8 M-CARE: Hygiene

Mobile Training for Home and Health
Caregiver For People with Disabilities and
Older People
539913-LLP-1-2013-1-TR-LEONARDO-LMP
Hygiene

Structure
• Unit 1: Hygiene
• Unit 2: Infection
• Unit 3: Disinfection / Self-Protection
• Unit 4: Disinfecting Hands
• Unit 5: Individual Hygiene – Shower
• Unit 6: Individual Hygiene – Full bath –
Partial bath
• Unit 7: Food refusal by clients suffering
from Dementia

Unit 1
• Hygiene
– Definition
– Objectives
– Infection source receiver
– Infection examples
– Individual / Personal
• Shower / Washing
• Toothcare
• Hair Hygiene
• Clothing Hygiene / Workware
• Nailcare
• Gloves

The PCG will obtain fundamental knowledge of
general hygiene basics, how to protect
her/himself from infection and how and by what
specific actions the infection of the client by the
PCG can be prevented.

Hygiene – Definition
• hygiene is the prevention of diseases and the preservation
and strengthening of health
• it includes all circumstances and practices, lifestyle issues,
premises and commodities that ensure a safe and healthy
environment

• to maintain health (physically, emotionally, mentally and
socially)
• to prevent disease
• to prevent the emergence and spread of disease
• to examine environmental influences on human health and to
take measures to promote well-being
Hygiene – Objectives

Hygiene – Infection source receiver
1. direct transmission:
– contact / lubricating function -> fecal / oral
– droplet infection -> airborne
– food and water -> alimentary
– blood -> hematogenous
2. indirect transmission:
– hands
– intermediate hosts
– inanimate sources of infection

Hygiene – Infection Examples
• Contact infection > not washing hands after using the toilet.
• Smear > false wiping technique in intimate hygiene
(back to front).
• Droplet infection > wet pronunciation, cough or sneeze over
open wounds or in the face of the
opposite.
• Food Products > Salmonella contaminated food.
• Blood > infection by contaminated syringe
needle.
• Hands > in hands abducted germs.
• Intermediate hosts > CC – fly, tick.
• Inanimate sources of infection > all items used everyday.

Transmission of infection
source, directly to the
receiver
Examples of direct
transmission path
Contact- / Smear infection (faecal /
oral)
Urinary tract infection by intestinal
bacteria on bladder catheter
Droplet infection (airborne) Tuberculosis caused by tubercle
bacilli spread by coughing
Food and water (alimentary) Gastroenteritis caused by
Salmonella transmission in egg
products
Blood (haematogenous) Hepatitis B due to injury with
second-hand infected needle

Transmission of infection
source, directly to the
receiver
Examples of indirect
transmission path
Hands Pneumonia by intestinal bacteria
of the PCG caused by insufficient
hands disinfection
Intermediate hosts Tick-borne encephalitis virus
Inanimate sources of infection Pneumonia after inhalation
therapy with water nebulizer

Hygiene - Individual / Personal
• objective of personal hygiene is to avoid the transmission of
germs

Individual / Personal Hygiene:
Shower / Washing
• elimination of surface dirt, sebum, rejections
• showers = ideal cleaning process
• unfavourable: washing equipment such as brushes and
sponges, because of colonization of bacteria
• suitable: washcloth, as they are germ-free again when
regularly boiled
• refuse common towels because of germ transmission

Toothcare
• consistent procedure = reduction in caries incidence
• do not use too hard toothbrush > risk for injury of the gums
• replace toothbrush regularly / modifications of the bristles
• avoid bad breath! (caused by smoking and lack of brushing
teeth)

Hair Hygiene
• Keep hair clean and well maintained
• tie long hair
• do not go with your hands through your hair
• take good care of your beard

Clothing Hygiene / Workware
• change frequently / every day
• separate dirty / clean / private clothing
• wear working clothes exclusively in the workspace
• use always protective clothing

