A caregiver's guide to hygiene for the terminally ill

When someone is terminally ill, they are often in the last stages of their lives and require more intensive care. To maximise our loved one's comfort and quality of life, we should try to cater to their hygiene needs. Moreover, keeping them and their living environment clean can protect them from further complications caused by infections.

If you are caring for a terminally ill loved one, here's how you can protect them from infections and how you can help them feel more comfortable at home.

Environmental Care 

Bed hygiene / bed making

Making the bed and changing sheets are important for terminally ill persons. This helps to prevent germs and bacteria from building up. It is recommended to use a breathable cotton bedsheet for the mattress. The guide below is written for terminally ill persons who are bedbound. 

Materials needed: 

• Clean bedsheets

• Pillowcases 

• Blanket 

Steps: 

• Adjust the bed to ensure that the bed is at a comfortable height for you, and the head and foot of the bed are level (if it is a hospital bed). 

• Ensure the person on the bed is safe by propping up the bed's side rails, if any, so that they do not fall. Otherwise, you may push the bed against a wall. 

• Get ready to remove bedsheets by loosening the bed sheets on all sides of the bed. Remove pillows and blankets if any. 

• Start to remove bedsheets by rolling the person to the opposite site, using a towel or blanket to cover them if necessary. Roll the loosened bedsheets towards the person. 

• Prepare new bedsheets by taking a clean sheet, folding it lengthwise and putting it along the middle fold on the centre of the mattress. Unfold the clean bedsheet and cover the unoccupied side of the mattress. 

• Cover the other side of the bed by rolling the person to the covered side of the mattress carefully, and then pulling out the remaining bedsheet to cover the other side of the mattress. You can find detailed ways to do this here. 

Frequency:

• Change the bedsheet once every few days, or when it is soiled. 

Infection control at home

Keeping safe at home helps to upkeep hygiene not just for your loved one, but for yourself as well. Here are some general ways to help prevent infections for your care recipient at home. 

General tips to minimise infections

• Always start with washing the cleanest area of the body and working towards the dirtiest areas

• Always wash your hands before and after coming into contact with the care recipient or other people, including those who are coming home from outside, and after using the toilet.

• Always wear disposable gloves when giving personal care.

Cleaning techniques 

Caregiver hand washing

• Hand-washing is the most effective way to prevent the spread of infections or germs. 

• Use bottle-dispensed hand soap. If the care recipient has an infection, use antimicrobial soap. 

• Rub your hands for at least 30 seconds to produce lots of lather before placing hands under running water. 

• Wash the front and back of your hands, between your fingers, and at least two inches up your wrists. Repeat this twice.

• Dry your hands on a clean towel or paper towel. 

• Use a nail brush on your nails and keep them trimmed. 

Helping the care recipient use a wheelchair 

• Wear a pair of leather gloves if possible, to prevent cuts. 

• Wash your hands often. For frequent in-between washings, you can use pre-packaged wipes to wipe your hands clean. 

Handling soiled laundry

• Dealing with soiled laundry: 

  • Do not carry soiled linens close to you. 

  • Do not shake or put soiled linens on common surfaces e.g. floor, on dining table. 

  • Immediately store infected, soiled linen in a leak-proof plastic bag and tie it up, in the same area where it was used. 

  • Separate soiled linens from other clothes.

  • Use rubber gloves when handling soiled linens.

• Washing soiled laundry: 

  • Wash soiled linens separately from other clothes. Always remember to wash your hands after handling soiled linens.

  • Fill the washing machine with hot water and add bleach (one/four cup or less) and detergent. Rinse twice and dry. Note that if any soiled linens are dirtied with highly concentrated urine (due to bladder infection or dehydration), do not use bleach. This will cause a chemical reaction with the urine which emits toxic fumes. 

  • Clean the washing machine by running it through a cycle with one cup of bleach or a cup of another disinfectant. 

Disposal of bodily fluids

• Wear disposable gloves when handling bodily fluids. 

• Flush liquid and solid waste down the toilet.

• Place used dressings and disposable pads in a sturdy plastic bag, tie up securely and place in a sealed container for disposal.

Sterilisation 

You should sterilise equipment if it is shared among different people. Otherwise, if the care recipient is the only one using the equipment, you can wash equipment with disinfectant liquid alone. Never microwave to sterilise as this could cause an explosion. Sterilise equipment after each use. 

Wet heat sterilisation

• Fill a large pot with water. 

• When sterilising glass items, put a cloth at the bottom of the pot to prevent breakage. 

• Place items to be sterilised in the pot and cover. 

• Bring the water to a boil, and leave it boiling for 20 minutes to sterilise. 

• Leave the items in a pot until ready for use.

Preventing strong odours caused by bacteria

Bacteria thrive in places with moisture, warmth, oxygen, darkness and nourishment. You can prevent and get rid of strong odours by eliminating favourable conditions for bacteria growth.

• Sprinkle baking soda on the care recipient's wound dressing.

• Put an open can of finely ground coffee under the bed. 

• Pour a few drops of mouthwash in bedpans and commodes. 

• Place cotton balls soaked in mouthwash around the room. 

• Mix white distilled vinegar with a few drops of eucalyptus or peppermint essential oil and spray it in the room. 

• Use natural organic room sprays or electrical devices to remove odours (e.g. plug in air fresheners).

Personal care

Mouth care

Oral hygiene includes toothbrushing, cleaning the gums, and oral toileting (rinsing the mouth, cleaning the oral cavity) to dentures or teeth as needed. This is an important part of palliative care to not only provide comfort but to ensure a care recipient's dignity and quality of life as well. 

Materials needed: 

• Toothbrush (preferably disposable)

• Warm water

• Towel 

• Disposable gloves 

• Basin

• Dental floss

• Toothpaste/baking soda

• Mouthwash as approved by doctors or nurses – usually this would be a mixture of hydrogen peroxide diluted with mouthwash, or a glycerin-and-water solution

Steps: 

• If the care recipient has teeth: 

  • Clean the mouth by using the toothbrush to clean the roof of the mouth, tongue, lips and inside the cheeks. 

  • Rinse out the mouth by using the toothbrush dipped in water to swab the mouth. Repeat until the foam is gone.

  • Perform oral care by applying a thin layer of petroleum jelly if the lips are dry. 

• If the care recipient has dentures: 

  • Clean the dentures by removing them from the care recipient's mouth and rinsing them under running water. Soak the dentures in a denture cup. 

  • Clean the care recipient's mouth by rinsing it with water or mouthwash using a toothbrush as described above (same as if the care recipient had teeth). 

  • Massage the gums by using a very soft toothbrush.

  • Finish oral care by returning the dentures to the care recipient's mouth. 

Frequency:

• Twice a day 

Shaving 

Shaving can be done by the care recipient themselves, or you can help them. For those who wear dentures, ensure that they are in his mouth before shaving. Take note that if the care recipient is on oxygen support or receiving oxygen, you must never use an electric razor to shave. 

Materials needed:

• Disposable gloves

• Safety razor

• Shaving cream

• Washcloth 

• Towel 

• Lotion 

Steps:

• Prepare for the shave by washing your hands and ensuring there is enough light to see the care recipient's face clearly. Spread a towel under his chin.

• Prepare the care recipient's face by wetting his face with a warm, damp washcloth. Apply the shaving cream to his face, avoiding the eye area. 

• Shave the face by holding the skin taut with one hand and shaving the beard using the other hand. Use short, firm strokes to shave in the direction of hair growth, avoiding sensitive areas. 

• Finish up the shave by cleaning his skin with a wet cloth and drying it with a towel. Apply lotion on shaved skin to moisturise after that. 

Frequency:

• Once every two to three days

• Otherwise, check in with your loved one what they prefer/observe the rate of hair growth

Shampooing hair

Shampooing hair helps to keep tresses healthy and improves blood flow to the scalp. Not only that, a shampoo session feels good in Singapore’s hot climate. A good time to shampoo would be before a bath, or whenever the care recipient is not tired. You can either do a wet or dry shampoo. 

Wet shampooing

Materials needed:

• Disposable gloves

• Comb and brush

• Shampoo (dilute it with water in a bottle first before using) 

• Conditioner

• Small pails of warm water

• Large basin

• Washcloth 

• Towels

• Cotton balls

• Large plastic sheet 

Steps:

• Prepare the care recipient for shampooing by having the care recipient sit on a chair or a commode. Put a large towel over his or her shoulders, and comb out any knots and tangles in their hair. 

  • Alternatively, you can cut a hole through a sheet made of waterproof material and drape it over the care recipient's head, so that their shoulders and neck are covered and water from shampooing drains towards the sink. 

  • If the care recipient is bed bound, waterproof the mattress by placing a plastic sheet over the whole mattress. Place a basin next to the bed and roll the edges of the plastic sheet so that the water will flow into the basin.

• Ensure the care recipient's safety by using cotton to protect their ears. Ask them to cover their eyes with a washcloth and lean over the sink. 

• Shampoo the care recipient's hair by using a wet washcloth to moisten their hair, then putting a small amount of diluted shampoo into their hair and massaging their scalp and hair.

• Finish off the shampoo session by rinsing off the shampoo from their hair, or using a wet washcloth to wipe off the shampoo. You can use a leave-in conditioner if desired. Dry off hair with a towel and comb hair. You can dry hair with a hairdryer on the cool setting if necessary. 

• Alternatively, you can cut a hole through a sheet made of waterproof material and drape it over the care recipient's head, so that their shoulders and neck are covered and water from shampooing drains towards the sink. 

• If the care recipient is bed bound, waterproof the mattress by placing a plastic sheet over the whole mattress. Place a basin next to the bed and roll the edges of the plastic sheet so that the water will flow into the basin.

Frequency: 

• Once every two to three days 

Dry shampooing

Materials needed: 

• Disposable gloves 

• Comb and brush

• Dry shampoo

• Towel

Steps: 

• Rub shampoo in until the foam disappears.

• Dry hair with a towel and comb it gently.

Frequency: 

• Once every two to three days (depending on whether a wet shampoo is done as well) 

Bathing

Baths need to be given to care recipients regardless of their mobility status, as this helps to improve their blood circulation and also keeps them clean. Do note that baths can dry out the skin and cause chapping, so the frequency of baths should be determined on a case-to-case basis based on the needs of the care recipient.

If the care recipient requires frequent bathing but has dry skin, you can alternate using soap and water with water alone and lotion to moisturise the skin after the bath. 

For care recipients who are immobile, you can do a bed bath. Otherwise, for care recipients who can sit up in a chair or wheelchair, consider a basin bath. If the care recipient is able to move around well and get in and out of a tub, you can do a tub bath for him or her. 

Cleaning the care recipient's ears is not necessary as earwax naturally gets rid of itself, unless advised by a medical professional. Poking things inside the ear canal may make things worse as it causes the earwax to go deeper into the ear, or injure the structures in the ear.

Do arrange for twice-yearly checks with doctors and nurses to clean the care recipient's ears, as a build-up of earwax may obstruct hearing. If the doctor approves, apply a little lotion to the outside of the ears to prevent drying and itching.

Bed Bath

Materials needed: 

• Disposable gloves 

• Mild soap/cleanser

• Washcloth

• Washbasin

• Lotion

• Comb 

• Electric razor 

• Shampoo

• Towel

Steps: 

• Prepare for the bath by ensuring the room and bath water is at a suitable temperature. If the care recipient is on a hospital bed, raise the bed to the highest level and bring the head of the bed to an upright position. Ensure good body posture by keeping your feet apart, standing firmly on both feet, bending your knees, and keeping a neutral back at all times. Help the care recipient with other needs before bathing such as urinating or defecating, tooth brushing or mouth cleaning. Remove the blanket and care recipient's clothes and cover their body with a towel or light blanket, and get them to lie flat. Only uncover the area you are bathing during the bath. Prepare one washcloth for soap, one for rinsing, and one for drying.

• Wash the upper body of the care recipient by taking a damp washcloth for soaping. 

• Wash the care recipient's face gently and pat dry with the dry cloth. 

• Repeat this with the front of the neck, then move on to the chest. 

• For females, also clean under the breasts.

• Wash the lower body of the care recipient by:

• Washing their stomach and upper thighs first, and pat dry. Remember to clean their navel with some lotion applied to a cotton swab. 

• Wash their arms upwards from wrist to upper arm to increase circulation, then pat dry.

• Wash the spaces between the fingers, clean their nails, and pat dry. 

• Wash the legs by first placing a towel under their buttocks, bend their knees, and wash the legs. Pat dry after washing. 

• Wash the area between his or her toes and dry well. 

• Apply lotion to the feet if they are dry but keep areas between the toes clean and dry to prevent fungal infection. 

• To wash the genital area: 

• For males: If uncircumcised, draw back the foreskin, rinse the penis, and dry it before bringing the foreskin down over the head of the penis again. Check for unusual tenderness, swelling or hardness in the testicles. 

• For females: Wash the vagina thoroughly by spreading the external folds. 

• Washing genitals must be done at least once daily.

• Wash the back of the care recipient by replacing the used bath water from washing the upper and lower body with fresh water first. Prepare the care recipient by rolling them away from you, then putting a towel under them. Wash their back starting from the neck to the buttocks. Rinse and dry well. 

• Finish bath time by applying lotion on the care recipient's back to improve circulation. Dress them with clean clothes and trim their toenails when necessary. Change the bed linens. 

Frequency: 

• If the care recipient has urinary and bowel problems, and perspires a lot, a bath should be given daily. 

• Otherwise, give a bath two to three times a week.

Basin Bath

Materials needed: 

• Disposable gloves

• Mild soap/cleanser 

• Washcloth

• Washbasin

• Lotion

• Comb 

• Electric razor

• Shampoo

Steps: 

• Prepare for the bath by ensuring the room and bath water is at a suitable temperature. Ensure good body posture as stated above. Help the care recipient with other needs before bathing such as urinating or defecating, and tooth brushing or mouth cleaning. 

• Wash the upper part of the body by washing the face, then the body. 

• Wash the lower part of the body by getting the care recipient to stand if he or she is able to. If not, lie the care recipient down in bed and wash him or her as per the instructions for a bed bath above. 

Frequency: 

• As per above in bed bath – consider care recipient's individual needs

• Otherwise, two to three times a week is sufficient.

Tub Bath

Materials needed: 

• Disposable gloves

• Mild soap/cleanser 

• Washcloth

• Lotion

• Comb 

• Electric razor

• Shampoo

• Bath tub 

• Rubber mat

• Shower chair 

• Grab bars (should be installed in the toilet)

Steps: 

• Prepare for the bath by ensuring the room and bath water is at a suitable temperature. Help the care recipient get in the tub by guiding him or her to hold on to the grab bars and assisting him or her as needed. Be careful as the care recipient may accidentally grab onto you and pull you down.

• Bathe the care recipient as necessary. 

• Finish the bath by helping him or her get out of the tub. 

• Empty the tub first, then guide him or her to use the grab bars to come out of the tub. Alternatively, have the care recipient stand up and sit on the shower chair. Get him or her to swing one leg over the edge of the tub, then the other leg, and help him or her stand up after that.   

• Place a towel on a chair or the toilet lid and have him or her sit there to dry off.

• See whether there are any parts of his or her skin which looks dry and apply lotion to the areas, before getting the care recipient dressed. 

Frequency: 

• As per above in bed bath – consider care recipient's individual needs

• Otherwise, two to three times a week is sufficient.

Nail care 

Check for irritation or infection while trimming nails or getting rid of dirt. Be aware that nails do thicken and get more difficult to trim with age. 

Materials needed: 

• Soap

• Basin of warm water

• Towel 

• Nail brush

• Scissors

• Nail clippers

• Nail file

• Lotion

Steps:

• Prepare for nail care by washing your hands, and washing the care recipient's hands with soap and water. Soak them in the basin of warm water for five minutes. 

• Perform nail care by scrubbing the nails with a nail brush to remove dirt. Dry the nails, and cut them straight across to prevent ingrown nails. File the edges of the nails

• Finish off by using lotion to massage his or her hands or feet.

ALSO READ: How to approach end-of-life planning for your loved ones

This article was first published in Homage.