QIO NHQI Weekly Update :: April 18, 2008  

 

TIP OF THE WEEK

Environmental considerations for bathing persons with dementia

 

Bathing can be a challenging task for some nursing home residents, particularly those with a degree of cognitive impairment. The National Guidelines Clearinghouse has compiled extensive, evidence-based guidance for Bathing Persons with Dementia. Below is an excerpt from the “Environmental Considerations” portion of the guideline.

ENVIRONMENTAL CONSIDERATIONS

In attempting to manage negative behaviors associated with the bathing process, the actual room in which this activity occurs plays a major role in the outcome and plan of interventions.

 

In older facilities the challenge is to make the bathing room a place that does not contribute to negative behaviors by alarming the individual who may interpret a large, sterile, cavernous room as threatening. How often do these rooms become the resting place of used or unused lifts, commodes, wheelchairs, linen hampers, and boxes of supplies or boxes of personal items waiting for disposal? With a little creativity and planning even an older facility can have a home-like, pleasing environment for the person being bathed as well as for the person giving the bath.

 

Because of the frailties and physical limitations of individuals requiring care, the tubs and accompanying bathing equipment required for facilities does not resemble anything the person would remember from their past. However, much can be done so that this equipment does not become the focal point of the room.

 

The following considerations can be used as a starting point in making any bathing room both functional and visually pleasing.

  • Try to find another location for extra supplies/equipment, which find their way into the space, or, if unable to relocate, hide it behind a screen or colorful curtain. Add extra cupboards if the area is large enough (Schindel Martin, 1998) (Evidence Grade = D). A shelving unit with baskets for personal toiletries or bathing supplies is pleasing to the eye and adds interest and organization to the area (Brawley, 2002) (Evidence Grade = D).
  • Look at the room from the other person's point of view. What is the first thing they see when entering the room? What do they see when they enter or leave the tub? The shower? Here's where creativity takes over. Hang colorful posters or prints where they would get noticed. Shelves with items such as decorative bottles, shells, or ceramic fish are easy to install and do not need to be expensive. Add colorful towels hanging on decorative rods (Calkins, 2002) (Evidence grade = D). (Sew in place if there is a possibility that someone may use them by mistake.) Paint a large mural or ivy on the walls accented with hanging baskets of greenery or flowers (Calkins, 2002; Furrow, 1996) (Evidence Grade = D).
  • Lighting is important. It needs to be sufficient enough for the caregiver but also subdued enough not to startle the person being bathed. Lights shining off ceramic tiles cause a glare that is distressing to the person with dementia. Cove lighting is good for this area as it reflects toward the ceiling, or try wall sconces (Calkins, 2002) (Evidence Grade = D). Either way, have lights on dimmer switches so that it can be adjusted to an individual’s need (Calkins, 2002; Furrow, 1996) (Evidence Grade = D).
  • The hard surfaces of tiled walls and floors cause echoes and can make any noise overwhelming. This is why it is important to limit the number of people coming in and out of the bathing area by removing excess equipment. Fabric will absorb sound. Use it generously for curtaining off bathing and showering areas and any windows in the room (Brawley, 2002; Calkins, 2002) (Evidence Grade = D). Vinyl wallpaper in pretty patterns will also absorb sound and create visual interest. Add it to the top half of the area around the tub and surrounding walls. Water resistant acoustic panels can also cover walls as well as ceilings and can be made as decorative as desired (Brawley, 2002; Calkins, 2002) (Evidence Grade = D).
  • Eliminate offensive smells by making sure that soiled clothing is removed immediately. Clean hampers and floors where odor may linger with disinfectants regularly and thoroughly. Some odors can be masked by the use of scented sprays or electronic dispensers (Calkins, 2002) (Evidence Grade = D).
  • Flooring needs to be examined from the aspects of cold and safety when wet. Floors should have a high coefficient of friction to be considered safe. Washable non-slip rugs are considerations if one is stepping out of tub or shower (Calkins, 2002) (Evidence Grade = D).
  • Commercial towel warmers come in a variety of sizes. When choosing the appropriate size, consider needing a good supply if a number of baths are done in succession. Also consider if there is a need to have the larger bath blankets warming as well (Brawley, 2002; Furrow, 1996) (Evidence Grade = D).
  • Stable grab bars are of prime importance where individuals who require assistance are moving into tub or shower. It is important that they be very visible and strategically placed for safety (Brawley, 2002; Calkins, 2002) (Evidence Grade = D).
  • Wet skin feels cold and therefore the room needs to be maintained at a higher temperature than other areas the individual may frequent. Some bathing rooms, because of the manner in which the facility was constructed may not have separate controls for adjusting the heat. A heat lamp on a timer or radiant heat panels can usually be permanently mounted to any room to supply an extra source of heat (Brawley, 2002; Calkins, 2002; Furrow, 1996) (Evidence Grade = D).
  • Hand held showers are easier to control and more versatile than wall mounted. They can usually be attached to a bracket to use in the traditional way if the person is more independent (Brawley, 2002) (Evidence Grade = D)
  • A seating area with a vanity can also be both a focal point and a "finishing" spot. A table with a makeup mirror can be set up off the bathing area and will add to the hominess of the room as well as serve to help individuals complete their appearance after the bath (Brawley, 2002) (Evidence Grade = D).
  • Tubs come in a wide variety of types in relation to their specific functions. Side entry, end entry, and those requiring specialized lifts are all available with a range of other functions such as water capacity, pre-fill features, manual versus digital controls, disinfecting systems, sitting or recumbent styles, and whirlpool systems. How the individual with dementia enters the tub is the most important considerations when choosing a tub. Those systems where the person has to be raised a considerable height caused the largest degree of negative behaviors (Namazi & Johnson, 1996) (Evidence Grade = C).

The grading schema used to make recommendations in this evidence-based practice protocol is:

  1. Evidence from well-designed meta-analysis
  2. Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention, or treatment)
  3. Evidence from observational studies (e.g., correlational descriptive studies) or controlled trials with inconsistent results
  4. Evidence from expert opinion or multiple case reports

 

REFERENCES SUPPORTING THE RECOMMENDATIONS

Brawley EC. How to improve the bathing experience. 2002;3(1):38-41.

Calkins MP. Design a better bathroom. 2002;10(3):26-8.

Corber W, Silberfield M, Feldman A. The need for uniform bathing policy. Can Nurs Home 1998;9(2):9-10.

Dougherty J, Long CO. Techniques for bathing without a battle. Home Healthc Nurse 2003 Jan;21(1):38-9. PubMed

Dunn JC, Thiru-Chelvam B, Beck CH. Bathing. Pleasure or pain. J Gerontol Nurs 2002 Nov;28(11):6-13. PubMed

Farrell Miller M. Physical aggressive resident behavior during hygienic care. J Gerontol Nurs 1997 May;23(5):24-39. PubMed

Furrow MA. Improving the environment to enhance the bathing process. J Long Term Care Adm 1996 Fall;24(3):54-5. PubMed

Hall GR, Buckwalter KC. Evidence-based protocol: bathing persons with dementia. In: Titler MG, editor(s). Series on evidence-based practice for older adults. Iowa City (IA): University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; 1995.

Hoeffer B, Rader J, McKenzie D, Lavelle M, Stewart B. Reducing aggressive behavior during bathing cognitively impaired nursing home residents. J Gerontol Nurs 1997 May;23(5):16-23. PubMed

Kovach CR, Meyer-Arnold EA. Preventing agitated behaviors during bath time. Geriatr Nurs 1997 May-Jun;18(3):112-4. [5 references] PubMed

Mickus M, Wagenaar DB, Averill M, Colenda C, Gardiner J, Luos Z. Developing effective bathing strategies for reducing problematic behaviour for residents with dementia: the PRIDE approach. J Ment Health Aging 2002;8(1):37-43.

Namazi KH, Johnson BD. Issues related to behavior and the physical environment: bathing cognitively impaired patients. Geriatr Nurs 1996 Sep-Oct;17(5):234-8; quiz 238-9. PubMed

Schindel Martin L. Developing a C.R.A.F.T. approach to resident bathing. Can Nurs Home 1998;9(2):4-8.

Sloane PD, Rader J, Barrick AL, Hoeffer B, Dwyer S, McKenzie D, Lavelle M, Buckwalter K, Arrington L, Pruitt T. Bathing persons with dementia. Gerontologist 1995 Oct;35(5):672-8. PubMed

Winslow E, Jacobson A. Reducing disruptive behavior during bathing. Am J Nurs 1997;9(2):20.

 

 

RESOURCE SPOTLIGHT

 

Look at Me Video
This video depicts an elderly man reflecting on a life well-lived, and offers a touching perspective of the elderly. It describes the goals and responsibilities of the VA Medical Centers, recounting the needs of elderly veterans. This video has implications for the care of all elderly in the long-term care continuum.

 

 

IN THE NEWS

 

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April 16, 2008 -- HealthDay -- A new study indicates that taking 2,000 IUs of Vitamin E may extend the lives of people with Alzheimer’s disease by 26 percent. Additional testing is required to confirm these findings and to verify that the benefits outweigh the health risks associated with large amounts of Vitamin E. Read more >>

 

INCIDENCE OF BREAST CANCER UNCHANGED IN BLACK WOMEN, DESPITE DROP IN HRT USE

April 15, 2008 -- HealthDay -- The incidence for breast cancer dropped significantly in the U.S. population, but not for black women. It is unknown whether this variation is associated with race, or with environmental or social factors. Read more >>

 

 

INDUSTRY EVENTS

 

NAVIGATING THE MDS THROUGH THE OHIO MEDICAID REIMBURSEMENT SYSTEM

May 1, 2008, 8:30 a.m. to 4:45 p.m. ET

Speakers: Claire Spellmire, RN, BSN, and Karen Jennings, LNHA, MHA, from the Case Mix Section, Bureau of Long Term Care Facilities, Office of Ohio Health Plans.

Cost: Free

 

For more information or to register, call Cheryl Robertson at (614) 466-9088.

Space is limited to two per facility.

 

Cuyahoga Community College Spring ’08 Continuing Education
Schedule for Gerontology Professionals

 

Health Policy Institute of Ohio: Regional Meetings on the Ohio Family Violence Prevention Project

Medicare Learning Network: Learning resources and products for the healthcare professional.

 

Alzheimer’s Association Training Events

 

AOPHA Events

 

Case Western Reserve University School of Medicine Courses

 

Ohio Department of Health, Technical Assistance Program – New Programs

 

Ohio Health Care Association Events

 

 

 

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