Nail care
• keep your fingernails short, clean, sharpened
• do not use nail polish
• be aware of the risk of injury
• be aware of the risk of contamination

Gloves
• they are not a substitute for hand disinfection
• body fluids / secretions must be handled as if they were
infected materials
gloves are no longer sterile:
– when leaking
– when handling waste
– when dealing with dirty / bloody laundry
– when cracks, cuts, abrasions occur
– when handling infectious material (blood / secretions)

Unit 2
• Infection
– Definition
– Types of Infection
– Period of Incubation
– Common infectious diseases
• Hepatitis A
– Definition
– Ways of Infection
– Symptoms
• Hepatitis B
– Definition
– Symptoms
– Protection

• Hepatitis C
– Definition
– Risk Groups
– Acute Hepatitis C
– Chronic Hepatitis C
– Protection
• HIV / AIDS
– Definition
– Symptoms
» Stages
• SARS
– Definition
– Symptoms
– Ways of
Infection
– Protection
• MRSA
– Definition
• TBC
– Definition
– Ways of
Infection
– Symptoms

Infection - Definition
• adhesion, penetration and propagation of a pathogen in an
organism

Infection – Types of Infection
• exogenous / endogenous infection
• local infection
• generalized infection, Sepsis

Infection - Period of Incubation
• time of entry of a pathogen until the occurrence of the first
non-specific symptoms
– Hepatitis C (35-70 days)
– Influenza (a few hours or days)
– Chickenpox (7-21 days)

Infection - Common infectious diseases

Hepatitis A
Definition:
– Hepatitis A is an inflammation of the liver
– the disease is caused by the Hepatitis A virus (HAV)
Ways of infection:
– it is transmitted through food that is contaminated with faces
residues
– the infection occurs mainly in South and Southeast Europe,
Africa, Asia and South and Central America
– about half of all hepatitis A cases occurring in Germany concern
tourists from southern countries

Hepatitis A
Symptoms:
– the incubation period is two to seven weeks
– two-thirds of hepatitis A infections are without symptoms
• thus, the patient does not realize that he has been infected
with the virus and the disease heals by itself
 rise in temperature (lower than 38 degrees Celsius), loss of
appetite, nausea, vomiting, reduced performance and pressure
pain in the right upper abdomen
 about a week later the skin becomes discolored yellow
(jaundice), the urine becomes dark and dejection becomes light
 at the beginning of yellowing of the skin, most patients feel
already better
 these jaundice usually lasts for four to eight weeks
 Hepatitis A is usually more a mild disease

Hepatitis B
Definition:
– Hepatitis B is an inflammation of the liver
– the disease is caused by the Hepatitis B virus (HBV)
– it is transmitted through body fluids (blood or blood
plasma, semen, vaginal mucus)
– the virus is many times more infectious than the germ of
AIDS, the HIV virus
– it’s enough to have microscopically small skin lesions,
through which the germ passes into the bloodstream
– the disease may be acute (healing within 6 months - 90
percent) or chronical (no cure after 6 months – 10 percent)
– Hepatitis B is the most common viral hepatitis worldwide,
in Germany about 0.5 percent of the population is infected

Hepatitis B
Ways of infection:
 contact with body fluids
 intimate, particularly sexual physical contact
 non-sterile instruments (needles, but also ear piercer,
manicures, acupuncture, tattooing)
 an infected pregnant woman can infect her child during birth
 by transfusion of blood or blood products (today all blood
samples are examined, so the risk of infection is very low)

Hepatitis B
Symptoms:
– loss of appetite, aversion to certain foods, nausea, muscle
and joint pain and mild fever
– in the second phase of the disease skin, mucous
membranes and eyes turn yellow (jaundice / icterus),
dejection is faded and the urine becomes dark
– after that in most cases an improvement occurs
– the disease usually takes four to six weeks
– two-thirds of adults and almost all infants having hepatitis
B will not notice anything of it

Hepatitis B
Protection:
 vaccination against Hepatitis B
• since a few years it is part of the standard vaccination for
all infants and is paid by the statutory health insurance
• older people have to pay the vaccine itself
 the duration of immunity is about five years
 vaccination is particularly recommended for the classical
risk groups
 there is also a combined Hepatitis A / Hepatitis B vaccine
which contains both vaccines
– avoid changing sexual partner, use condoms during sexual
intercourse
– syringes should not be used by multiple people
– do not share shaving gear, toothbrushes, nail clippers or
nail files with infected persons

Hepatitis C
Definition:
– Hepatitis C is an inflammation of the liver
– caused by the Hepatitis C virus (HCV)
– in Germany, about 0.4 percent of the population are
carriers of the Hepatitis C virus
– Hepatitis C is after alcohol the second leading cause of
cirrhosis and liver cancer
– vaccination against Hepatitis C does not exist

Hepatitis C
Ways of infection:
– the disease is transmitted primarily through blood and
blood products
– transmission through intimate contact is rare, Hepatitis C
was formerly known as hepatitis non-A, non-B
– the disease is acute in 20 percent of cases
– in 80 percent of cases, it takes a chronic course
– the time between infection and the appearance of the
disease (incubation period) is 15 days to six months

Hepatitis C
Risk groups:
 doctors, nurses and laboratory technicians
 drug addicts often use shared needles and are very
vulnerable
• about 80 percent of drug addicts who inject drugs
are infected
 in just over a third of cases the infection route is
unclear

Hepatitis C
Acute Hepatitis C (20 percent):
– in the first phase (prodromal) the infected persons feel
uncomfortable, but essentially healthy
• more uncharacteristic symptoms:
– fatigue, muscle and joint pain and mild fever ("flu
symptoms")
– loss of appetite and aversion to certain foods
– nausea
– pressure pain in the right upper abdomen

Hepatitis C
Chronic Hepatitis C (80 percent):
– chronic Hepatitis C often proceeds without symptoms or is
associated with the following unspecific symptoms:
• fatigue
• joint and muscle pain
• anorexia
• occasionally a pressure below the right costal arch.
• if the liver function is restricted, changes occur in the
skin and mucous membranes (called liver skin
characters):
osmooth, red tongue and lips, vascular spiders,
itching, reddened palms

Hepatitis C
Protection:
– syringes should not be used by multiple persons
– do not share shaving gear, toothbrushes, nail clippers or
nail files with infected persons
– avoid changing sexual partners or use condoms

HIV / AIDS
Definition:
 the virus and the infection are called HIV
 the term AIDS (acquired immunodeficiency syndrome) is used
for a late stage of HIV infection
• AIDS is a chronic, life-threatening disease that is caused by
the human immunodeficiency virus (HIV)
• the HIV virus damages or destroys certain cells of the
immune system
• as a result, the body can not effectively combat bacteria,
viruses or fungi that cause diseases

HIV / AIDS
Ways of infection:
– sexual contact
– transmission by infected blood
– transmission by the common use of needles
– transmission by injury
– mother to child transmission
– other transmission options:
• in very rare cases, the HIV virus can be transmitted
through organ transplantation or poorly disinfected
surgical instruments

HIV / AIDS
Symptoms:
 depend on the stage of the disease
 in 1987 the Centers for Disease Control and Prevention (CDC) in
the United States defined four different stages

HIV / AIDS - Stages
• Stage I:
Acute HIV disease
 can pass free of symptoms
 in about 10 to 20 percent six days to six weeks after infection
flu-like symptoms such as fever, headache, sore throat,
swollen lymph nodes and rash
 the infected person can transmit HIV to others
 only one to three months after infection, antibodies can be
detected in the blood
• Stage II:
Asymptomatic infection (latent phase)
– often, what follows is a symptom-free period lasting about
eight to nine years
– the virus multiplies in this time and destroys the immune
cells
– tests show a significant decrease of these immune cells in
the blood

HIV / AIDS - Stages
• Stage III:
Lymph node syndrome
– about 40 percent of the infected suffer during this period
under lymphadenopathy
• Stage IV:
HIV-associated diseases
– develops about ten years after infection and it is divided into
several sub-stages
– examples: cervical cancer, lymphoma, HIV-associated brain
impairment, tuberculosis, etc.

