This presentation is a resource developed as
part of a face to face education event or
workshop.
The target audience is health and social care
professionals in roles providing palliative and
end of life care
The author has agreed to share the work to enable
best practice in the provision of end of life care
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Comfort Measures Mouth, Skin, Bowel & Bladder Care
Fundamentals of Care series no 2
Corine Koppenol & Catherine Hughes Education facilitators
Housekeeping
• Mobile phones
• Breaks
• Fire Alarm
• Toilets
• Question time
• Warning own experiences?
Learning objectives
• To explore Mouthcare in EOL Care
• To explore Pressure Relieving Care in EOL Care
• To enhance our understanding Bladder and Bowel Care
Mouthcare in End of Life
What can we do about it?
Good oral hygiene …
…is integral to promoting and maintaining
elements of patients’ quality of life including:
• Comfort
• Nutrition
• Communication
• Motivation
• Self-esteem
The mouth; oral cavity
The oral cavity includes:• the lips, • the inside lining of the lips and
cheeks (buccal mucosa), • the teeth, • the gums, • the front two-thirds of the
tongue, • the floor of the mouth below
the tongue, and • the bony roof of the mouth
(hard palate).
What is important about Saliva?
• Lubricates and it is mostly made of water, proteins and electrolytes
• Protective effect on the mucous membranes in the oral cavity and upper digestive tract, provide antimicrobial and buffering activities that protect the teeth from dental caries.
• Act as a barrier to irritants & remove cellular and bacterial debris
• Keeps your mouth moist and comfortable and it helps lubricate the throat for easy swallowing the food
• A healthy individual is estimated to produce between 1000-1500ml of saliva per day by hundreds of glands of the oral cavity
• Production drops to almost zero in sleep
What can affect the production of Saliva ?
causing dry mouth = xerostomia
• Medication (sedatives, diuretics, antihistamines, β-blockers, antipsychotics, anticonvulsants,…)
• Radiotherapy for oral or head & neck cancer
• Progression of oral cancer
• Oral infections
• Dehydration
• Depression, anxiety
• Connective tissue or immunological disorders
Consequences of xerostomia
• Reduction of bacterial barrier, increase of microbial flora (streptococcus, lactobacillus and candida) with dental damages and tooth decay
• Impairment of cleansing action of saliva
• (Further) decay of teeth causing pain
• Difficulty chewing, swallowing and digestion
Other problems with the mouth
• Sialorrhoea (excessive salivation),
• Taste alteration in patients with cancer (disease itself) food taste bitter, metallic or is tasteless. (Did you know that taste buds decrease with age?)
• Halitosis (unpleasant or bad breath):
• Infections of oral cavity: fungal infections
How do you assess a mouth?
• Why do you assess a persons mouth?
• What equipment might you need?
• What problems have you seen in residents mouths?
Oral Assessment
Oral assessment
• Establishes preferences for hygiene routine
• Identifies baseline oral status followed with reviews to identify changes
• Act to identified changes: follow care plans
• Important for quality and consistent care
Equipment to use
• Pair of disposable gloves
• Tongue depressor
• Pen torch
• Denture receptacle, if required
• Tissues
Check for
• Odynophagia (painful mouth)
Ulceration
Mouth care for semi-conscious/unconscious patients
• Prepare mouthcare tray
• Remove any dentures as appropriate
• Wipe oral/buccal mucosa and tongue using a moistened pink tipped sponge swab
• Apply saliva replacement gel to mucosa and lips
How often should we do mouthcare?
Use of oral swabs or soft tooth brush
Dentips
Moutheze
Soft Baby Toothbrush
Oralieve moisturising mouth gel
Lets have a go
• Split into pairs
• How did that feel? • Would you do mouth care any differently now?
Dementia care and oral hygiene?
• Provide a calm environment• Approach the patient at eye level and
establish a rapport• Check if the patient is accepting of touch• Stand/sit the patient in front of a mirror and
sink • May open mouth in response to carer
positioned behind, when in front of a mirror• Give short, simple instructions• Encourage the patient to complete the task• If unsuccessful, ask a second carer to
complete the task
Skin Care
&
Pressure Ulcer
Prevention
What does our skin do?
• Skin is your first line of defence, protects against infection. It fends off millions of germs, chemicals and other contaminants that are out to invade you.
