basket at bedside" and the majority 93 (61.6 %) observed and 58 (38.4%) did not observed.              shows that the observation regarding item twenty which is "Remove the basin and dry the client's arm, shoulder, and hand" and results revealed that majority 91 (60.3%) were observed and 60 (39.7%) were not observed. Figure 29 shows that the item twenty-one was "Repeat steps 21-23 with arm closer to you." and results revealed that 94 (57%) were observed and majority 57 (37.7%) not observed. 89 Figure 30 shows that the observation regarding item number twenty-two which was "The In-Home Aide may perform fingernail care at this time." and results revealed that 94 (57%) were observed and majority 57 (37.7%) not observed while giving bed bath to the patients.  Figure 32 shows that the item twenty-four was "Wash and rinse chest and breasts while lifting towel" and results revealed that 99 (65.6%) were observed and majority 52 (34.4%) not observed. Figure 33 shows that the observation regarding item twenty-five which is "Dry skin thoroughly" and results revealed that majority 93 (61,6%) were observed and 58 (38.4%) were not observed.

Figure 33
The figure 34 shows that the frequency of item twenty-six which was "Keep chest covered with towel." and results revealed that 85 (56.3%) were observed and majority 66 (43.7%) not observed. Table 5 shows the frequency percentage of 25 items of checklist regarding bed-bathing and results revealed that mostly above 50 % nurses have good practices and follow the standard guideline for bed bathing of admitted patient. Further the observation of nurses, having different level of education and also working in different department such as ward or critical care unit is varying to each other, such as the observation regarding twenty seven item of checklist and results revealed that the 67 (44.4 %) were observed as wash, rinse, and dry abdomen and 84 (55.6%) were not observed while giving bed bath to the patients. The observation regarding item twentyeight which is "Change bath water in basin. Obtain a clean washcloth." and results revealed that majority 77 (51%) were observed and 74 (49%) were not observed. The results of item twenty-nine was 81 (53.6%) were observed and 70 (46.4%) not observed as Expose the farther leg; flex (bend) leg and place bath towel lengthwise under the leg up to the buttocks while going to give bath to the admitted patients. It was also observed that the majority 76 (50.3 %) provide proper privacy to the patient during bed bating but 75 (49.7%) did not observed as wash and rinse leg and foot. 94 (62.3 %) observed and 57 (37.7%) not observed as dry leg, foot, and in between toes. Observation regarding item thirty-two which was "Repeat steps 32-34 on leg nearer you; cover client with bath blanket." and results revealed the 83 (55%) observed and 68 (45%) did not observed. The observation regarding item thirty-three which is "May perform toenail care at this time." and results revealed that majority 91 (60.3%) were observed and 60 (39.7%) were not observed. The results of item thirty-four was 93 (61.6%) were observed and 58 (38.4%) not observed as place the towel and washcloth in a laundry basket and get clean ones while going to give bath to the admitted patients. The results of item thirty-five was 81 (53.6%) were observed and 70 (46.4%) not observed as Change bath water in basin. Obtain a clean washcloth while going to give bath to the admitted patients. It was also observed that the majority 85 (56.3 %) observed to ask or assist the client to turn on his side with back towards you, to the patient during bed bating but 66 (43.7%) did not observed. 76 (50.3 %) observed and 75 (49.7%) not observed as Fold a towel over the client's side to expose his back and buttocks; place clean towel parallel to client's back. Observation regarding item thirty-eight which was "Wash, rinse, and dry the client's back and buttocks" and results revealed the 82 (54.3%) observed and 69 (45.7%) did not observed. The results of item thirty-nine was 88 (58.3%) were observed and 63 (41.7%) not observed as Give backrub using warmed lotion while going to give bath to the admitted patients. It was also observed that the majority 88 (58.3%) observed to turn client to back; place clean towel under buttocks to the patient during bed bating but 63 (41.7%) did not observed. 95 (62.9%) observed and 56 (37.1%) not observed as If client is able, provide wash cloth, soap, and towel and instruct him to wash and dry peri area. Observation regarding item forty-two which was "If the client is unable, wash peri area from front to back" and results revealed the 82 (54.3%) observed and 69 (45.7%) did not observed. The observation regarding item forty-three which is "Place dirty linen in appropriate container" and results revealed that majority 86 (57%) were observed and 65 (43%) were not observed. The results of item forty-four was 99 (65.6%) were observed and 52 (34.4%) not observed as remove and dispose of gloves, wash hands while going to give bath to the admitted patients. The observation regarding item forty-five which is "If client did own peri care, provide fresh water for client to wash hands" and results revealed that majority 81 (53.6%) were observed and 70 (46.4%) were not observed. The results of item forty-six was 91 (60.3%) were observed and 60 (39.7%) not observed as Apply warmed lotion and deodorant as needed while going to give bath to the admitted patients. The observation regarding item forty-seven which is "Put clean clothing on client without exposing him." and results revealed that majority 75 (49.7%) were observed and 76 (50.3%) were not observed. The results of item forty-eight was 108 (71.5%) were observed and 43 (28.5%) not observed as remove, clean, and store equipment while going to give bath to the admitted patients. The observation regarding item forty-nine which is "Wash your hands" and results revealed that majority 92 (60.9%) were observed and 59 (39.1%) were not observed. The results of item fifty was 93 (61.6%) were observed and 58 (38.4%) not observed as Make the client comfortable while going to give bath to the admitted patients. The results of item fifty-one was 76 (50.3%) were observed and 75 (49.7%) not observed as record observations and report anything unusual to nurse/supervisor while going to give bath to the admitted patients.  Table 6 shows that the statistics (mean, median, mode and standard deviation) of 26 items of checklist regarding bed bathing and results revealed that the highest mean value is 1.69 of item nineteen which is "Wash and rinse far shoulder, axilla, arm, and hand" and comparatively lowest mean value is 1.47 for item three which is "Explain what you are going to do". The mean value for others item is between 1.47-1.69 respectively. Median and mode value of most of items is 2 and lowest is 1. Standard deviation value .502 is highest and comparatively .465 is low.

Checklist regarding Bed-Bathing (Part 2)
Statistics Checklist regarding Bed-Bathing (Part 1)  Table 7 shows that the statistics (mean, median, mode and standard deviation) of 25 items of checklist regarding bed bathing and results revealed that the highest mean value is 1.72 of item forty eight which is "Remove, clean, and store equipment" and comparatively lowest mean value is 1.44 for item twenty seven which is "Wash, rinse, and dry abdomen.". The mean value for others item is between 1.44-1.72 respectively. Median and mode value of most of items is 2 and lowest is 1. Standard deviation value .502 is highest and comparatively .453 is low.  Figure 35 shows that the observation regarding twenty-seven item of checklist and results revealed that the 67 (44.4 %) were observed as wash, rinse, and dry abdomen and 84 (55.6%) were not observed while giving bed bath to the patients. Figure 36 shows that the observation regarding item twenty-eight which is "Change bath water in basin. Obtain a clean washcloth." and results revealed that majority 77 (51%) were observed and 74 (49%) were not observed.     Figure 40 shows that the observation regarding item thirty-two which was "Repeat steps 32-34 on leg nearer you; cover client with bath blanket." and results revealed the 83 (55%) observed and 68 (45%) did not observed. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 97 Figure 41 shows that the observation regarding item thirty-three which is "May perform toenail care at this time." and results revealed that majority 91 (60.3%) were observed and 60 (39.7%) were not observed. Figure 42 shows that the results of item thirty-four was 93 (61.6%) were observed and 58 (38.4%) not observed as place the towel and washcloth in a laundry basket and get clean ones while going to give bath to the admitted patients. Figure 43 shows that the results of item thirty-five was 81 (53.6%) were observed and 70 (46.4%) not observed as Change bath water in basin. Obtain a clean washcloth while going to give bath to the admitted patients. Figure 44 shows that the majority 85 (56.3 %) observed to ask or assist the client to turn on his side with back towards you, to the patient during bed bating but 66 (43.7%) did not observed. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 99  Figure 46 shows that the observation regarding item thirty-eight which was "Wash, rinse, and dry the client's back and buttocks" and results revealed the 82 (54.3%) observed and 69 (45.7%) did not observed. www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 100 Figure 47 shows that the results of item thirty-nine was 88 (58.3%) were observed and 63 (41.7%) not observed as Give backrub using warmed lotion while going to give bath to the admitted patients. Figure 48 shows that the majority 88 (58.3%) observed to turn client to back; place clean towel under buttocks to the patient during bed bating but 63 (41.7%) did not observed. Figure 49 shows that the 95 (62.9%) observed and 56 (37.1%) not observed as If client is able, provide wash cloth, soap, and towel and instruct him to wash and dry peri area. Figure 50 shows that the observation regarding item thirty-eight which was "If the client is unable, wash peri area from front to back" and results revealed the 82 (54.3%) observed and 69 (45.7%) did not observed. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 102 Figure 50 Figure 51 shows that the observation regarding item forty-three which is "Place dirty linen in appropriate container" and results revealed that majority 86 (57%) were observed and 65 (43%) were not observed. Figure 52 shows that the results of item forty-four was 99 (65.6%) were observed and 52 (34.4%) not observed as remove and dispose of gloves, wash hands while going to give bath to the admitted patients. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 52 Figure 53 shows that the observation regarding item forty-five which is "If client did own peri care, provide fresh water for client to wash hands" and results revealed that majority 81 (53.6%) were observed and 70 (46.4%) were not observed. Figure 54 shows that the results of item forty-six was 91 (60.3%) were observed and 60 (39.7%) not observed as Apply warmed lotion and deodorant as needed while going to give bath to the admitted patients. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 104 Figure 54 Figure 55 shows that the observation regarding item forty-seven which is "Put clean clothing on client without exposing him." and results revealed that majority 75 (49.7%) were observed and 76 (50.3%) were not observed.

Figure 55
The results of item forty-eight was 108 (71.5%) were observed and 43 (28.5%) not observed as remove, clean, and store equipment while going to give bath to the admitted patients.

Figure 56
Figure 57 shows that the observation regarding item forty-nine which is "Wash your hands" and results revealed that majority 92 (60.9%) were observed and 59 (39.1%) were not observed. Figure 58 shows that the results of item fifty was 93 (61.6%) were observed and 58 (38.4%) not observed as Make the client comfortable while going to give bath to the admitted patients. Figure 59 shows that the results of item fifty-one was 76 (50.3%) were observed and 75 (49.7%) not observed as record observations and report anything unusual to nurse/supervisor while going to give bath to the admitted patients.

CHAPTER -IV Discussion
Vulnerable skin is more prone to damage, and infection. Bathing the critically ill can result in significant variations such as extremely dry skin, greater nursing time, and the potential for colonization of the skin and the spread of microorganism. Critically ill patients are unable to provide self-care and critically ill patients are unable to perform self-care because of many reasons such as decrease level of consciousness, sedation and mechanical ventilation (Grealy & Chaboyer, 2011;Petlin et al., 2014). Frequency, timing and duration bed-bath in ICUs in the current study, the majority of nurses performed bed bath three times/day. Little literature exists on the frequency of bedbath. However, Coyer et al (Peate & Lane, 2015) Conducted an exploratory study on bed-bathing performed to critically ill patients, and showed that 37.5% of all bed baths were routine daily baths. It is acceptable that nurses provide bed-bath for critically ill patients at least once daily. However, bed-bath should be performed according to patients' needs such as for comfort to reduce anxiety, or for cleanliness to respond to diaphoresis, or incontinence. In the current study, patients had bed-bath once/shift (12 or 8 hrs.); nurses were performing bed-bath once/shift as a nursing routine and according to ICU policy. Bed-bath is associated with an increase in oxygen consumption. The current study revealed that nurses took into consideration patients' physiologic tolerance to bathing. This result is in agreement with the AACN guidelines who recommends that patients' physiologic tolerance to the activity should be considered when determining optimal time for bed-bath (Makic, Rauen, Watson, & Poteet, 2014).
On weaning trial days, the researchers found a longer weaning trial (average 3 hours) when the bath is given during weaning. During bed-bath, patients may remain in supine position, which may decrease ventilation and causes hypoxemia. In addition, during bathing, nurses may be unable to observe patients' hemodynamic state accurately. Bed-bath may be performed according to the suitability of nursing routine or workload without considering patients hygiene needs. In the current study, time of bed-bath for patients was at 6 a.m., 1 p.m. and 6 p.m. and the majority of patients had bed-bath at 6 a.m. and 6 p.m. However, Coyer et al. found that a routine bath was given between 2 a.m. and 6 a.m. in 30% of bed-bath episodes (Coyer, O'Sullivan, & Cadman, 2011).
Many studies did not present the duration of bed bathing. From the current study findings, it was noted that, eighty percent of bed-bath performed by nurses took 15-20 min. However, based on the records of some studies that published the bathing time variable, the global average total bathing time was calculated as 20 minutes and 14 seconds (El-Soussi & Asfour, 2016;Lima & Lacerda, 2010).
The quality and skin microbial scores were similar, but the prepackaged bed-bath resulted in the use of significantly less product, a reduction in time to gather supplies and perform the bath, lower cost, and higher nurse satisfaction (O'Horo, Silva, Munoz-Price, & Safdar, 2012). However, the results in this study revealed that water was not changed during most traditional baths, and washcloths were reused from contaminated regions. However, a study compared fifty traditional baths.
Nurses in the study had higher satisfaction with the CHG-impregnated cloths produced colony count reduction on the skin when compared with soap-and-water bed-bath and a significant reduction in CLABSIs was demonstrated with CHG bed-bath. A study comparing CHG cloth bed-bath with non-antimicrobial basin-less cloth bed bath showed, the rate of multidrug resistance organisms (MDRO) acquisition, UTIs and hospital-associated bloodstream infections was lower 5.10 with CHG cloth bed-bath than with non-antimicrobial cloth bed-bath (Hines et al., 2015).
In the current study, an emollient was not applied for all patients after bathing. In a study of bed-bath practices, the researchers found that 64.4% of patients did not receive an emollient after a basin bath. The washcloths used mainly have rough surfaces; therefore, they increase the amount of trans-epidermal water loss and increase dry Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 skin. Some patients had dry skin and need an emollient after bathing; the results of the current study may be due to lack of resources (Oranje, Ordonez, De Raeve, Spierings, & van der Wouden, 2016).
his study has described an important basic nursing care that is bed-bath practice in critically ill patient. Although, bed-bath is a routine nursing procedure, critical care nurses in the current study had poor skills and knowledge regarding it. Factors affecting bed-bath practice as reported by nurses were financial resources, lack of equipment, no policy, lack of knowledge, workload. This study has implications for clinical practice and nursing research. Bed-bath is a routine nursing care; many nurses understand that bathing is just for cleaning. Therefore, inservice training program should be conducted for nurses regarding putting priority of nursing care, determining timing, frequency for the bed-bath and prevention of infections during bathing. It is important for the organization to develop a protocol for bed-bath of critically ill patients to be applicable in the settings. Basins used for bathing can be replaced by towels or prepackaged clothes used individually for each patient and disposed after use. Further research is necessary to determine the appropriate timing of bed-bath and other patient care activities. Studies are needed to determine the effect of bed-bath on patients' outcomes such as sleep disturbance, infection and other stressors in ICU. There is a need for further research on the efficacy of disposable bed-bath products such as pre-packaged cloths. Conclusion: This study has described an important basic nursing care that is bed-bath practice in critically ill patient. Although, bed-bath is a routine nursing procedure, critical care nurses in the current study had poor skills and practices regarding it. This study has implications for clinical practice and nursing research. Bed-bath is a routine nursing care; many nurses understand that bathing is just for cleaning. Therefore, Inservice training program should be conducted for nurses regarding putting priority of nursing care, determining timing, frequency for the bed-bath and prevention of infections during bathing. Recommendation: It is important for the organization to develop a protocol for bed-bath of critically ill patients to be applicable in the settings. Further research is necessary to determine the appropriate timing of bed-bath and other patient care activities. Studies are needed to determine the effect of bed-bath on patients' outcomes such as sleep disturbance, infection and other stressors in ICU. There is a need for further research on the efficacy of disposable bed-bath products such as pre-packaged cloths. Limitation/ Scope of the study • Investigation discoveries will be restricted and can't be summed up generally that the little example and chose from one topographical zone in Pakistan. • The extent of the investigation will be likewise restricted not utilized benchmark group.