NURSING HOME PATIENTS ARE GETTING YOUNGER – NO SURPRISE

The conversation around the conference table was familiar. Why are our patients getting younger and younger we asked each other?  I had heard this many times before, but this time it was different. The speaker, who was so questioning about what could possibly account for this, was herself only twenty-five. Kelly was concerned for her parents and grand-parents. She said she was regularly going home and telling her Dad, “We just had another patient come in today, who is so much younger than you are.” Why is this happening she asked, “aren’t these people supposed to be old?”

We talked about the fact that these people didn’t just have one diagnosis that brought them to the nursing home. No, they had led a life that led to multiple systems breaking down.

Proven life choices that keep the elder out of a nursing home:

  • exercising and maintaining an active lifestyle
  • getting enough sleep
  • spending time outdoors, enjoying sunlight and fresh air
  • having satisfying, close relationships
  • being a life long learner
  • minimizing stress in your life
  • being of service to others
  • having employment (or volunteer positions) that use your talents and skills
  • maintaining a spiritual life – remaining close to your faith
  • eating a balanced (a variety of foods) and nutritious (focused on vegetables/fruit/protein) diet

Yes, patients in the nursing home are getting younger and younger. At the same time nursing homes are getting better at providing all the therapies, social service counseling, diet counseling, etc., to help the elder turn around their health. So much better for Kelly’s dad to make these choices now, before he has fewer options.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

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

THE NURSING CARE PLAN

The Nursing Care Plan is what directs all of the care of the patient. In a nursing community, when a new patient arrives the care plan is started immediately. At first it might only be a rough outline of the challenges the patient faces. Maybe the patient has had recent surgery and has a wound that needs to be tended to. Or the patient might have been admitted due to a recent fall or injury.  The staff needs to immediately know about safety precautions and the amount of assistance the patient needs on admission.

Within hours of admission that preliminary care plan is replaced with a complete plan created by all facility departments. These individual care plans are developed after extensive assessments. Now the patient who has fallen has had; a complete plan written by physical therapy, occupational therapy and if needed speech therapy, as well as:

  • nursing care plans for safety, how much assistance the patient needs to walk, stand up from a chair, even turn in bed, if the patient has safety risks due to dementia what does the confused person need to be safe, nursing care plans for every medication the patient is on from diuretics to psychiatric medications, nursing care plans for the nursing assistants for basic care – if the patient wears upper and lower dentures, does the patient go to the bathroom independently or does he wear incontinent products, how much assistance does the patient need to dress, bathe etc. nursing care plans for every disease process the patient has such as diabetes, congestive heart failure, arthritis etc.
  • social service care plans are where you would find out if the patient is a smoker or not, information about the family, especially if there is a problematic relationship, information about mood especially if the patient suffers from depression, information about the language the patient best communicates in and social services will track information from all departments to determine a discharge date
  • activity care plans will tell staff what specific interests the patient has, if he is religious to make sure he doesn’t miss any religious services, does he like animals, gardening, art, music, live entertainment, all of those activities available in a nursing community
  • dietary care plans these plans range from what the patient likes to dislikes, dietary restrictions and dietary needs  as well as how independent the patient is in eating or drinking

At first the care plan reflects the immediate problems, then after complete assessment it includes all the information necessary to take care of a person. Then the staff begin the real work of getting to know the patient, many times through family interview. Knowing the patient was a night worker and might still in old age like to be up at night, or that the patient was in the military and likes things as well as himself very neat.

This very personal information turns nursing care plans into person-centered care plans, by far the best kind of plan of care.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

READING BETWEEN THE LINES, IS THE REAL STORY OF ALZHEIMER’S DISEASE

“Harvey died just before Thanksgiving,” his widow wrote, this is his story.

“Harvey showed signs of memory loss three or four years ago. Then after Christmas last year it got worse. In April he fell off our front step and all tests were negative, then it seemed to escalate. Through the summer the nights were really bad. Pills were not working. The month of August after what seemed like hundreds of phone calls we found a care center. Harvey had two good months there. Then one night he wanted to get up to go to the bathroom. Afterwards, the staff took him back to bed and he died in his sleep. What a blessing!”

One brief paragraph, nine short sentences, not really enough to tell the story of Harvey. But maybe it is, his story is like so many others.

Just a few years when the family identifies his memory loss?  We know he was struggling for longer than that. The time of mild cognitive impairment, when the person is mildly confused, yet functioning, can be many years. Years when the person doesn’t need any help dressing, bathing, eating, but might be having trouble remembering a word or an event. He could remember how to drive the car, and as long as his wife was giving him directions, they didn’t get lost. By having a routine to life and sticking to the routine, it makes it harder to see the changes, they just creep up on you.

The 3-4 years of memory problems she remembers, was most likely when his struggles were becoming more obvious. Especially if other people now noticed. Having a fall, any injury, infection, anything to change the normal routine tends to escalate the symptoms. And the person no longer bounces back to their previous level of function.

Pills were not working. No, medications for Alzheimer’s disease tend to only help for a period of time.

Nights were really bad. So many people caregiving for someone with Alzheimer’s disease come to that place where they are looking for a care center because the nights are bad.

But it wasn’t all bad. Between these few lines you know there were holidays and birthday celebrations. Grandchildren were born and many family get togethers were enjoyed by Harvey. The elderly couple enjoyed going to a movie, or out to eat. They were faithful members of their church, where Harvey was well known. He died at the age of 85, and only lived those last two months in a nursing home.  What a blessing!

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

THE ANGRY AND AGGRESSIVE CONFUSED ELDER

Many an angry confused old man goes to live in a nursing facility because the caregiver can no longer manage the aggressive behaviors. And in many cases the caregiver might even be frightened and concerned that they may get hurt. The elder who becomes physically aggressive, hostile and combative puts everyone including himself in harms way.

Sometimes the behavior follows a pattern and you can see the anger building until there is an act of aggression.  But for some the aggressive act comes suddenly, almost from nowhere.

Ed, was the suddenly aggressive type. Ed married late in life and he and his wife never had children. Ed became the favorite uncle to his nieces and nephew.  He was the one who tirelessly pushed them around the block on their bikes until they got the hang of balance, and could take off on their own. Yes, Ed was known as a very kind, thoughtful, and quiet man. Well, respected in his community.

Now he was confused, diagnosed with mid-stage Alzheimer’s Disease and living in a nursing community. The first thing the family did when Ed moved into the community, was to inform the nursing staff that Ed could become physically aggressive. They realized that when Ed was asked to do something he no longer could do, he would quickly become frustrated and then angry.

They told the staff that what worked very well with Ed was to use courtesy, say “please” when giving directions. Words that were inclusive worked well, “Walk with me to the dining room,” “Lets get dressed, its almost time for breakfast.” Using specific, concrete, and positive words, while avoiding negative words like “No,” or “Don’t.”

When a confused elder shows signs of getting annoyed, uncomfortable and uneasy in a situation, the caregiver can use humor. If the elder, like Ed, looks like he is struggling with putting his shirt on, turn the focus to the caregiver. Blame yourself. “Oh no, what did I do now, did I give you that shirt inside out?” Then laughing say you don’t know what you are doing, it is a crazy day.

Give the elder that gift of preserving their dignity, by not pointing out mistakes. Ed knows he is making mistakes, his day is full of them. And when he is frustrated and angry, he is really angry at himself.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing