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