8 TERRIBLE DAYS OF REHAB AT HOME – HE SHOULD OF GONE TO A SKILLED NURSING FACILITY

I ran into Shirley at the local grocery, and while we were only the most casual of acquaintances, Shirley clearly had a story to tell and wanted to talk.   Her husband George had just had a long over due, knee replacement. Planning for this surgery didn’t seem to include a plan for his recovery. The story Shirley had to tell was how the hospital personnel had let her down, coordinating George’s recovery. It seemed that the discharge planner had not fully informed George of his Medicare benefit, that would cover care in a nursing facility. Instead she urged him in the most aggressive terms, to recover at home.

Shirley said, this “hospital woman” talked to them for over an hour, and all she said about skilled nursing facilities, is that George would be in “great danger” of getting an infection. The hospital woman had many scary stories to share with the elderly couple. Stories, about how nursing home personnel had made mistakes and the horror of infection lurking everywhere.

So this fragile, elderly woman drove her husband home after discharge. Now instead of having young hands ready to help at the push of a button, it was only Shirley. She shared that what followed were eight days of arguing, yelling, pain, crying, and anxiousness. Yes, home therapy came, but that was only one hour a day. The rest of the time it was Shirley who was on duty.

George was very qualified under Medicare to go directly to a skilled nursing facility. The major Medicare qualifier, is that you have been admitted to a hospital for 3 days. If you go for an emergency and are only under “observation” that time does not apply to the 3 day rule. You must be admitted for 3 days. As well, the day you are discharged from the hospital, does not qualify as one of the 3 days.

Medicare provides 100 days of coverage in a skilled nursing facility.  Days 1 through 20 are at 100%, days 21 through 100 they pay $161 a day and your coinsurance picks up the balance. After day 101, Medicare no longer pays.  This coverage is for a semi-private (shared) room, includes nursing care, therapy, meals, activities, and all of your medical supplies.

Following those 8 difficult days, Shirley drove George to their local nursing home and he was admitted for 2 weeks. Shirley couldn’t say enough about how wonderful those weeks were. George loved the  meals, therapy, staff and other patients he met there. George is now happily gaining strength at home.  When fully recovered, George is now planning on volunteering at the nursing home, to keep in contact with those kind people who had helped him. And he also wants to give encouragement to the many other “Georges” he will meet.

I was more than sorry to realize that I didn’t know Shirley well enough for her to have called me, and ask about this surgery. We might have been casual acquaintances, but now after seeing this glimpse into Shirley and George’s life, this won’t happen again, we are now trusted friends.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

HOW THE NURSING HOME PREVENTS FALLS

Every year the average nursing home will have between 100 to 200 patient falls. The people who fall the most often are men, and patients who are confused. Men fall almost twice as often as women because they are less likely to call for assistance, because it is more difficult for them to admit needing help. Patients with Alzheimer’s disease or another form of dementia fall frequently, because they no longer have safety awareness.  Statistics tell us that 35% of those patients who fall are unable to walk, yet they try.

Most patient falls happen in the patient’s room, when the person is attempting something without assistance. Few falls happen in places like a dining room or at a nurses station where many staff members are available to monitor for unsafe behaviors. The majority of those falls in patient rooms have to do with needing to go to the bathroom. Being incontinent of urine, having diarrhea, and having to urinate frequently at night all contribute to the high number of falls.

Added risk factors are poor vision, going bare foot, clutter on the floor, poor lighting and possible a slippery/wet floor from the patient becoming incontinent. As well as the patient forgetting to reach for their cane or walker in their rush to the bathroom.

A nursing home fall prevention program includes assessing each and every patient for their fall risk. All of the above mentioned problems are identified. A plan of care is developed and all staff members are informed of the plan. Safety devices are put in place, most of those devices are in the form of alarms. A good web site for safety devices is -www.Rehabmart.com. Their site is very user friendly and they have a large selection of safety alarms.

Looking at the environment, follows the assessment. Are the grab bars placed correctly? If the patinet is getting out of bed, is the bed in a low position, with an alarm? Is the lighting adequate, are there motion sensors in place? Is the patient on a regular toileting schedule before bed? How often does the staff check on them during the night?

A big deterrent for falls is a busy, engaged patient, a patient who has activities to go to that they enjoy. A patient who is really tired when it is time for bed, that they enjoy a good nights sleep.