• It helps regulate your body temperature and, of course, lets you touch and be touched, so you sense pain, feel pleasure, and express love.
• Skin does one more genius thing: When the sun shines on it, your skin makes vitamin D3, the ultimate antiaging vitamin.
Prevention is better than cure
• Keep skin clean and dry (Skin pH 5.4 – 6.5)
• Use a PH balanced skin cleanser
• Do not vigorously rub the skin
• Develop and implement a continence management plan
• Protect skin from excessive moisture
• Consider use of an emollient to hydrate dry skin
What does older skin look like?
Skin thins as we age (loss of collagen and elastin & underlying fat layer)
Easily damaged
Decreased Sensation
Slower regeneration & healing process
Loss of oil & sweat glands
Pressure Ulcer Classification
A classification system is used to aid the description of the extent of skin and tissue damage presenting as a pressure ulcer: category 1–4
(NPUAP/EPUAP)
EPUAP: European Pressure Ulcer Advisory Panel
NPUAP: National Pressure Ulcer Advisory Panel
How To Care ?
Best Practice Statements are intended to guide practice
and promote a consistent and cohesive approach to care WUK BP (2013)
Risk Assessment
Risk factors include:
• Difficulty in moving
• Loss of sensation
• Previous or current pressure ulcer
• Unable to eat and drink well
• Inability to reposition themselves
• Memory problems Dementia (forget to move)
Skin Assessment (Standard no 4 NICE)
• Observe the skin integrity in areas of pressure
• Notice colour changes or discolouration
• If skin is pink think! If skin is Red Report!
• Variations in heat, firmness or moisture
• Finger palpate to determine whether erythema / discolouration is blanchable
If it is pink, press it
The tissue will go white under light finger pressure then return to the original colour when the pressure is released
Group Work
Waterlow Scoring System
Click on the picture for a link to the document
1. Contributing Factors
• Posture / reduced mobility
• Excessive moisture to the skin
• Sensory impairment / reduced level of consciousness
• Extremes of age
• History of previous pressure damage
• Nutritional and hydration status, above or below a normal weight
• Patient’s mental health, capacity, cognition and psychosocial status
• Acute, chronic or end stage illness
2. Areas at risk
30° Tilt
Summary
• Risk assessment
• Skin assessment
• Individualised care plan with defined
goals of care
• Appropriate use of skin care products and
pressure redistribution devices
• Reposition – frequency, technique, aids
• Document and evaluate care
Click on this page for a hyperlink to this web site
Little break
• Please
come back
in 15
minutes
Bowel & bladder Care in End of Life Care
Objectives of the training:
• Understand the Anatomy and workings of bowel and bladder
• What are common problems
• How to manage the problems and maintain dignity?
Bladder Care
Some bladder problems
• Aging and end of life stages increases the risk of kidney and bladder problems such as: Bladder control issues, such as leakage or urinary incontinence (not being able to hold your urine), or
• urinary retention (not being able to completely empty your bladder) Bladder and other urinary tract infections (UTIs) Chronic kidney disease.
Some facts
As you get older, the bladder changes:
• The elastic bladder tissue may toughen and become less stretchy.
• A less stretchy bladder cannot hold as much urine as before and might make you go to the bathroom more often.
• The bladder wall and pelvic floor muscles may weaken, making it harder to empty the bladder fully and causing urine to leak.
Signs of a Bladder problem can include
• Inability to hold urine or leaking urine (called urinary incontinence)
• Needing to urinate eight or more times in one day
• Waking up many times at night to urinate
• Sudden and urgent need to urinate
• Pain or burning before, during, or after urinating
• Cloudy or bloody urine
• Passing only small amounts of urine after strong urges to urinate
• Trouble starting or having a weak stream while urinating
• Trouble emptying the bladder
Caring for a (supra pubic) catheter
• Hygiene is important. Once healed, the insertion site should be cleansed with warm soapy water with morning and bedtime care.
• Talc, creams and strongly perfumed soaps should be avoided.
• Direct cleaning away from the insertion site.
General Catheter Care Principles
• Ensure drainage bag is placed below the level of the
bladder.
• Catheter bag is NOT to be placed on the floor.
• Ensure catheter tubing is secured to clothing before
moving resident.
• Ensure bag clamp is closed at all
• times, unless emptying the bag.
Day bag: A leg bag which is worn under the normal clothes during the
day and is held in place by straps or a holster.
Night bag: A bag used whilst the person is in bed. This bag is much
larger and is attached to the leg bad to hold all the urine that drains
from the bladder overnight.
Generally day bags and drainable night bags are changed every 5-7
days according to the manufacturer guidelines. Non drainable ‘night
bags are changed daily.
What do I do with the drainage bag?
Common Problems
Poor or absent urine drainage. Usually
kinked tubing or occluded by tight clothing or
urinary sediment.
Try:
• repositioning the tubing
• adjusting clothing or
• doing a sterile irrigation (only if advised)
When should the catheter be changed?
Suprapubic catheter changes are usually done every 1-12 weeks, depending on the material used (Latex: 7 days, Foley: 7-28 days, Silicone: 12 weeks)
When:
• On an individually scheduled basis (by a qualified professional)
• As needed for signs of degradation, balloon breakage, malfunction, bypassing of urine or irreversible blockage.
Think ‘Bladder’ with agitation
The Digestive System
• The function of the digestive tract is to digest
food into simple components that can pass
through the wall of the gut and into the
bloodstream.
• After passing down the oesophagus food
passes into the stomach where it is mixed with
the gastric juices to begin the main process of
digestion.
• After 1-4
hours the semi-digested fluid, called
chyme, is released in small quantities
into the small bowel
• The large bowel (or colon) has three main sections – the
ascending, transverse and descending colon and the principle
function is the absorption of water, bile salts and electrolytes.
• The large bowel also acts as a reservoir for the faeces until it is
convenient to evacuate from the anus.
• The gastrocolic reflex (the need to go!) usually occurs after meals,
but particularly in the morning, making the terminal ileum contract
which pushes the faecal material through the sigmoid colon and
into the rectum. The rectum is normally empty and the entry of
faeces results in the desire to evacuate.
Large Bowel
Large Bowel
What is Normal?
Did you know… in your lifetime you’ll spend
a whole year on the toilet
Normal Bowel Movements
❖ The frequency of bowel movements varies from person to person.
❖ Some people have a bowel movement every day, some every 2-3 days, some 2-3 times a day.
❖ Many people have a bowel movement in the morning, some in the evening.
❖ Stools are normally brown in colour. ❖ Faeces are normally soft , formed , moist and shaped like
the rectum❖ Faeces have a characteristic odour (due to the gut bacteria).
❖ See Bristol stool chart & variations.
Common bowel problems
• problems emptying your
bowels (constipation)
• loose and runny poo
(diarrhoea)
• pale, oily poo that floats,
smells horrible and is
difficult to flush down the
toilet (steatorrhea).
Other Causes of Constipation ?
Treatment DebilityRelated Illness
Weakness
Inactivity or bed rest
Poor nutrition
Poor fluid intake
Confusion
Inability to get to the toilet/ unfamiliar with toilet
arrangements.
High blood calcium levels
Tumours in the bowel or stomach
Spinal cord Compression
Depression
Dehydration
Medication such as Opioids, diuretics, anti convulsants,
iron, antacids,
What are the symptoms?
• Abdominal pain
• Bloating
• Flatulence
• Nausea
• Malaise
• Headache
• Halitosis (bad breath)
Bowel Care at End of Life
• Consider if bowel intervention is still appropriate ( regular laxatives, change drugs?) with the aim to comfortable defecations, not aiming a certain frequency
• Still expect some bowel movements
• Observe and record movements
• Watch for signs of restlessness
• Use containment products
• Use products that neutralise smells
Bowel Care at end of life
• Maintain dignity
• Involve and support
family and patient
• Skin care is very
important monitor for
moisture lesions
• Treatment of moist
lesions with barrier
products
Aroma stream
A useful Guide for carers
http://www.ncpc.org.uk/news/new-guide-help-prepare-people-what-expect-when-someone-they-know-dying
https://southwest.devonformularyguidance.nhs.uk/formulary/chapters/16.-palliative-care
Thank you
http://www.e-lfh.org.uk/programmes/end-of-life-care/
Free access to end of life e learning
www.rowcroft.org.uk01803 210800