Making the Bathroom Safe After a Stroke

How stroke affects bathroom tasks

Every stroke is different, but common effects include:

• Weakness or paralysis on one side (hemiparesis or hemiplegia): an arm that cannot grip, a leg that gives way.
• Poor balance and trunk control, so the person leans or slumps.
• Reduced feeling on the affected side, so burns or injuries may go unnoticed.
• Visual field loss, where one side of the vision is missing.
• Neglect, where a person ignores the weak side of the body or of the room, forgetting to wash the arm or bumping into the door frame.
• Spasticity or stiffness, where muscles tighten.
• Problems with judgement and memory, making sequences hard.
• Fatigue, worse in the hot, steamy bathroom.
• Speech and communication difficulties, making it hard to ask for help.
• Bladder and bowel changes, such as urgency.
• Mood changes, including anxiety and depression, which affect motivation.

Recovery varies. Needs may change over weeks and months, so the bathroom may need re-adapting as strength returns. See stroke recovery at home guide and caring for a parent after stroke.

Before you change anything: ask the stroke team

If your parent has been in hospital or a rehabilitation unit, ask the occupational therapist and physiotherapist there for advice before discharge. They can tell you:

• which side is weaker and how much help is needed;
• how your parent transfers and stands;
• what equipment to get, and which to avoid;
• whether a home visit is available.

If no one has assessed the home, ask your doctor for a referral. Do not buy a lot of equipment in a rush; some items, such as a seat or bar, help almost all stroke survivors, but the sides and heights depend on the person.

Setting up the room

Think in terms of strong side and weak side. Place equipment so the stronger arm can reach it. If a person's right side is weak, grab bars should be positioned on the left side, in their direction of approach, and mirrored if needed in the shower. The layout should work entering and leaving; sometimes a bar on each side, or a vertical bar at the entrance, is needed.

Grab bars. Fix them securely into solid walls, at the right height for your parent; see where to fit grab bars and grab bar buying guide. Never encourage reliance on a towel rail or basin. A person with one weak hand cannot rely on a bar they cannot grip, so make sure the strong hand can reach and hold.

Seat for bathing. A shower chair with a backrest, and often an arm on the strong side, gives stability. A person with poor trunk control may need a more supportive chair. For a bathtub, a bath transfer bench allows sitting down outside and sliding in. See shower seat, bath bench or commode.

Handheld shower. It lets a seated person wash both sides without twisting; see handheld shower guide. Place the controls on the strong side.

Toilet. A raised seat and a frame or a wall bar on the strong side make sitting and standing easier. Place the toilet paper on the strong side, or consider a bidet spray. In homes with only a squat toilet, a commode or Western toilet is needed; see adapting an Indian bathroom for knees and hips.

Floor. Non-slip surfaces and mats are even more important, since a weak leg is likely to slip; see non-slip bath mats.

Lighting and contrast. Good light and contrasting colours help a person with visual loss or neglect. Add a night light.

Doors and space. Make sure the door is wide enough for a walking aid or wheelchair, and that the person does not have to turn towards their blind or neglected side to enter. See bathroom layout for wheelchair and walker users.

Water safety. Reduced feeling on the weak side means burns are a particular danger. Test the water yourself and set the geyser low; see hot water and scald safety.

Mirror and storage. Put items on the strong side, at a comfortable reach. Use a pump dispenser for soap and a suction brush or a wash mitt, as it is easier than a bar of soap.

Call for help. Make sure there is a way to call, such as a bell or pendant on the strong side; see calling for help from the bathroom.

Teaching safe transfers

A transfer is the move from standing to sitting, or from one surface to another. After stroke, the technique matters. Your therapist will teach what suits your parent, but the following principles apply generally:

• Move with the strong side leading when getting on to a seat or entering, and often lead with the weak side into the bath or shower tray, depending on the instructions. Ask the therapist: the rule differs between locations.
• Use the strong hand to hold the support.
• Keep the weak arm safe by placing it in the lap or resting it on the seat or arm, rather than letting it hang or be caught.
• Turn feet and hips before sitting, so the back of the legs touch the seat.
• Sit well back and stable.
• Pause before standing and before walking.
• A carer should stand on the weak side to guard, and use a transfer belt if advised; see how to use a transfer belt. Do not pull on the weak arm, which can injure the shoulder.
• Use "nose over toes" to stand: lean forward, push with the strong leg and arm, rise.
• Avoid rushing.

Check the helping an elderly parent stand from a chair for the basics, and how to lift and transfer safely for carers.

Washing and dressing with one working arm

• Use a long-handled sponge or wash mitt, loop towel or a flannel clipped to the strong hand.
• Wash the weak arm first with the strong hand, and take care to dry between fingers, in the armpit and elbow crease, where skin can break down.
• Support the weak arm on the lap or the knee.
• Dress the weak side first, undress the strong side first, as a general rule, while seated.
• Elastic waists, front-opening shirts and slip-on shoes simplify dressing. See dressing after a stroke and dressing aid guide.
• Do not leave the weak limb hanging where it could be injured.
• Check the skin on the weak side for redness, pressure marks and bruises after each wash.

Special concerns

Neglect and visual loss. If your parent tends to ignore one side, place items on the side they notice, and cue them to look to the weak side by placing a bright strip or marker. Keep the bathroom clear on the neglected side so they do not bump into obstacles. Teach them to turn the head to scan.

Spasticity. Warm water often helps stiff muscles to relax, but not too hot. Follow therapist advice on positioning and splints.

Fatigue. Keep bathing short and give rest. Bathe at the person's best time of day.

Bladder and bowel urgency. Schedule toilet visits and keep the route short; a commode at night can help. See bladder training and timed toileting.

Communication. Agree on a simple signal for "I need help" or "I am finished", such as a bell or a hand signal, if speech is difficult.

Mood. Frustration and low mood are common. Praise small gains, and avoid doing everything for your parent, as practice aids recovery.

Avoid these mistakes

• Fitting bars on the wrong side.
• Buying a stick or equipment without therapy advice; see quad stick after a stroke.
• Using the towel rail or the weak arm for support.
• Pulling on the weak arm.
• Leaving a person alone in the shower too early.
• Using very hot water.
• Letting the person bathe without a seat.
• Forgetting to re-check the set-up as recovery progresses.

When to ask a professional

Involve your occupational therapist and physiotherapist as early as possible, and ask for a home visit. They can fine-tune the layout and teach transfers. A speech and language therapist can help with communication and swallowing. Tell the doctor about any new weakness, speech change, severe headache or confusion, which may be a new stroke: call emergency services at once; see stroke warning signs and first hour. Ask a nurse about skin care and continence.