Virginia Garberding RN

Certified in Restorative Nursing and Gerontology

FALLS, SENIORS AND NURSING HOMES

Phil lives alone unless you count his dog, Clare. Phil now is seventy-three and most people would have considered him in better than average shape. He is not one for exercise but he always has watched what he eats, and was blessed with good genes. However, Phil made some very bad decisions.

It happened on a very nasty night in the Midwest. There was a ugly ice-sleet storm raging outside when Clare needed to go out. Phil did his usual thing at night he took Clare out into the backyard. Too bad his usual thing was to walk Clare in his underwear. So when Phil fell, he was too embarrassed to call out to his neighbors for help.  So there he lay with an injured leg, shoulder and arm, out there on the ice.

Because Phil didn’t want to call for help it took him two and a half hours in the cold, on the ice, to pull himself to his back door and drag himself in.   This experience caused Phil to be hospitalized for five days and is now in a nursing home due to the pneumonia that set in while hospitalized.

What seniors can do to protect against falls:

  • if you live alone (and are even if in very good condition like Phil) wear an alert button
  • think ahead, make good decisions and be proactive – is it really a good idea in any weather to be outside in your underwear
  • prepare for the weather – when in snow, ice, sleet – carry a small bag of salt, sand or gravel to throw out in front of yourself as you walk
  • for those who have to go out in all weather – consider rubber ice cleats that easily attach to the bottom of any shoe or boot – they are easy to put on and off and very in expensive

It really didn’t seem like it would be Phil who would be in a nursing home, at least not until a very old age. Bad weather got him there, and a fall, but more than that it was bad choices.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

GRANDMA CAN’T FIND THE BATHROOM – WHEN THE ELDER IS INCONTINENT

Grandma Lucy always has a big smile on her face. She is already in the late stage of Alzheimer’s disease. Grandma no longer talks or seems to understand what others are saying to her. She now needs total assistance bathing, dressing and eating.  Yet, Grandma Lucy can still walk and while she cannot go through the many steps of dressing. Once dressed she is able to pull down her slacks, as well as  incontinent brief, and then go to the bathroom.

The problem arises because Grandma no longer can identify the correct place to toilet. When she feels the urge to go to the bathroom, any flat surface she can sit on, will do. She no longer plans or anticipates that she will be needing a bathroom. In the moment when she feels the urge, she answers the call in a public place, secret place, anywhere she finds an opportunity to sit.

Missing the toilet, and using either another object such as a waste basket, or a flat surface such as a chair, sofa, or recliner is common, in a dementia unit, in a nursing home setting. Especially common, for those elderly who continue to be able to walk independently. Grandma Lucy always was a great walker, and has continued to be able to walk, even though now she walks without a destination. She just appears to be wandering as she keeps retracing her steps, all day long.

But contrary to the many who are no longer this active, she has no problems with constipation. On the contrary, Grandma is as regular as clock work. And this fact provides the solution for Grandma’s problem.

When a confused elder like Grandma Lucy can’t plan or anticipate needing to use a toilet, the caregiver needs to provide this service. Her caregiver knows that Grandma Lucy has a bowel movement everyday, about a half hour after breakfast.  As many people know, having a cup of hot coffee in the morning, and chewing breakfast, stimulates the colon and bowel.

Now the caregiver keeps a close eye on Grandma Lucy after breakfast, and right on time walks her to the bathroom. Grandma Lucy is now greeted with smiles and welcome during her wanderings instead of looks of suspicion.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

TIME TO COME HOME – GREAT GERMAN COMMERCIAL – ALONE AT CHRISTMAS

The story begins with the senior in his home, which is beautifully decorated for Christmas. He starts to receive the bad news from his children that they won’t be making it home, this Christmas. They appear to be spread all over the world, these high achieving children.  Promises are made that they definitely will be there with him the next Christmas.

There he sits eating a meal alone, at his large family dining room table, next to his decorated tree. Then the children all seem to be receiving a stunning message. Tears flow, grief is written on their faces as they all make a dash for transportation. They arrive together for what they clearly think is a funeral.

Upon entering the family home they see the table set for a holiday dinner. Walking out of the kitchen is their old Dad, saying “How else could I get you here?”