SARS
Definition:
• it is caused by a modified (mutated) pathogen from the
group of corona viruses
Symptoms:
• about 2 to 10 days after infection occurrence of fever
(usually above 38 ° C) and of general symptoms such as
headaches, body aches, etc. and respiratory symptoms
such as cough / wheezing / shortness of breath

SARS
Ways of infection:
– droplet infection
– smear infections are also estimated possible as corona
viruses can be excreted through the gastrointestinal tract
– transmission through skin contact (especially when shaking
hands
– other pathways are discussed:
• transmission through water / waste water, insects /
bugs, incorrect maintained air conditioning

SARS
Protection:
 compliance with the general hygiene rules
 use only safe drinking water
 regular hand washing, especially after using toilet facilities
 avoid direct or close contact with interlocutors
 keep distance when talking, avoid skin contact (shaking
hands)
 after each direct skin contact with people in areas with SARS
cases, wash hands
 in case of direct contact with people in areas with SARS
infection optionally wear a breathing mask

MRSA
Definition:
 bacteria of the genus Staphylococcus aureus may occur as
part of the skin flora in humans and animals
 in humans, the front nose and groin are mostly inhabited
 Staphylococci, compared to other types of bacteria, are
resistant to desiccation and can survive long times on dry
surfaces / objects
 in case of seepage into normally sterile parts of the body
Staphylococcus aureus can cause infections
 in addition to relatively harmless boils severe wound
infections, pneumonia and sepsis cases are caused by these
bacteria

TBC
Definition:
– Tuberculosis is a bacterial infection spread worldwide
– caused by the bacterium Mycobacterium tuberculosis
– Tuberculosis tends to be chronic
– the most common form of the disease is pulmonary
tuberculosis
– it can affect all organs in general, also the skin

TBC
Ways of Infection:
– normally via droplet airborne
– it is generally a disease of poor countries due to poor
hygiene and a high population density
– for this reason, you should also think of tuberculosis after
holiday tours to such countries at onset of clinical signs
– in Europe, the disease itself is rare, but the proliferation of
resistant strains to treatment is found more frequently in
recent years
– TB is a disease that needs to be reported to health
authorities

TBC
Symptoms:
– immediately after infection
– the symptoms are mostly non-specific, including
• fever, malaise, chronic fatigue, loss of appetite
– in 90 percent of cases the disease is deposited in the lung
– the development of coetaneous tuberculosis is rare in primary
tuberculosis
– the symptoms last for 3-4 weeks
– in affected individuals with a weak immune system, the primary
tuberculosis may develop
– in most cases, the disease then spread out from existing herds
in the lungs
– the bacteria are spread throughout the body, so that it can set
the pathogen in the skin also

Unit 3
• Disinfection / Self – protection
 Prevention
 Washing hands
 Objectives
 Indication
 How to do with low and medium impurity
 Postprocessing

Disinfection / Self-protection
The most important: Prevention!
• compliance with the prescribed hygiene guidelines is the
most important
• hand hygiene after contact with a care-recipient
• disinfection of countertops, chairs, carrying devices etc.
• this ultimately is not just about self-protection but also
protection of the next care-recipient from any pathogens

Disinfection / Self- protection
Washing Hands
• washing hands is an important part of hand hygiene
• it serves to remove rough dirt
• by washing hands, up to 99 percent of all microbes will be
removed
• to compare: by hygienic disinfection of hands 99,99 percent will be
devitalised

Objectives
• hands will be cleaned from rough dirt
• your skin will be protected from useless strains

Indication
different causes for washing hands:
• before beginning work, after the lunch break, after having
ended work
• before preparing and before serving meals and drinks
• after having used the toilet
• after cleaning the nose
• after contact with pets
• for cleaning dirty hands

How to do with low and medium impurity
• take liquid soap from the dispenser
• all parts of the hand have to be evenly covered with the soap

• turn the water on
• it should not be switched to warmer than 40°C, warmer
water would lead to a stronger grease removal on the skin

• soap your hands for at least 15 to 30 seconds
• assure that the environment and the clothing will not be
contaminated
• avoid especially strong splashing

• leavings of soap on the skin can lead to irritation, so assure,
that all leavings are carefully washed out under fluent water

• dry the hands thoroughly
• avoid strong grinding

• close the water flush with the elbow (if possible)
• if there is a tap, it will be turned off using a one-way-towel
• if not there could be a recontamination

WHO ‘How to
Handwash’ poster

Postprocessing
• if possible, after every washing of hands a skin care should
follow
• if the distributor for liquid soap will be reused, it has to be
cleaned and disinfected before refilling
• the agreeability of the liquid soap will be assessed regularly

Unit 4
• Disinfecting Hands
– Definition
– Essentials
– Objectives
– Suggested procedure

Disinfecting Hands - Definition
• disinfecting hands: 99.99 percent of germs are killed
• more effective than a soap washing, which removes only 99
percent of the germs
• we use ready-made solutions
• they offer a broad spectrum of impact and rapid effect
• they are also easy to use and well tolerated
• they protect especially the skin

Disinfecting Hands - Essentials
• only washed but not disinfected hands are potential germ
carriers and a danger to the health of care-recipients and to
you
• frequent hand washing strains the skin much more than hand
disinfections
• disinfecting hands is a difficult and complex measure that
must be carried out with the necessary concentration
• hand disinfection is only part of the hand hygiene
• equally important are hand washing and hand care

Disinfecting Hands - Objectives
• germs located on the skin are killed completely
• contamination and infection are prevented, infection chains
are broken
• we find the balance between the need for hygiene and skin
protection
• the number of hand disinfection is limited to the extent that is
necessary for infection prophylaxis

Disinfecting Hands
Suggested procedure
• operate the crank of the dispenser with the elbow
• with the „cupped“ other hand disinfecting fluid is caught –
without any contact to the distributor

• rub your hands together and spread the disinfectant roughly
on the skin
• rub palm to palm

• rub the right palm on the left hand back and vice versa
• the spaces between the fingers have to be disinfected

• cover the thumb of one hand with the palm of the other
hand, turning the thumb and rubbing it in the palm

• the fingernail area of each finger has to be disinfected

• close the fingers and rubs them in the palm of the other hand

Unit 5
• Individual Hygiene – Shower
– Definition
– Objectives
– Preparation
– Autonomous
– Dependant from assistance
– Postprocessing

Individual Hygiene – Shower
Definition
• for younger generations, taking a shower is part of everyday life
• on the other hand many older people prefer a weekly full bath
and complete it with washing at the sink
• there are many factors speaking against a full bath and promote
having a shower:
– shorter time of exposure
– much more tolerant to the skin

Definition
• streaming water is more hygienic
• a shower gives less stress to the blood circulation
• getting in and out of the tub is more exhausting than using a
walk-in shower
• a full bath requires much more water and energy and is
therefore inefficient

Objectives
 the body will be cleaned
 circulation is stimulated, especially by contrast showers
 privacy is respected
 falling can be avoided
 the client is not cooled by cold water and also does not come
in contact with too warm water

Preparation
We prepare the following auxiliary materials and supplies:
– if necessary, shower stool, 2 non-slip shower mats, if
needed a lift
– a one-way apron and 2-3 pairs of one-way gloves
– 2 washcloths
– a towel, a small towel
– bathrobe, clean underwear, slippers
– depending on the time of day pajama, nightgown or fresh
clothing

– shampoo, shower gel if necessary, soap, skin lotion, hair
brush, comb and hair dryer
(Note: It may be useful to pierce the soap with a cord ,
attached to the tap. The client can thus easier soap
himself.)
– the bathroom is heated to a comfortable temperature
– windows are kept closed
– if necessary, towels are preheated on the heater
– all materials are stored within hand reach
Preparation

Autonomous
• after a short sprinkling with water, soap the body with a
detergent and than rinse with clear water

Dependant from assistance
• accompany the client into the bath room
• if needed help to go to toilet beforehand
• close the door; if needed apply a sign „Occupied“
Note: Never lock the bathroom door, independently whether
you are with the client or not. A locked door hinders quick help
by other persons if there is an emergency that cannot be
handled alone by you.

• other tools are stored or prepared ready for shower:
– glasses, hearing aid and possibly wig are deposited
– if necessary, arm and leg prostheses are removed
– if necessary, the stoma bag is unrolled and a purification of
the stoma area is performed
– condom urinals are to be unrolled, the urinary catheter bag
is emptied
– materials for incontinence care have to be removed, if
necessary, impurities are roughly removed
– if necessary, perform a hygienic hand disinfection and
change the one-way gloves
• control the tightness of the shower mat and bathroom mats
• check the handles for stability
• check the functionality of the thermostat

• ensure that the care-recipient
does not cool down
• if necessary, skin areas are kept
warm by the shower spray
Important!
• Some people, especially
wheelchair users, don't have
sensation in some parts of their
body. This also means they
cannot feel the water
temperature.
• This can cause injuries if the
water is too hot (burns and
blisters), or hypothermia if the
water is too cold. Try the water
yourself first.

• as far as the client does not want it differently, the following
sequence of soaping and showering is chosen:
– feet and lower legs
– thighs and hips
– arms and upper body
– back and chest
– genital area: to do it the client should stand upright if
possible and spread her/his legs
– shampooing: cover the face with a second washcloth, so
that no foam gets into the eyes
– the face is purified with the second washcloth
– rinse entire body again
• it is important to ensure that soap is used sparingly to avoid
unnecessary burdening of the acid mantle of the skin
• turn off the shower

• place the small towel over the head of the care-recipient,
place the large towel as protection against the cold on the
shoulders
• help the client to go out of the shower cabin
• the client dries himself or with help of you - take care that no
humidity is left in skin folds
• keep the client from any draught
• comb and dry the care-recipients hair
• perform a skin care to protect the skin from drying out
• depending on the support needed, the care-recipient dresses
himself or does it with the help of you

• blow-dry the hair of the client and reset the hairstyle
• if necessary, the client’s makeup has to be refreshed
• if necessary, a finger nail care has to be done
• if necessary, re-apply watch and jewellery
• if necessary, necessary prophylactic measures are carried out
• renew bandages
• reinstall the urinary drainage system etc.

Postprocessing
• tidy up the bath room, wipe humid places and ventilate
• remove the notice „Occupied“ if you used it
• ask the client again how s/he feels
• clean, disinfect or dispose materials and consumables
• perform a hygienic hand disinfection

Unit 6
• Individual Hygiene – Full bath – Partial bath
– Definition
– Fundamentals
– Objectives
– Material to be used
– Preparing the bath room
– General preparations
– Planning
– Bath additives
– Autonomous and mobile
– Need for assistance
– Postprocessing

Individual Hygiene – Full bath – Partial bath
Definition
• the significance of taking a bath is more than just pure
personal hygiene
• use the relaxing and well-doing impact of warm water to calm
down the body or i.e. to free it from a cold
• there are different forms to take a bath:
o full-bath, which means a complete dunking into the water
except the head.
– The water-pressure and the heat does have a stressing impact on the
circuit
o partial bath, is the partial diving (only the lower part of the
body) or the selective dunking of parts of the body (arms, feet
…).

Fundamentals
• if primary goal is the cleaning of the body, it is not useful to take a
bath but preferably to take a shower
• the client has in any case to agree with taking a bath – never
against his will – even in case of dementia
• the client should be able to do the most part of the activities
needed by herself

Fundamentals
• even if the client is only able to wash a few regions of the body,
she will receive all the support needed for it
• especially washing the genital area should be done by the cared
person him/herself if possible
• time and procedure of taking a bath has to follow the needs and
wishes of the client

Objectives
• relaxation, recreation
• cleaning
• blood circulation in the skin will be improved
• temperature of a patient with fever will be reduced
• a comfortable coenaesthesia (general awareness of one's own
body) will come
• symptoms of a skin disease or a cold will be palliated

Material to be used
Prepare the following material:
• two washrags
• two small towels, one bath towel
• add-on for the bath if needed
• thermometer for the bath
• shampoo if needed
• fresh clothing
• anti-slip-mat in the bath-tub and in front of the bath-tub
• a bathroom lift if needed
• skin cosmetics
• hair dryer

Preparing the bath room
• make sure that no electrical devices are near the bath tub
• the bath-room is ventilated and heated to a comfortable
temperature
• while taking the bath the window has to be closed in any case
• before going in the water, the bath tub has to be flushed out
• the anti-slip-mats before and in the bath tub are placed
personally by you

• let the water run into the bath tub
• if no other provision, temperature of 35°C to 38°C is chosen
• for a full bath, the tub has to be filled only for half, after getting
in, more water can be given
• if provided and if wished, bath-add-on can be filled in and
distributed
• do not close the bathroom, so that in emergency help can come
immediately

• Put an „Occupied“ sign on the door
• prepare a seat if needed, i.e. a stool
• if needed, pre-warm the towels
• Prepare fresh clothing

• functioning of all instruments is well known
• before bathing, mouth care an tooth care can be done
• going to the toilet should be done before taking the bath
• remove jewellery, watch, glasses, hearing aid etc.
• take off clothing
• if applicable, remove material for incontinence or bandages
• in case of rectal discharge, clean before taking the bath
• measure blood pressure and pulse, especially before a full-bath
General preparations

• taking a bath should be the earliest two hours after the last
full meal taken and never in inebriation (being intoxicated)
• two full baths per week are the upper limit – even for very
healthy elderly people
• this limit is lower, accordingly to the health state or for
weakened elderly people
• in case of itchiness, long and hot baths should be avoided
• for people with heart disease, a bath should be reduced to 10
minutes; water should be taken up to the navel the highest
Planning

• the following bath additives can be used:
– calmative and anti-inflammatory: arnica, spruce needle,
camomile
– calmative: valerian, lavender
– stimulating circular flow: birch
– antipyretic: eucalyptus
– disinfective: rosemary, sage
Bath additives

• in case of skin disease salt or sulphur can be used
• before using bath additives the first time it is important to have
clear weather because there might be allergic reactions
• we use only pure essential oils
• in a whirlpool never use foaming bath additives
• take care: when using oily additives there is a very high slip
hazard!
Bath additives

• stabilize with both hands on the rim of the bath tub, lift the
leg the nearest to the bath tub
Autonomous and mobile

• move the balance point more to the bath tub and stand with
this leg into the tub

• now move also the other leg into the bathtub, then sink
slowly into the water

• the client leans ahead as far as possible, so s/he can move
easier his pelvis from the stool
• your feet and the feet of the client should be shifted to each
other
Need for assistance

• the client stretches her/his knee and stands up
• give support when turning and sitting on the bathtub rim

• the client can lift first one than the other leg into the water

• use the slope to slip slowly into the water
• prevent uncontrolled slipping by fixing hands on the person’s
pelvis

• all clothing is brought in order
• ask how the client feels
• put the alarm button reachable for the client
• ask the client if he has some desires – especially offer a drink
• dispose all used material
• empty the leaving water
• ventilate the bath room, clean the bath tub and disinfect it
Postprocessing

Postprocessing
• remove the sign „Occupied“
• put all cosmetics back to its place
• make a hygienic disinfection of his/her hands
• tidy up the room
• make sure there is an appropriate pause for the client

Unit 7
• Food refusal by clients suffering from Dementia
 Why a person suffering from dementia cannot (does not
want to) eat?
 Positive influence on nutrition
 Feeding-tube yes or no?
 Tube-nutrition in case of severe dementia
 Tube-nutrition and Dementia - Conclusion

Why a person suffering from dementia
cannot (does not want to) eat?
Loss of appetite because of
• chronic pain !!!
• other excruciating physical complaints
• psychotropic medicine
• anxiety, depression, grief
• sense of loneliness
• disturbing environment (noise, disturbance ...)

Dysphagia
• psychotropic medicine
• insult
• delayed swallowing reflex
• tendency to aspiration
• end-stage of dementia (bite in mouth is "forgotten")

Is unhappy in her/his environment !!!
• does not understand, feels not to be understood
• feels disrespected
• receives too little attention
• feels constantly reprimanded
• can not live without her autonomy
• feels treated as an object

Food has not good taste
• unusual or unfamiliar food
• too softly spiced food (or that is over-spiced, according to
her/his taste)
• no consideration of preferences or aversions
• food that looks shabby, is mashed, is mixed
• wrong time for a meal

116
Eating spoiled by
• dry mouth
• thrush
• poor oral hygiene
• poorly fitting, jiggling prosthesis
• pressure points, wounds
• nausea

117
Refusing type of food supply
• rejecting food supply by the caregiver
• loveless food supply (“feeding")
• meal is too hot / too cold
• spoon too big
• spoon too full
• feels under time pressure

Ahead of dying
• sign of the approaching life end
• this can last: days - weeks - months, regardless of
nutritional status

Positive influence on nutrition
• successful communication
• absence of pain (low-level pain)
• reduction of psychotropic medicine to the unavoidable
level
• trustful relationship with caregiver
• care, body contact
• familiar atmosphere
• the greatest possible normality of the environment

Positive influence on nutrition
• adequate supply of sensory stimuli
• colourful plates on white tablecloth
• offer drinks in an ongoing manner
• let the care-recipient eat independently
• serve “finger food”
• offer favourite foods

Feeding-tube yes or no?
Since there are few or no benefits - but many potentially
adverse effects of tube feeding for very elderly people,
routine use for care –recipients with severe dementia is not
justified.
The New England Journal of Medicine, Jan 2000

In the final stage of dementia, the benefit of
nutritional therapy could exist only in
improving the quality of life.

Tube-nutrition in case of severe
dementia
• does not prevent: aspirational pneumonia, pressure
ulcers, infections
• does not improve: body functions, palliative care
• does not prolong survival
Finucane TE et al: JAMA 1999; 282: 1365-137
Gillik MR: N Engl J Med. 2000;342(3): 206-210

• Tube-feeding is an important risk factor for aspiration
Fox KA, Mularski RA et al: Am J Surg 170: 554-56, 1995
• Tube-feeding has more risk to cause infection than to
prevent it
Locket MA, Templeton ML et al: Am J Surg 68: 117-120,
2002
• Tube-feeding is an important risk factor for of
Clostridium difficile infection
Bliss DZ, Johnson S et al: Ann Intern Med 129:1012-1019,
1998
124

Tube-feeding for people suffering of severe dementia is
characterised by an extremely high mortality rate:
• 54% die in 1st Month
• 90% die within half a year
Sanders DS, Carter MJ, D‘Silva J, James G., Bolton RP,
Bardhan KD. 2003

The average time of survival after tube
feeding is about 6 months.
Mitchell SL, Tetroe JM (Metaanalye): J Gerontol A Biol Sci Med Sci 55:
M735-M739, 2000

Tube feeding and Dementia -
Conclusion
1. The gradual ending of food intake at the end-stage of
dementia is not the cause but coincides with dying.
2. In this situation it is an ethical demand.
• To give care with love.
• To offer small amounts of food and beverages.
3. The tube is seldom the best but always the easiest
way…

8 M-CARE: Hygiene

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