Compared to many commercials now airing, where you end up scratching your head, thinking what was that even about? This one from a German grocery chain couldn’t be more clear. Decorating is good, the meal even nicer, but holidays are about showing up.

This commercial is certainly worth taking a look at, during this hectic holiday season. So many people are alone during the holidays. If you don’t have someone in your immediate vicinity, go to your local nursing home. Many people are in the nursing home because they are alone and have lost their loved ones.

What a wonderful message, whether for a senior, a child, the lonely, anyone in need, just show up.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

KINDNESS AND BENEVOLENCE IN THE NURSING HOME

There they sat in their usual places next to the nurses station, in the nursing home. The two of them, good friends, enjoying a warm and deep conversation. Just the way all, old friends enjoy doing. They were deep in discussion about other residents of the home. One by one, they went through the list of people living on their floor.

Talking about Barbie who is so cheerful even though she has had MS now for many years. The friends talk about how sad they feel for her, how hard her life is, how hard it must be for those young nursing assistants to take care of her.

They talk about Lillian who isn’t so cheerful, and even though Lillian has said many a harsh comment to these two old friends. All they can say about her is that she must have had a hard time, something must have happened to her to make her so grumpy. They express as much sympathy for Lillian as they do for the so cheerful and nice Barbie.

And so they go on, talking about each elderly neighbor of theirs in this nursing community. As they talk, what you hear is genuine caring for their neighbors. A total lack of judgement on their part for either difficult personalities or for behaviors that most likely caused the declines in health. Like the parade of neighbors constantly making trips outside to smoke. No judgement here.

When they give kind words of encouragement to others, they don’t expect anything back. They have taken the time to get to know their neighbors families, so they can brighten people’s days by mentioning how smart or cute someone’s grand-kids are. When a neighbor gets bad news, they cry with them as though it is their bad news.

They are the true meaning of benevolence, they live it. What makes it so much more surprising is that one of the friends is only 57 years, living in the nursing home because she has end stage renal disease. She never married, has only one brother living who never comes to visit. She is living on medicaid, clips coupons, goes to dialysis, and looks forward to trips to Walmart.

The other friend keeps waiting for the day when her daughter will arrive to move her to a nursing home closer to her family. She is a very fragile 87 year old, living with the hope that her family will come and get her.

Benevolence – when there is nothing in it for you. So surprising, how much people with nothing can give and continue to be benevolent.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DENTAL CARE FOR THE CONFUSED ELDERLY – THE KEY TO PREVENTING INFECTIONS

Once again the flu and cold season is rolling around. Not only at your local drug store will the pressure be on to get a flu shot, but all of those people in nursing homes will be vaccinated as well.  While try as they will, the pharmaceutical companies cannot get those significant numbers that prove that vaccines prevent flu. However the proof is easy to obtain that regular brushing of teeth, can prevent infections.

I was recently told by a speech therapist that a Japanese study proved that dental hygiene was twice as effective against pneumonia than medical intervention including antibiotics.

When teeth are not brushed regularly, a slime starts to develop on the teeth and gums. I have heard it compared to the slime that collects on the water in a vase, once the flowers have passed their prime. Poor dental care is one of the most upsetting situations for the family visiting in the nursing home. When Mom or Grandma is unkempt, smells of urine or has dirty teeth and nasty breath, she just doesn’t seem like Grandma.

Many times for the elder in a nursing home, they have medications that impact on their dental hygiene. The medications may cause excessive saliva or dry mouth, either condition impacts the ability to keep teeth clean. There are several products available for dry mouth and dry lips, Biotin works well.

For the elder with excessive secretions using a suction machine with an adaptive tooth brush attachment prevents the build-up of secretions at the back of the throat. The brush can have a small smear of tooth paste or be dipped in mouth wash or Biotin. This works well with the elder who is no longer able to clear and spit secretions independently, or is unable to follow directions from the caregiver to do so.

For the confused elder I always recommend a children’s toothbrush. The smaller size is less invasive in the elder’s mouth. When the elder is no longer able to rinse and spit, the use of a children’s toothpaste is also recommended. These are made for someone who will most likely swallow the paste. By far the usual favorite is grape flavored toothpaste over the minty ones used by adults.

The most important thing is to just get started. Being accustomed to the feel of a toothbrush, as well as the feeling of clean teeth should never be allowed to be forgotten.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

THE NURSING HOME – WHY THE FAMILY IS AN IMPORTANT PART OF THE TEAM?

PART III

(Four things to notice when visiting an elder in a nursing home, cont.)

2. Observe the elder’s skin. Skin is the largest organ of the body. In the average person, the skin stretches about two square yards and is about 15 percent of the individual’s weight. We consider the skin the first line of defense against environmental factors. Skin is also a barometer of health. We want to be aware of any redness, warmth, or swelling. It is perfectly appropriate for family members to ask the nurse or nursing assistant “Does Mom have any skin breakdown?”

When elder sit for hours in a wheelchair or are unable to move themselves independently, they may be at risk for skin to break down because of decreased circulation. Nursing homes may provide special pressure-relieving mattresses to prevent skin breakdown. A special pressure-relieving gel cushion is an excellent aid for wheelchair-bound elders.

3. Report any significant change. The rule of thumb is that a dramatic change in any body system must be reported to the physician immediately. This includes an abrupt change in:

  • Behavior
  • Difficulty arousing the elder
  • High fever
  • Dizziness or unsteadiness
  • Sight or hearing
  • Ability to communicate or speech pattern
  • Personality
  • Eating
  • Difficulty swallowing
  • Weakness or decreased use of an extremity

Book excerpt from: Please get to Know Me – Aging with Dignity and Relevance Available on Amazon.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing

THE NURSING HOME – WHY IS THE FAMILY AN IMPORTANT PART OF THE TEAM?

PART II

When a family member or friend is visiting the elder in the Nursing Home, here are four things to look for:

1. Be aware of the elder’s pain. Pain is the most underreported problem in nursing communities. This applies to the general nursing home population and even more so for those with dementia. Sometimes the elders can’t express their pain in words, so those who know them need to be alert and able to read their body language. Signs of pain in elders with dementia may be increased restlessness.

Elders with chronic pain should have routine orders for pain medication. Orders for pain medication written “as needed” are not appropriate for chronic pain. When the order is “as needed” for someone with arthritis, that means we have to rely on the nursing assistant to notice that when they bend the elder’s knees and observe a grimace, or the joint may be swollen or warm to the touch, the elder is hurting.

When elders suffer from any kind of chronic pain they don’t sleep well. Fatigue is another symptom. Or they may not eat well or start to withdraw. A nursing assistant is there to assist, and it lays a heavy responsibility on them – for which they’re not trained – to observe and communicate pain accurately to the nurse.

This is when the family can be of tremendous help and support to the staff. When the family members observe signs of pain, they can communicate effectively by stating the behavior, area of the body, and provide any history the nurses need.

I noticed that Mom is rubbing her knees,” a daughter might say. “She has had problems with arthritis in the past and it must be bothering her again.” The daughter might have said that after spending hours with her mother. Nurses saw her mother only at brief intervals.

Book excerpt: Please Get to Know Me – Aging with Dignity and Relevance available at Amazon.

Virginia Garberding RN
Certified in Gerontology and Restorative Nursing

THE NURSING HOME – WHY IS THE FAMILY AN IMPORTANT PART OF THE TEAM?

PART I

In a Nursing Home, family members aren’t always the recognized authorities on their loved one’s condition. Yet, they are an invaluable resource for the nursing staff. Family and friends have the one-on-one time, usually for hours, that the facility isn’t able to provide. The best time for the staff to catch a change in condition is when they assist an elder to get up for the day or help her get into bed.

However, that is when problems occur because the staff member may:

  • Not be the usual caregiver
  • Be a caregiver who’s not perceptive
  • Be the caregiver who sees a change but assumes that “everyone already knows”
  • Be someone with poor communication skills
  • Be a new nursing assistant or one with little experience

Such a situation places responsibility on the front-line workers who have the least amount of education. Such workers may think of their job primarily in terms of the tasks they have to accomplish. When asked specific questions, they usually have the answers, but didn’t realize they needed to pass the information on to the nurse.
That isn’t an uncommon problem, and questions naturally arise. For what should the family watch and listen? What is the most effective way to communicate the observation without seeming confrontational or judgmental?

Book excerpt: Please Get to Know Me – Aging with Dignity and Relevance available on line at Amazon

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing