Preventing Abuse in Care Homes

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 3 - Approximate time required: 180 min. 

Educational Goal:

To provide Adult Foster Care providers with information and resources that will help them with the stress of caregiving to prevent patient abuse.

Educational Objectives:

1. Realize that any caregiver can be pushed into abusive behaviors.
2. Learn about caregiver burn out.
3. Discuss how emotional health is important in avoiding patient abuse.
4. List interventions that prevent caregiver abusive behaviors.
5. Explore aspects of chemical restraints.
6. Define neglect.

Procedure:           

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

Disclaimer      

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Preventing Abuse in Care Homes

   Anyone who has worked in a care home knows that it is the most difficult and stressful “easy” job they’ve ever held. The job doesn’t require a college degree, there’s no heavy labor involved, and what could be easier than working by just doing the normal activities of daily living? Then why do you feel so stressed, stretched, and strangled – often to the point of going crazy? When caregivers are pushed too far for too long, it’s easy for them to snap, and patient abuse can follow. It’s just like an irritating spider bite. You know you’re not supposed to scratch it, but you do it anyway just for a moment of temporary relief.  This continuing education article provides a numbing balm to combat the urge to scratch and some ideas on how to not get critter bitten in the first place.

Special note to all caregivers:

Many times preventing patient abuse focuses on the actions of caregivers after the abuse has occurred, taking into consideration little of what led up to the event - punishment instead of prevention. I’ve been there, or my employees have been under that uncomfortable microscope of attention. Not much learning occurs, just a lot of anguish. This course is written from your perspective BEFORE the fact in hopes that you will be able to avoid the problem in the first place. This is a serious matter, but I write this course with a lighter touch to make it more entertaining and easier to read. If some of the topics hit a little too close for comfort, just remember this is training to prevent future occurrences. We are here for you and hope you and your residents benefit from taking this course.

Prevention

No one gets up in the morning and says to themselves, “I’m going to get that ‘onery cuss that’s been making my life miserable, then I’m going to start laying it thick on everyone else for good measure.”  We do have our bad days, but for the most part, each day is a fresh start. It is the bad events of the day that pile up and push us over the edge. The more we control those events, the more likely no abuse will occur that day.

Stress Relief

Caregiver stress is a common but complex cause of abusive behaviors that is not fully understood. The labor, demands, and conditions on one day might put you on the edge of bursting while other days the same conditions can be managed without stress. It’s hard to know how one day’s reaction differs from another. In my opinion, stress can be defined as an emotional response to environmental conditions that trigger the physical reactions of the body’s flight-or-fight response. Adrenaline and other hormones start to flow, and the body is hyped up, ready to jump at anything. That means that stress occurs not from the burdens we shoulder, but when we feel threatened by those burdens.  Again in my opinion, managing stress is more about controlling our reactions to the occurrences swirling around us so that we don’t feel threatened.  Of course, that is easier said than done. Here are some ideas that might help.

• Realistic expectations for outcomes - We don’t live in a perfect world so you and those around you shouldn’t have to be perfect either, especially your clients. I like to apply the 90-day test. Ask yourself who is going to care about this event in 90 days. If the honest answer is no one, then the stress level should go down considerably even if things don’t turn out the way you expected or people don’t act the way you want them to.  In short, most of the time it just doesn’t matter.
• Burden reduction through proper planning and scheduling - Chaos breeds uncertainty, which leads to stress. Take time to plan your activities, even if it is a to-do list. Establish a set schedule of daily activities.
• Relaxation techniques - Combat the fight-or-flight hormone response through self-guided relaxation. Close your eyes. Breathe normally through your nose. As you exhale, silently say to yourself a relaxation word or phrase the mind can focus on, for example “be at peace” or “I want to be calm.” Continue for several minutes. Another technique is to take slow deep breaths while building a relaxing scene in your mind.
• Keep a journal - Writing down information about stressful times will help you mentally organize yourself to fight against stress. Record things such as: What is causing your stress (make a guess if you’re unsure)? How did you feel, both physically and emotionally? What was your response to the stress? What did you do to make yourself feel better? Writing things down forces you to think through the events of the day. It helps reflect on what is really happing and what the outcomes of those action where.
• Physical activity - During stress, your body is all hyped up, ready for action. Don’t bottle up or deny that response. Over the long run that can do harm. What is more helpful is to channel the pent-up excess into actions. Physical activity will bleed off the fight-or-flight response to stress hormones and make you feel better. Gardening or taking a walk are great and are my favorite activities for stress relief. If you take a resident for a walk, you will feel less guilty for taking time away from your caregiving duties.
• Connect with people. Humans are social, and communicating with others makes you feel safer, more in control, and less stressed. We are hard wired to feel more secure in a group. That’s how we are built.  Your friends don’t have to fix the problems you talk about - they just have to listen. Tell your friends you just need a friendly ear to talk into to de-stress your life. There are a number of caregiver chat groups online that you can plug into that are quite therapeutic.

Burnout

One of the hidden dangers of in-home caregiving is that you’re constantly on duty, making foster care providers more susceptible to caregiver burnout. Caregiver burnout is a well-documented source of patient abuse that comes from the physical, emotional, and mental exhaustion of caregiving. You have to deliberately take action to control burnout or burnout will take control of your actions.

The remedies for caregiver burnout are easy to understand and implement if you realize that it is all a matter of balancing everyone’s needs, including your own.  If this still isn’t clear, then think of the image of trying to run a car that is low on gas. You wouldn’t drive the car until the gas gauge reads empty, would you? Of course not. So you have to ask yourself, how do I refill my personal tank?

 Here are some ideas:

• Keep healthy - refocus on health habits
  • Proper nutrition (No snacking your way through stress.)
  • Plenty of exercise (Didn’t I mention the walking thing?)
  • Plenty of sleep (No unwinding with computer games until the wee hours of the night.)
  • Eliminate bad addictions like smoking, alcohol, and pornography. (They’re just crutches that do more harm than good.)
• Get help - Learn that you can’t do it all, all the time
  • Hire some help, even if it’s just a temporary maid service.
  • Encourage family members of the residents to take them out more often
  • Change around the work schedule of existing employees or rotate the duties performed by everyone. If you’re the employee, ask for the change.
  • Learn to say no more often, which is just another way of saying, “I need your help - you do it for me.” Saying no allows you to say a better quality yes later on.
  • Assign duties to residents. Everyone likes to feel useful.
  • Utilize technology to be more efficient. A few examples are: a high-capacity washer and drier, webcams that allow you to monitor different parts of the home, mobility monitors that alert you if a wandering resident slips away (they strap to the wrist or ankle), a high-quality or robotic vacuum, time-saving kitchen gadgets, and a pill-counting tray.
• Be more organized
  • Chore list plan
  • Menu plan that is tied to an inventory system that also ties into a shopping system
  • Create a computer file system of recordkeeping. (If you need a resident med list, all you need is to push print.)
  • Hire a bookkeeper or invest in a bookkeeping program.
• Divert yourself - All work and no play… well you know the rest.

Caregivers can always recharge themselves with activities like puzzles, computer games, listening to music (my favorite), gardening, and hobbies. Start the day with a relaxing ritual like reading the scriptures or journal writing. Be creative (a very powerful antidote to burnout).

• Spiritual health - Paying attention to spiritual matters really does make you a better caregiver and fights caregiver burnout and all its negative aspects. It reinforces virtuous thoughts, supports the service aspects of caregiving, helps you have a positive attitude, dissuades negative actions, and gives you the social support that is so needed in the isolated world of in-home caregiving. You might think it too difficult, too burdensome to really doing anything “Churchy.” I’m here to tell you it’s doable, and you’ll get more than you give. Here’s a few things that my wife and I did to be “Churchy.”
  • Hire relief help so you can go to church.
  • Watch church services on TV.
  • Read the scriptures and religious books.
  • Visit church-oriented websites.
  • Go to church activities.
  • Volunteer for church assignments.

Emotional Health

As a 24-hour-7-day-a-week caregiver, often we give too much of ourselves. After a long stretch of “on-duty all the time” all the vitality in your life seems to drain away. Everything becomes a chore. You focus on the drudgery of your duties and not the joys. You come to despise those who take from you even if it’s just taking your time and attention. Soon, negative emotions dominate your thinking. Believe me when I say, “I’ve been there.” To combat this downward spiral that will inevitably lead to caregiver burnout and patient abuse, you have to focus on yourself. For some that is hard to do. There always seems to be someone who needs your attention.   Fortunately there is a simple solution - budget time for yourself. Purposely schedule “me” time.  Make it part of the daily, weekly, and monthly routine. During this “Me” time, try doing a variety of activities that you like to do. Don’t get stuck in a rut, like playing computer games all the time (been there, too). If you don’t vary your personal enrichment activities, they will start to lose their desired emotional health effect.

Here are a few suggestions:

• Exercise all your senses. Listen to good music while enjoying a hot drink and looking at a picture book. If you think that you can’t afford all that stuff, you have forgotten that most of it can be obtained for free at the local library. The public library is one of the caregiver’s best friends. If it’s a small library, they can always get materials from larger libraries through interlibrary loans.
• Engage in a creative hobby. That includes playing a musical instrument, cooking, gardening, sewing, and knitting. You really don’t have to be good at it. The purpose is just to be mentally creative.
• Get a collection of quick diversions, for example puzzles, word search books, solitaire cards.
• Get a pet. I know that this can be problematic for a care home. But studies have shown there are multiple benefits in owning a pet. Even state prisons have pet programs. If such a restricted controlled environment institution like prison can figure how to do it, so can you.
• Write in a journal. The act of thinking about what to write that others might read can be quite mentally relaxing. It can really help you mentally work through the trials of the day.
• Do things that positively affect others. Helpful service outside of work goes a long way in helping your self-esteem.
• Take walks or other repetitive physical exercises that don’t require any mental energy.

You may have  noticed I have repeated myself a lot with different remedies. I’m not trying to make this course longer but rather show you that many of the mentioned activities are helpful to a caregiver on several different levels. These activities can really work. They will help you be a better caregiver and avoid patient-abuse-causing circumstances. Try them and see how more in control and less stressed they can make you feel.

Intervention

In my experience, despite the caregiver’s best efforts, things can escalate to the very brink of abusive behaviors on any day of the week. Again, it’s not because the caregiver plans on it. Sometimes bad things just pile up. Let’s just call it a bad mojo day. Nonetheless, no one is justified in abusing another person. When everything is going bad that’s when you need to dig deep and act professionally. I hope the following training helps you weather the storm. I recommend that you read this over and over so that when push comes to shove, your training and professionalism will intervene automatically before anything worse happens. If all else fails, it’s better to get a replacement caregiver and walk away to take a breather. Keep walking until you got yourself under control. (I remember taking several Looong walks in my caregiving days.)

Anger Management

Anger is often associated with resident abuse, yet feeling angry is not the root of the problem. The emotion of anger is a normal, even healthy response to mistreatment or occasions when you’ve been wronged. It can even be a very motivating, useful tool to accomplish great things. The feeling isn’t the problem; it’s the actions that cause harm to others that’s the problem. The following are some interventions that may help.

• Reflection - Try reflecting on what you automatically do when you get angry. Look at it from an action-by-action process.

For example: I get angry, I feel agitated, I start to yell, I react badly to any responses to my yelling, I want everyone to agree with me. Now. I start to grab or shake to emphasize points that I am trying to make etc.

When anger is analyzed in this way, you start to see where intervention is needed to side track abusive responses to bad situations. This only works if you’re honest and humble with yourself.

• Interrupt the Cycle - Once you have identified your anger pattern, here are a few ideas that can disrupt your anger cycle.
  • Yell in your thoughts - STOP, STOP, STOP.
  • Count to 20- Diverting your concentration on a simple mind task really does work.
  • Breathe deeply or use other relaxation techniques.
  • Focus on a positive image. (Chocolate cake and vanilla ice cream works for me.)

• Professionalism Check - When you’re angry, it is easy to get caught up in the argument of the moment. It turns into a contest of who’s right and who’s wrong. When that happens, you have placed yourself on the resident’s level. But you are not a resident. You are the care provider and they are the cared for. You will always have the duty of being the servant to the needs of the residents. Yet for the residents’ own good, you are also the medical supervisor of the house. Keep those duties straight in your head and you will never lower yourself into a willpower contest that you feel a need to win.
• Act not React - Anger that leads to abuse is often an un-thought- out “knee jerk response” to a negative event. Here are a few ideas to help think your way out of anger.
  • Use empathy - Place yourself in the other person’s shoes.
  • Look at the situation from the outside, like a “fly on the wall.”
  • Think of a compliment, what is good about the other person.
  • Think how can you get what you want without the use of anger.
• Don’t believe the anger myths. There is a lot of misinformation that just isn’t true no matter how popular the belief is. The following are some myths about anger.
  • Venting rage releases anger emotions. Research shows that letting anger control your emotion actually escalates the emotion not reduce it.
  • I’m just built hotheaded, and there’s nothing I can do about it. While it is true that there are genetic factors involved in how easily a person gets angry, it is not true that there is nothing you can do about it. Feeling anger may be automatic, but acting on anger is always a choice. If you are someone who is genetically easily angered, that just means you have to work harder to control it.
  • Anger is all in your head. Anger emotions actually trigger the fight-or-flight responses in the body. You can better control anger if you purposely learn to relax your body.
  • Anger is the same thing as aggression. While anger is a normal reaction, aggressive behavior is not. Aggression is a learned behavior that must unlearned to prevent abuse.
  • You must get angry to get what you want. The truth is you must think to get what you want.
  • Other things or people make you angry. The truth is that things or people are triggers not causes. You can learn new responses to anger triggers.

Communication Management

”Words are singularly the most powerful force available to humanity. We can choose to use this force constructively with words of encouragement, or destructively using words of despair. Words have energy and power with the ability to help, to heal, to hinder, to hurt, to harm, to humiliate and to humble.” Yehuda Berg

Communication is the tool that we use the most often in caregiving. We give instructions, question and listen, sooth, and comfort the patient. Properly used, the tool of communication can be the difference between proper caregiving and abusive caregiving. Poor communications most assuredly lead to troubles.  Here are a few ideas that will help you interact with your residents in ways that avoid abuse.

Effective Communication Methods

Effective communication goes a long way in caring for residents without any conflicts, and it involves more than just talking to give orders. It is a two-way effort to give and receive.

• Effective technique - Some caregivers communicate better than others because they use and practice the following:
• Ask open-ended questions: Stating questions that require the resident to explain what they are thinking. Examples: “"How does this medicine make you feel?" NOT: "Do you feel nauseated when you take the medicine?"
• Reflecting back: Make comments that convey understanding. Examples: “After listening to you, I can understand why you’re so painful today.” Not “Let’s get going. I’ve got others to take care of.”
• Sum up what is being said: Examples: “So, you don’t want to eat breakfast because you’re feeling nauseated this morning?” If I understand you right you said . . .”
• Non-verbal Communication-

We continuously give and receive wordless communication from our body and facial actions, which often speak louder than the caregiver does. Body language has often been called the true message because our actions come from how we are feeling at the moment. In most cases, the hearer disregards the verbal message and goes with the non-verbal message instead. To control non-verbal signals, the caregiver must pay attention to what they are feeling during potentially abusive situations. Staying in control and professionally distant from the situation can go a long way in non-verbally communicating properly.

The astute caregiver can also read the resident’s non-verbal communication. It is a way to see past the grouchy words and figure out what the resident is actually trying to say.

I remember a time when an elderly gentleman was acting very ‘onery and pushing all of my wrong buttons. I saw past the verbal abuse he was dishing out and noticed that he had been bumping into things and acting confused. I picked up on the clues and looked straight into his eyes and noticed that one pupil was bigger than the other. I realized he wasn’t being abusive. He was in the middle of having a stroke.

• Active listening - Active listeners not only hear the residents’ words but understand the complete message being sent, including the non-verbal clues being communicated. Those who are not actively listening spend most of their efforts tuning out the speaker and jumping ahead to plan out their own responses to dominate the conversation. Caregivers can direct a conversation, but trying to dominate one can easily lead to abuse.

      Elements of active listening

• Give undivided attention: Acknowledge the message, look directly at the speaker, put aside distracting thoughts and activities. Do not mentally prepare a response or pay attention to outside distractions such as other conversations or future tasks.
• Show that you are listening: Rephrase what is said back to the resident. Use nonverbal (body language) cues like nodding occasionally, smiling, or other facial expressions to convey attention. Adjust your posture to convey an interest. Do not

use "negative" facial cues, such as eye-rolling, yawning, or  fidgeting with things like cleaning tools or folding laundry. Provide verbal and nonverbal feedback: Give occasional indications that you understand what is being said by saying “I understand” or rephrasing the core of what is being said. Ask questions liberally or ask for the resident to clarify the comment. Do not interrupt or go off topic. 

• Avoid being judgmental: Understand that the resident is speaking from their own point of view not yours. Most residents come from a completely different background and culture with its own rules of right and wrong. Do not present counter arguments while the resident is speaking. Do not cast blame. Example, “I can’t believe you just said (or did) that.”
• Respond appropriately: Treat the resident like an adult or person of respect and affection. Be candid, open, and honest. Assert opinions and instructions thoroughly. Do not overstate your response. Do not belittle, demand, shout, or use other abusive behaviors.

Special cases 

There are times when the normal rules of communication go out the window. These are the times that can really stress the caregiver and easily lead to abusive behaviors. By using a few simple techniques, the care provider can successfully navigate through these dangerous waters. Think of these techniques as caregiver tools in your mental equipment box to be pulled out when facing a tough situation.

• Empathy - Be able to place yourself in the resident’s shoes. Knowing what motivates them and their fears can make all the difference in stressful situations
• Alter communication to fit the patient’s reality - The resident may not have the ability to see things as they really are or adjust to new situations. Caregivers need to bridge the gap between the resident’s world and the real world. This may be a temporary occurrence or a progression of a disease.
• Make allowances for physical and mental handicaps - When you live with a resident, it is easy to forget that they are not normal- functioning humans. They are in the home because they can’t take care of themselves. It is unrealistic to expect them to communicate normally all the times.
• Do not take things personally - Professional caregivers are able to separate their personal feelings from caregiving moments. It’s like standing behind a shield where negative words and emotions can’t penetrate.
• Know when to walk away (even if it’s just for a little while). One of the advantages of foster care is the flexibility in duties. Except for emergency situations, you always have the option to face an event later when things have calmed down.
• Letting the resident feel like they won - Saying one thing and doing another is all part of in-home caregiving. If a resident (who has given up so many things in their life) feels in control, they will be much more cooperative when action needs to be taken. So do the action in a way that gives them some control, even if it’s just a portion of it.
• Appeal to authority - Discover who the resident respects (a doctor or a family member) then tell them that the person would want them to act in a proper way. Don’t over use this tool or it will lose its effectiveness.
• Shift the focus - Distract the resident’s focus away from the stressful situation. A favorite of mine is an ice cream treat or a favorite TV show.
• Control your body language - Do not convey anger through body language (squared shoulders, hands on hips, finger shaking). It’s very hard not to have a confrontation when your body is arguing with the resident.
• Patience - In most cases, you have all day to get things done. Take the time required to handle special situations. If one tool doesn’t work, try another and another and another.

Communicating with Dementia Residents

Dementia is a particularly hard case for foster care providers. If handled incorrectly, it’s a situation where abuse is just waiting to happen. The most important thing I can convey is that, by definition, dementia sufferers have physically lost the capacity to think and act normally. Why do caregivers expect them to communicate normally when they can’t? It is up to the caregiver to adjust to the dementia patient, not the other way around. For example, if the dementia resident says the sky is red, you say, “What a lovely shade that is. It’s making everything look just rosy.” As long as the resident is calm and cooperative, who cares if they think the sky is red. If you try to make them realize the sky is blue, it will just lead to a stressful danger zone. Use all of the tools mentioned above, apply a generous amount of patience, and try to control the situation by means other than direct confrontation. Direct confrontation is the quick path to dementia patient abuse.

Communicating with Abusive Residents

It is a sad fact that abuse by caregiver is frequently triggered by resident aggression. Violence and abuse go both ways far too often. It is a normal human behavior to protect oneself from abuse. But unlike other relationships, caregivers don’t get to justify their abusive reactions by saying, “Well he started it, I was just finishing it.” Caregivers have to find ways to control their normal tendencies and maintain control when the resident is abusive to them. Here are a few caregiver tools to add to your mental tool box that might be helpful with an abusive resident.

• Be prepared - Abusive residents show patterns of behavior that can be predictable. They are trying to take control of you through their abuse. Do not become reactionary. That’s what they want. Maintain your professional composure and ignore their attempts.
• Allow resident to vent frustrations - Your residents have given up so much and lost some of their physical ability to cope. It is easy to understand how a resident’s frustration can build up when so many things have gone against them. Make allowance for frustration venting. Once it’s over, show understanding kindness to let them know you’re on their side. The effort will pay off big dividends of future cooperation.
• Remove triggers - View the situation from the stand point that no one really wants to be mad. Something triggered the combative behavior. Figure out what wrong button was pushed and eliminate it so that the resident can return to a calm state. Look for things like a loud TV, too much commotion, physical ailments, environmental conditions (too hot, too cold). Sometime just taking them to a familiar place like a bedroom or a quiet porch is all that is required to get them calm again. If the caregiver is the trigger, remove yourself and adjust circumstances and schedules temporarily. Sometimes just getting the resident by themselves is enough to regain control.
• Control by example - Do not escalate the abusive behavior by feeding into it. If you mirror the bad behavior, they are in control, not you. By remaining calm and collected you are showing by example the behavior that is expected of the residents.
• Get help - It’s harder to maintain abuse behavior if reinforcement arrives when trouble starts. Also more help equals less stress. Many times just having extra witnesses on the scene is enough to curb bad behaviors from the resident and the caregiver. Bosses, owners, and supervisors must be responsive to calls for help. I know at times it can be a real hassle, but dealing with the aftermath of abuse is even more of a hassle.
• Shift focus - Divert attention from the abusive situation. Know what the resident likes and be quick to offer an attention-getting bribe. A walk is a wonderful attention getter. It also has the benefit of bleeding off the resident’s tension and stress. Start talking about unrelated subjects as if the abuse behaviors are not occurring. Form questions that they have to answer. The longer the response the better at diverting the attention away from the abusive behavior. For example, “I’m getting kind of tired of the meals we have been having. I’m running out of ideas. What foods have you had in the past that you have really liked? (residents answer) Describe it to me so that I can see if we have the ingredients to make it.”
• Enforce appropriate limitations and non-abusive consequences - The resident’s safety and health are the caregiver’s prime concern. It is a caregiving priority that that those concerns are never compromised by even the resident themselves. Consequences for crossing the safety boundaries have to be minimalistic and preventative, not a punishment. For example, I was helping a male resident who started swinging his cane in anger. I grabbed the cane with both hands and twisted it until he lost his grip. I put the cane out of his reach until he calmed down - preventative and minimalistic. I made sure he understood why I took the cane and that he would get it back. I did not talk in an angry tone, and I used nonchalant body language that said this is what happens when you try to hurt someone.  He got the message and eventually calmed down after I left the room.

A Couple of Words about Chemical Restraints

If you complain to a doctor and to a lesser extent a home health nurse, most likely you’re going to get a prn prescription that is designed to chemically control a resident’s behavior. In reality, that’s all a doctor can really do to help. Unfortunately, that doesn’t make the problem go away. For most cases, mood-altering drugs are just a bandage. If you as a caregiver rely on these drugs to solve your behavioral problems, you are using a caregiver crutch. They will temporarily help, but they will inhibit you from developing more expert caregiving skills. The more you rely on them solely to solve your behavioral problems, the more your residents turn into zoned-out chemical zombies. At some point, that becomes abuse itself.  Speaking as a caregiver and a pharmacist, these drugs are just a tool, not a cure. Add them to the rest of your tool chest and use them with skill, along with the rest of your tools.

When using prn chemical restraints, remember the following:

• Chart everything in the MARs to keep yourself out of trouble. It will also help you see patterns over time that will give you and the doctor important clues and insights.
• Drugs come with side effects. Some are more problem creating than problem solving. Pay attention to everything that occurs after you dispense the med, even days or weeks after you start therapy. Here’s an example. I was taking care of an elderly resident who was having hallucinations that were causing problems. The doctor prescribed resperidol, which helped control the hallucinations but it made him grouchier and even violent. (This is the cane guy I mentioned earlier.) We switched the offending drug for other meds and caregiving techniques, and both problems went away.
• There are always alternatives. Keep the doctor informed of the effects of the drugs. If it doesn’t work or causes more problems, let the doctor know. If they don’t hear from you, they assume that the problem is solved. So if the problem behavior doesn’t go away, tell the doctor and ask for something else.
• Drugs always take a while to kick in fully. 1. If you need instant help, drugs will not work fast enough. 2. Do not be tempted to give more doses. You’ll have to wait until they take full effect. For example, Haldol takes four hours to reach maximum effect. If you panicked and kept re-dosing, at four hours you’d have a drooling drugged-out resident on your hands. (I bet that explained a few past events, didn’t it?) 3. The fastest working pill medication I know takes at least 15-30 minutes to start taking effect. If the drugs work immediately, it’s a placebo effect. If that happens, you can use that to your advantage by dishing out Tic Tac candy that looks like pills. Counsel with the doctor before using any placebo therapy.
• Drugs can work differently on different residents. Don’t get stuck in a rut always asking for the same drug to use on different residents. Pay attention to outcomes, and develop your medication-monitoring skills.

Neglect

The last caregiver abuse critter bite that I want to cover is Neglect. Stressed, burned-out caregivers often seek relief by giving up and stop caring in their caregiver duties. They start taking short cuts or flat out just stop doing certain duties. At first when you are alone with the resident, you can get away the neglecting your duties. But when family members arrive or worse state officials show up, that’s when the real trouble starts.

So how do you avoid being bitten by the “neglect your caregiver duties” bug? The first step is to realize that this is an insidious critter that can creep up on you slowly and a little bit at a time. You forget to clean something once, you get too tired to wash something a couple of times. You fall into ruts of taking short cuts. You don’t start out being neglectful, but if this pattern continues, serious neglect issue will arise. 

The second step is to realize that it is so easy to justify away your neglect. Many times you really are too tired or stressed or burned out to finish your caregiving duties. You may feel that you are totally justified in taking a break, but neglect abuse is not about you. The residents under your care have the right to be taken care of properly regardless of how you feel. That’s how state officials view things. That’s what family members expect out of you. It may seem heartless to the worn-out caregiver, but that is the job you signed up for. You have to find ways not to get neglect bug critter bit. Here are a few suggestions.

• Company policies - If you’re the owner of the care home, written policies are probably worth the effort. They provide a standard on which to judge caregiving efforts. They also help maintain higher standards of care. This falls under the general wisdom category of “a goal not written is only a wish.” It does make being a supervisor easier in the long run.
• Schedules - Schedules are really a budget for the time it takes to do tasks. They help organize efforts and make it easier to be efficient. If you’re overworked or burned out, this is a way to get yourself a lot of extra time in a day. Time that could be used as “Me” time. Finding extra time in the day will give you hope, which is very potent in fighting burn out.
• Check lists – Check-off lists are a great way to fight corner cutting and laziness. They are an easy way for supervisors to maintain higher standards, including their own efforts. Take the check-off list seriously or it loses most of its punch. Bosses should visibly collect and review them in front of employees to show they are taken seriously. Don’t use them to punish bad behavior or employees will find a way to fudge on filling them out, which also takes away from their effectiveness. If check-off lists do show substandard behavior, the supervisor should catch the employee in the act then take corrective action.
• Inspections - Inspections are a great way to maintain standards. That’s how the state operates; you can use this tool, too. I recommend taking a pre-inspection inspection before the state comes out. A fresh look at things can keep you out of hot water. They are a hassle, but think of them as bug spray that kills the neglect critter that you don’t or won’t see in everyday caregiving. Specifically look at the appearance of the residents. Do they look neat, clean, healthy, happy, and content?
• Temp help - Need an extra pair of hands? You don’t have to hire a full-time employee. Part-timers or temp help can really make a difference. If you don’t want the hassle of finding and screening new employees, hire a temp agency. It’s more expensive, but it might be worth the effort. They take care of all the annoying aspects of hiring help, for example employment taxes. It also makes it a lot easier to get rid of the bad employees. Part-time day help is also a potent way to keep the good live-in employees longer.

Conclusion

OK-listen up! Last time I’m going to say this. If you don’t take control of your caregiving efforts and act professionally, they will take control of you. That is just part of the 24-hour-7-day-a-week industry you have chosen to be in. You will be pushed into the red danger abuse zone if you don’t take steps now. If you’re already in the red zone, take back your control. Use the ideas in this article. Practice the suggested caregiving techniques. There is NO excuse for abuse, there are only reasons why. Pay attention to the reasons why. Purposely work on eliminating them. Don’t get critter bit in the first place so you won’t be tempted to scratch. You are too valuable of a caregiving asset to waste on abuse. You are not alone in this. We at AFC-CE.com are here for you. And there are others who want to help, too.

Mark Parkinson RPh

As always, good luck in your caregiving efforts.

References:

1. The Essentials: Preventing Elder Abuse. National Committee for Prevention of Elder Abuse, Met Life Mature Market Institute, 201, L0513325128[exp0416] https://www.metlife.com/assets/cao/mmi/publications/essentials/mmi-preventing-elder-abuse-essentials.pdf
2. Lawrence Robinson, Joanna Saisan, MSW, and Jeanne Segal, Ph.D.Elder Abuse and Neglect. HelpGuide.org. December 2016. http://www.helpguide.org/articles/abuse/elder-abuse-and-neglect.htm
3. Melinda Smith, M.A. and Gina Kemp, M.A. Caregiver Stress and Burnout. HelpGuide.org. January 2017. https://www.helpguide.org/articles/stress/caregiving-stress-and-burnout.htm
4. Jeanne Segal, Ph.D., and Melinda Smith, M.A. Anger Management. HelpGuide.org. January 2017.
5. Bronwyn Timmons. Dealing With Combative Residents as a CAN. Chron.com. http://work.chron.com/dealing-combative-residents-cna-22658.html
6. Controlling anger before it controls you. American Psychological Association. APA.org http://www.apa.org/topics/anger/control.aspx
7. Lawrence Robinson, Melinda Smith, M.A., and Robert Segal, M.A. Stress Management. HelpGuide.org. January 2017. http://www.helpguide.org/articles/stress/stress-management.htm
8. Tips to Manage Caregiver Stress. WebMD.com. http://www.webmd.com/balance/stress-management/caregiver-advice-cope
9. Melinda Smith, M.A., Jeanne Segal, Ph.D., Lawrence Robinson, and Robert Segal, M.A. Burnout Prevention and Recovery HelpGuide.org. January 2017. https://www.helpguide.org/articles/stress/preventing-burnout.htm
10. Stage Three, Section 1: Preventing Caregiver Burnout Area Agency on Aging of Pasco & Pinellas, Inc. 2013. http://agingcarefl.org/stage-three-section-1-preventing-caregiver-burnout-2/
11. Jeanne Segal, Ph.D., Melinda Smith, M.A., Greg Boose, and Jaelline Jaffe, Ph.D. Nonverbal Communication. HelpGuide.org. January 2017.http://www.helpguide.org/articles/relationships/nonverbal-communication.htm
12. Katherine Wandersee, Timothy W. Cutler, PharmD, CGP. Module 5. Communication Essentials: Tips for Patient and Provider Communication. Powerpak.com. UAN: 0430-0000-14-035-H04-P. July 23, 2014. http://www.powerpak.com/course/preamble/109810

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Caregiver Tips Being Prepared

Author: Mark Parkinson RPh:  President  AFC-CE

Credit Hours 4- Approximate time required: 240 min.

Educational Goal:

To familiarize Adult Foster Care providers with various emergency and situational caregiving techniques.

Educational Objectives:

Suggest an emergency plan of action.

Provide caregiver techniques on what to do for specific life threatening occurrences.

Provide caregiver techniques on what to do for accidents and other non-life threatening occurrences.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Caregiver Tips Being Prepared

Be in Adult Foster Care long enough and you will see the entire medical treatment continuum, from minor bruises to residents passing away. Practicing your occupation at the point of patient first contact the caregiver has to be prepared to get the ball rolling on a large variety of medical occurrences. This CE will give you some practical caregiver tips so you will be better able to act when you are needed. For those who are new to Adult Foster Care this lesson will really help you out. I suggest that you print out the lesson for a quick reference guide. For those who have been in the biz longer, periodically refreshing your knowledge base never hurts.

Tips on getting ready for ….. anything

First things first, anything can and does happen in your homes. To be prepared for "come what may", it’s good to have a plan in place. I’m not talking about the nitty gritty details for each emergency; I’m talking about an overall generalized plan of action.  1. Be mentally prepared, 2. Assessment, 3. Act, 4. Follow through.

1. Being Mentally Prepared

It may sound funny but everything starts in your head. You have to be always mentally ready to act. I know that there was a lot of eye rolling and mentally saying, “Duh, everyone knows that”.  I’m here to say to you not everyone is ready mentally. In fact most new caregivers fall into the trap of being mentally asleep at the wheel. It happens to be one of the common occurrence in our care home industry. Let me explain.

Most of what we do in Adult Foster Care is mundane household chores, day in and day out. It’s so easy to mentally go into autopilot. It’s what we as humans naturally do when tasks are repeated over and over.  Foster caregivers also slip into autopilot, but that auto pilot is set on a normal non-medical professional household chore mode.  The result is the caregiver becomes a reactionary responder, not proactive medical professional.  Think of the common saying “running around like a chicken with its head chopped off”.  What’s even worse is when really bad things happen and the caregiver freezes.  Here is a true story that illustrates my point.

I once worked in a pharmacy, and in the adjoining bathroom a customer had a heart attack. I found the victim slumped over on the toilet, and it appeared he’d been there for some time. I immediately notified the pharmacy manager and 911 was called. I went back in and placed the body flat on his back, but I knew it was too late because the arms had turned blue from the lack of circulation.  As a caregiver to the elderly, I had seen death before and recognized the signs. The pharmacy manager, though, was quite distressed. Later he confided in me that he felt really bad because he didn’t do anything. He had been trained in CPR, yet he froze. The moral of the story is being trained and being prepared to act on that training are two different things. If a pharmacist who had a 7 year doctorate in pharmacy and was a certified CPR responder can freeze in an emergency any one can.

Are you mentally prepared to act when it’s necessary?  What will help you to be prepared is to remember that you are a valuable medical PROFESSIONAL. You are not a glorified house keeper/ babysitter. You have more patient interaction than any other medical profession.  Get up every morning and tell yourself, “I can be proud of myself because I have a huge impact on the lives of those I service.  I am a proud medical professional - hear me roar!”  After that morning self-pep talk,  always be mentally ready to act like a medical professional when the need arises. Being calm and deliberate may be the difference between a quite peaceful home and house full of turmoil. When decisions are made in advance about how to act, responding to stressful situations becomes easier and quicker. In short being mentally prepared is being mentally relaxed and medically focused.  One of the secretes to our industry is that this is usually the main difference between a well-run full home and a poorly run, usually almost empty home.

2. Assessment

Before you jump into any emergency whether it is great or small you have to size up the situation. Rushing in to help the resident is reactionary, doing so may cause even more harm. Assessing the situation first is what medical professionals do. First quickly look at the overall scene, then assess the patient.

Reviewing the scene

A.When assessing the overall scene there are a number of things to consider.

• What caused the accident?
• Are there dangers in the area?
• How many victims are there?
• What resources do you have?
• Will bystanders need guidance so that they do not become injured or ill themselves?

B. Determine if professional emergency responders are needed.

• Is the situation life threatening?
• Are there intermediate or long-term medical concerns that require professional medical attention?
• Are there hazardous conditions like live electrical wires, gas leaks or smoke?
• Are you just not sure if extra help is needed?

     If you can answer yes to any of the above questions, it’s time to get help.  Assign someone else to call 911. That leaves you free to act. In addition, have them or someone else be responsible for directing the emergency responders to the scene.  In the case of doubt, it is always better get professional emergency responder help.

C. Prepare to respond

• Make the scene safe to respond by removing threats.
• If speed is required send someone else to gather supplies- first aid kits, etc. while you do to the patient assessment.
• Use universal precautions.

     Just a reminder about universal precautions for care providers- There is always the risk of communicable disease transmission.  The risk of infection may be low, but treating all bodily fluids as potentially harmful substances is the safe way to proceed. Whenever possible, use medical exam gloves, mouth-to-mouth barrier devices, and isolation techniques when applying first aid. Safety first and always.

D. Initial victim assessment

     Once it is safe to proceed, make a victim assessment. If there are multiple victims, make a quick assessment of each.  It is generally wise to start with the quiet and nonmoving victims because they may not be breathing or unconscious. Always look for the life-threatening emergencies of non-breathing, stroke, severe bleeding and heart attack first. How do you do that?

     Start by checking for responsiveness. If unresponsive, tap the resident and shout “Are you OK?” If there still is no response, check the airway by performing a head tilt-chin lift maneuver. This will open up the airway and you can make a breathing assessment by placing your ear near the victim’s nose and mouth. Listen for breathing and look for the chest to rise and fall.  Next, look for signs of severe bleeding.  Undo any outer clothing that might be hiding signs of injury.  Check for a pulse. If the residents eyes are open look at the pupils. Are they the right size for the lighting, are both eyes the same?

     Until you know what is going on it is important to move the victim’s body as little as possible. Stabilize the head and neck so that the spinal cord is protected. If necessary, have another person hold the head and neck steady to keep the victim in proper alignment.

E. Further physical exam

    When life-threatening issues have been resolved, conduct a more detailed examination of the body.

• Look for unusual body occurrences or signs such as open wounds, tenderness, deformities and swelling, and skin color and temperature abnormalities.
• Question the victim on how they feel and determine a chief complaint. Try to obtain any important medical information that might be helpful later. For example, was there dizziness or nausea beforehand?

3. Act

Now that the scene is safe and you have made your assessments, it is time to do something to resolve the problem. As you know home caregivers have some limitations on what they can do. You can do simple first aid and resolve some temporary issues but for everything else your role switches from primary caregiver to patient advocate. Your job is to connect them to the right medical professional and stabilize the patient while they wait.   

4. Follow through

As the caregiver and patient advocate it is up to you to act or start the process and most importantly continue acting until the situation is resolved.  Not only do you have to put the band aid on the cut, you have to keep it clean and infection free until the cut is healed. It may seem like such an obvious thing but in my experience how well it is done is the difference between an average home and a great care home.

My most important caregiver tip for you is to be tenacious. Keep at it until the problem goes away completely. That include being forceful with doctors, nurses and pharmacists. Get right in there faces and make them do the right thing. Do it professionally of course or you won’t get anywhere.

Monitor and Report

Adult Foster Care providers also perform one more essential duty that they are uniquely positioned to perform best. That is monitor the patient and report to the doctor.  No other health professional lives with the patient 24/7/365. You will see things that no one else will.  If you don’t communicate what you see to the doctor who else will? The more information the doctor has the better decisions they make. That makes the patient healthier, which makes your job easier and keeps the resident in your home longer.  My tip on making this easier to do is becoming a better record keeper. Write lots of notes in the residents file and prn MARs. Then include these notes in the file you send with the patient when the ambulance or family member picks them up. Yes, it is a tedious task to do but it will pay off in the end.

Maintain the patient

    If emergency responders have been called, maintain the patient until they arrive.  If there are no injuries to prevent it, lie the patient down and slightly elevate the feet.  Keep the patient warm. These activities will help prevent shock and fainting.  When the emergency responders arrive, pass on the information you have gathered and any pertinent medical record print outs from your files. It looks very professional if you have them ready and in a folder along with any written patient condition notes. 

Most of the time you will not be dealing with life threatening situations. But you never know what’s around the corner or in the next bedroom. Make it a habit to be thorough in your assessments. Here’s another story for you:

     A resident was acting very agitated and literally bouncing off the walls. When I questioned him he was unresponsive. I grabbed his face and asked him to look me right in the eyes. One pupil was bigger than the other.  I immediately call 911. He was in the middle of a stroke. 

Tips on what to do for specific life threatening occurrences

Choking

     If you see someone choking, they might be experiencing an obstructed airway and possibly need help. The goal of your effort is to dislodge the obstruction by applying ever increasing pressure until the airway is clear.

• Verify the victim is truly choking.
• Encourage the victim to cough harder.
• Apply back blows. Apply hard blows with heal of your hand five to 20 times to the upper back between the shoulder blades.
• Abdominal thrusts, also known as the Heimlich maneuver.
• If they become unconscious, place the patient on the floor and begin CPR unless there is are advanced directives directing you not to.
• Do not do the Heimlich maneuver or CPR unless your certified and comfortable doing so.

*Special Notes on Chocking.

1. During difficult to dislodge cases, at some point 911 should be called.
2. It is common for the patient to throw up after abdominal thrusts.

Heart Attacks

     Heart attacks occur to individuals that have reduced blood flow to their heart. Symptoms vary with each occurrence but may include uncomfortable pressure, fullness, squeezing, or angina (pain) in the center of the chest lasting more than a few minutes. Pain may be felt down the shoulders to the arms and in the neck and jaw. Signs may also include uncommon sweating patterns, dizziness, fainting, nausea, shortness of breath, and a feeling of weakness.

     Treatment for heart attack is to reduce the strain on the heart by sitting the patient in a relaxed position and loosening the clothing. Call 911, be calm, reassuring and monitor breathing. If the patient has no aspirin allergy have them take one adult aspirin (325mg) or four children’s aspirin (81mg). If the patient has nitroglycerin pills, place one underneath their tongue every five minutes if needed. The maximum amount is three doses. If after three pills there are still problems, call 911.

*Special Note on Heart Attacks

1. Nitroglycerin evaporates out of the pills over time. The only way a first aid responder will know if the nitro pills are potent is to ask if they tingle when placed under the tongue. If the victim can’t feel the tingle, it would be wise to call 911. There is a chance that there is no lifesaving medicine left in the pills they are counting on to save the victim’s life.

2. It would be wise to have prn orders for emergencies from the doctor. For example, in case of heart attack or stroke administer aspirin.

Stroke

     A stroke happens when inappropriate blood flow to the brain occurs and portions of the brain are damaged (CVA- cardiovascular accident). Transient ischemic attacks (TIA) are less serious events, and the brain function returns to normal after a period time. During a stroke, the victim may not be able to perceive their surroundings correctly or understand what you are saying or doing. Time is of the essence.  With every minute that passes, more brain cells may be lost permanently.

     Because of this confusion and time crunch, you must be proactive in screening for a stroke.  Administer the F.A.S.T. procedure:

• F- Face: Examine for appropriate and equal pupil dilation. Have the person smile or show their teeth. Look for drooping of one side.
• A- Arms: Ask the person to raise their arms. Look for uneven arm raising.
• S- Speech: As the person to repeat a simple sentence like, “It is not time for bed.” Watch for slurring.
• T- Time: Time to call 911 if the victim cannot perform any of the fast procedure.

     Have the victim chew on an aspirin if you have the prn orders. Lie them down with the head slightly elevated to reduce blood pressure to the brain.

Asthma Attacks

     Asthma is a medical condition that prevents oxygen from reaching the blood of the lungs because of mucus build up and airway constriction. A person suffering from an asthma attack experiences:

• Coughing
• Bluish skin color in the checks, nose, and under the nails and finger tips (Cyanosis)
• Difficulty catching their breath, wheezing, or speaking in short phrases.

Care for Asthma Attacks

• Place the victim in a comfortable upright position.
• Loosen restrictive clothing.
• Retrieve the residents rescue inhaler medication (most often it is albuterol).
• Call 911 if the patient collapses or the rescue medication is ineffective within the first few minutes of use.

Patient Recovery Position

     A victim who is unconscious but still breathing or who is at risk for vomiting should be placed in a recovery position. Lay the victim down flat upon their left side, with the top leg bent slightly at the knee and the bottom arm extended straight above the head, in line with the spine. If a spinal injury is suspected, keep movement at a minimum by rolling the body as one single object.

Tips on First Aid Supplies

“You cannot render first aid if you do not have the tools and supplies necessary to treat an injured or ill person.  A well-stockedkit is an essential item for all first aiders.” Boy Scout First Aid Merit Badge Pamphlet 2010 pg. 21

     Just as every care home is different, first aid supplies should reflect the possible needs that our different care homes present. Commercially produced first aid kits can be purchased, but the supplies should be reviewed to see if the contents meet the changing needs of your residents and employees. As a former Boy Scout Master and as a pharmacist, I strongly advise going through your first aid kit yearly. Replace expired and damaged supplies and add new items as required. Tie the yearly review to your yearly inspection or taxes so that you can remember easier. I recommend the addition of the following to any kit.

• Burn relieving gel, commonly called burn gel.  It contains numbing agents for the pain, has antiseptic qualities, and helps replace some of the lost moisture.
• Sunburn spray. It contains a topical numbing agent for touch-free pain relief.
• Hand sanitizer. It makes it easier to clean up. Be warned, though, it contains alcohol that will be painful to open sores.
• Latex-free gloves, multiple pairs. Latex allergies are on the rise because of our increased exposure to the substance.
• Breathing masks for mouth-to-mouth rescue breathing.
• Instant Cold packs, good for cooling burns and reducing swelling
• Tweezers, round pointed scissors, safety pins, and a magnifying glass.

Here’s a First Aid Kit story from my personal life.

When my children grew and moved out I did the dutiful pharmacist dad thing and gave them all first aid kits for Christmas. My youngest daughter just threw it in her husband’s truck and forgot about it. Many years later while visiting her home she cut herself pretty bad. (She was trying to show off some of her cooking skills). We grabbed the first aid kit from the truck and searched for some band aids. The kit had not been looked at since she placed in the truck. The bandage wrappers were falling apart and the adhesive did not stick to the skin. Fortunately she had some 4X4 in gauze and some paper tape that we were able to utilize to stop the bleeding.  The moral of the story is to check your first aid kit before you need them.

Tips on what to do for burns

     Burns are defined as injuries to the skin and tissues caused mostly by heat (thermal), chemicals, and electricity. The degree of the burn is classified by how much tissue is involved. First degree (superficial) affects only the outer layer of the skin or epidermis. Second degree affects the inner layers of the skin or the dermis.  Third degree penetrates all the layers of the skin. The goal of burn care is to reduce pain, protect against infection, and prevent evaporation of skin fluids.

Care for Minor Burns

      Hold the burned area under cool water or apply cold compresses until the pain subsides.  If blisters form, do not break them. Keeping them intact prevents infection. Apply Mole skin dressings in layers to keep pressure off a blister.  (Mole skin should be an item in your first aid kit) If keeping the blister intact is impractical, pierce the blister at its base with a sterilized needle.  Save as much of the blistered skin as possible as a natural barrier to pathogens. After the initial cool-down time, clean and dry the area and apply burn gels and/or antibacterial ointments and bandages if needed. Cover the burn with non-stick sterile dressing. If toes or fingers have been burned, place dry dressings between them. Have the patient drink water.

Care for Chemical Burns

     Remove the harmful chemicals from the skin as soon as possible. Brush off dry chemicals from the area before flushing. Flush the area with cool water for at least 20 minutes to remove all traces of the chemical. Trying to neutralize the chemical is not recommended because some neutralizing reactions cause extra heat. Neutralize the chemical only if the manufacturer advises you to do so. Look for instructions on the package labeling. Remove contaminated clothing and jewelry while flushing with water. Flush a chemical out of the eye from the nose outward for 15 minutes.

Care for Third-Degree Burns

     After cooling the burn, cover the area with a dry, non-stick dressing or clean cloth for larger areas. Treat the victim for shock.

Care for Electrical Burns

    Look for entrance and exit burns. Cool both areas with cold water. Cover with non-stick dressing and treat for shock.

Urine or Feces Burns

   Naturally, keeping the resident clean and regularly taken to the toilet prevents troubles. There have been plenty of times though in my homes when the resident was put to bed just fine and dandy only to wake up with chemical burns from urine or feces accidents that occur during the middle of the night. Clean the bottom and pat it dry. I recommend putting on some gloves and applying a barrier cream, like A&D ointment for diaper rash or Budreaus Butt paste. It will give the burned area some extra protection from further accidents or sweat while the resident’s body heals itself. It also makes it less irritating for the resident. 

*Special Notes on Burns

• Seek additional medical attention for burns covering 25 percent or more of the body, respiratory burns, electrical burns, and any third-degree burn.
• Remove any jewelry before swelling prevents its removal.
• Do not remove clothing that is stuck to the skin.
• Treat all serious burn victims for shock.
• If further medical attention is needed, do not apply burn gels or numbing sprays. They may interfere with advanced medical procedures.

Tips on Bleeding Wounds

     The red color of our blood is a sure sign of a wound and the need for first aid. The seriousness of the wound is determined by how much blood is lost. If the blood spurts from the wound, an artery has been severed and the patient is at the greatest risk. Deep vein bleeding can also be life threatening. The goal of therapy is to stop the loss of blood and retain as much flow as possible to the vital organs until help arrives.

Bruises

     Bruises are internal bleeding and for the most part can be reduced by applying a cold pack. Larger bruises may be an indication of greater internal damage, and medical follow up may be needed.

   The blood thinning medications; Rivaroxaban (Xarelto), Dabigatran (Pradaxa), Apixaban (Eliquis), Heparin and Warfarin (Coumadin) makes it easier to bruise. If you see one of those medications on the resident’s MARs, especially Warfarin, you need to take extra care when handling them. It also would be wise to educate the resident’s friends and family about the extra bruising potential they have. Notify the doctor if excess bruising is occurring. Also tell any visiting nurses, government regulators, or other such visitors of the medication. It will help keep them from accusing you of patient abuse.

Internal Wounds

    Not all wounds can be seen. If the victim coughs up blood, vomits blood or black-coffee-ground-appearing substance, has black, tarry stools or red blood in the stool, notify the doctor, further medical attention is needed.  It’s a judgement call if the resident should go to the hospital, it all depends on of how much and why the blood is occurring.  As I always say, “When in doubt, send them out”.

Care for External Bleeding

     Protect yourself by using universal precautions (assume it’s infected) when handling any blood.

• Expose the wound by removing or cutting away interfering material.
• Place a dressing (gauze pad, clean clothing, clean wash cloth) over the wound and apply direct pressure for at least five minutes. The patient themselves can apply the pressure if your attention is needed elsewhere. If the bleeding continues and the wound becomes blood soaked, apply additional dressing on top of the original. Keep pressure on the area until the bleeding stops or help arrives
• If the wound is on an arm or leg, elevate it so that gravity may assist in stopping the bleeding. If the bleeding does not stop, apply pressure on a pressure point to reduce blood flow to the wound. Tourniquets are not recommended and are used only as a last resort to save a life.
• If needed, a pressure bandage can be applied by tightly wrapping the area with roller gauze. Be sure to roll on the gauze above and below as well as on the wound.
• Extreme caution should be used with larger foreign objects in the wound like a nail or piece of glass. Generally speaking, they should be left in place and the dressing placed around the object. Attempting to remove the object may cause greater damage. A ring bandage can be made by wrapping rolled gauze or other material around your fingers then placing it around the object in the wound.
• For minor cuts, when the bleeding stops wash the area with soap and water. Flush the wound with water under pressure to remove dirt and debris. Remove remaining small objects with tweezers. If bleeding restarts, reapply pressure again. Apply antibiotic ointment and place a clean bandage on the cut.
• Replace bandages daily or more often if they get dirty. If the bandage sticks to the scab, soak the bandage in warm water before removing.

Skin Tears

     Skin tears are wounds where the outer most layer of skin has been peeled away and the skin is still attached. Gently clean the wound by flushing with water. Air dry or gently pat dry the area and put the skin back in place. Apply a tent bandage or other covering that will not disturb the wound. Seek medical help.

• Tent bandages are made by creasing a larger non-stick gauze pad down the middle to form a tent-like shape. Place over the tear so that the tent bandage covers but not touches the wound. Secure it only on two opposite sides of the tent with easy-to-remove paper tape. They are handy on bad burns and other wounds where bandage contact with the wound is not desirable.

Nose Bleeds

     Noose bleeds are usually not serious and are controlled by leaning the victim forward and pinching the nose for about 10 minutes. If bleeding continues, pinch the nose again. If the bleeding continues after 15 more minutes, seek medical attention.

*Special Notes About Bleeding Wounds

• Superficial head wounds tend to bleed more but are not as serious unless the skull has been fractured.
• Do not apply pressure on a skull fracture, an eye injury, or foreign objects in the wound.
• In serious cases, do not give food or drink. It may induce vomiting or complicate future medical procedures. If vomiting does occur, roll the victim on their side so that the material is not inhaled.
• Seek medical attention for animal bites, cuts over joints, deep puncture wounds, and infected wounds, especially if red streaks appear leading from the wound (a sign of blood poisoning).
• Save any body part that has been amputated from the body, including teeth. Do not clean the part. Wrap it with clean, dry material. Place the part in a bag or waterproof container and place it on ice.
• If pressure wraps have been applied, monitor the color and feel of the fingers and toes to seek if blood flow has been restricted too much.
• Treat all major wounds and amputation victims for shock.

     When I was an adult foster caregiver, my patients would sometimes fall and bang their heads. Because elderly have naturally thin skin, the bump would often bleed. The first couple of times I became overly concerned and rushed the patients to the hospital. The emergency room personnel made us wait and wait and wait. I became even more concerned and got angry at the staff. They were kind enough to tell me that the bleeding was actually a minor skin wound. The nurse told me that superficial head wounds bleed a lot and look ugly but are not as serious as they tend to look.

Tips on Shock / Anaphylaxis

    Shock occurs when body parts do not get enough blood flow and can result in fainting and death. The goal of emergency care is to shunt the blood flow to essential body parts.

Caregiving to Prevent Shock

• Lay the victim on their backs.
• Raise the legs six to 12 inches to promote blood flow toward the trunk of the body.
• Prevent heat loss with blankets or coats. This helps reduce the need for blood flow to the skin.
• Victims with head injuries should be placed in a reclined sitting position.

Anaphylaxis

     Anaphylaxis is a severe allergic reaction and can be life threatening within minutes. The goal of therapy is to slow the allergic reactions by antihistamines or prescribed epinephrine auto injectors (EpiPen).  Antihistamines (Benadryl, Claritin, Allegra) can take up to 20 minutes to take effect. Watch for breathing difficulties and be prepared to perform mouth-to-mouth rescue breathing. EpiPens are used by removing the cap and stabbing it into a major muscle mass like the thigh. Treat for shock until the patient recovers or help arrives. If you see an EpiPen on the med list get instructions on how to use it, along with nurse delegations from a home health nurse. There will be side effects that will occur if the EpiPen is used. Count on at least a major headache.

Tips on Muscle Bone and Joint Injuries

     Muscle, bone, and joint tissues all combine to give the body support and promote motion. Injuries to these tissues can be debilitating and easily lead to greater harm. The goal of therapy is to prevent further injury to the surrounding tissue while retaining necessary body movement.

Muscle Cramps

     Muscle cramps (charley horses) are an involuntary contraction of the muscles. They tend to happen when the body is fatigued, lacking hydration or electrolytes. Charley horses can be resolved by massage and stretching. Multiple or continued muscle cramps might be a sign of more serious issues. Proper hydration, stretching, rest, and electrolyte replacement are all acceptable treatment and prevention therapy.  

Sprains and Strains

     Sprains are caused from overstretched joint ligament while strains are overstretched muscles. Both create continued soreness, swelling, pain, and weakness that need external support for normal functioning.

     Minor occurrences can be treated by massage, OTC pain killers, and pain relieving sport creams. First aid for more serious events requires supporting wraps and cold packs. Do not attempt to straighten severely hurt limbs and joints.  It should be assumed that there is fractured bone in the more serious cases. Back strain is often a precursor or indicator of a more serious back injury and should not be taken lightly.

Major Trauma Events

     Major trauma such as falls, collisions, or violent blows can fracture and break bones and dislocate joints.

• Open fractures are when the bones stick out of the skin and are serious situations. Control any bleeding by packing off the area without applying pressure. Do not move the victim. If needed, immobilize the fracture with as little movement as possible with soft or hard material splints.
• Closed fractures are when the skin is intact and broken bones are harder to detect. Look for deformities, tenderness, pain, and open wounds that may indicate broken bones underneath. Rapid swelling frequently occurs after fractures. Immobilize the fracture with a splint. When investigating for broken bones, ask the victim these questions:

1. Did you hear or feel a bone snap?
2. Are you unable to move the injured limb?
3. Do you feel pain when you press on the skin over the suspected fracture?

• Dislocated joints happen when joints come apart. They appear as deformities and reduce the ability to move correctly.

Care for Fractures, Dislocated Joints, and Muscle Injuries

     Every major trauma case will require further medical attention, but first aid given in the first few hours can greatly reduce the pain and discomfort of an injury. Treat every injury as follows:

• Rest or immobilize the injured area. Reducing movement prevents further injury and reduces blow flow in the area, subsequently reducing swelling.
• Apply cold packs or ice. Cold also reduces blood flow and numbs the area. Be sure to provide insulation between the ice and the injury and monitor for circulation problems and tissue freezing.
• Compress the injury with elastic wraps or securely tied soft splints. Monitor for proper blood flow.
• Elevate the injury so to that gravity can help with swelling issues.
•  

Splints

     A splint is any material used to stabilize a fracture and is useful in reducing pain and preventing further damage. For the most part you’ll never need to splint to anything. Apply splints only if it does not cause further pain to the victim and you have to significantly move the resident.

1. Before applying a splint check the area for proper circulation. Look at the color, warmth, and feeling.
2. Keep the area above and below the injury still and stable.
3. Select a splint that extends beyond both ends of the injury.
4. Providing support above and below the fracture, apply the splint with as little movement of the injury as possible.
5. Secure the splint by ties above and below the injury.
6. After the splint is secured, monitor for circulation and feeling.

Soft Splints

     Cushioning the injured area with large amounts soft material can also immobilize the injury. Pillows, folded blankets, and heavy coats can be used as soft splints.

*Special Notes on Muscle, Bones, and Joints

• Slings can be used to support and immobilize injured arms and collar bones.
• Tying the injury to the body (anatomical self-splint) can be a useful splinting alternative. Example- securing a sling to the torso of the patient to prevent collarbone movement
• Pinching the upper lip hard can help reduce muscle fatigue and discomfort. (acupressure)
• Continued cold pack applications for the first 24 hours after an injury can reduce healing time.
• Provide cushioning under bulky knots for patient comfort.
• Hip fractures are very serious. If suspected don’t move the resident and call 911. Major hip fractures will probably mean the resident will have to be moved out of your home.

Tips on Head, Neck, and Spine Injuries

     The brain and spinal cord are very fragile and can be harmed in trauma injuries. Nervous system damage may not be readily apparent. When rendering emergency care, it is wise to assume head, neck, and spine injury if:

• There’s been an automobile wreck or a body blow involving heavy equipment.
• There’s been a fall from higher than standing height.
• The victim if fragile or over 65.
• The victim is confused, acts intoxicated, or is not fully alert.
• There’s a complaint of neck or back pain.
• The victim feels a tingling or numbness in the finger or toes.
• The pupils are dilated unequally or unnaturally (too large or too small).

Care for Brain and Spinal Injury

     Nervous system damage can cause permanent paralysis or death, so the goal of therapy is to immobilize the patient to prevent further harm.

• Stabilize the neck and head if spinal cord injury is suspected. Additional help should be called on to hold the head still while you render emergency care.
• Do not move the resident unless circumstances force you to.
• If there is a breathing problem, make only slight adjustment until the airway is open.
• Treat for shock without moving the victim.
• Do not use a pillow under the head.
• If the patient has to be moved, get assistance and move the body all at once as a single unit. For example, rolling to the side in the case of vomiting.
• Do not apply pressure directly on skull fractures. Control bleeding by applying a bandage and putting pressure around the edges of the wound.
• Do not stop the flow of blood or fluid from the ears or nose. Doing so may create increased pressure on the brain.

Tips on Other Body Injuries

     Accidents happen, and injuries can occur to any part of our body.  

Eye Injuries

• Small foreign objects- Flush the eye with clean water or pull open the eye lid and remove the object with a cotton swab or sterile gauze.
• Major trauma- Immobilize gently with sterile gauze any penetrating object, eyeballs knocked out of socket, or major cuts. Cover both eyes to further prevent eye movement. Seek additional medical attention
• Minor blows to the eye- Apply cold pack to the eye for about 15 minutes.
• Chemicals in the eye- Keep eye open as wide as possible. Flush with warm water for 20 minutes from the nose side out. Have the patient continuously roll the eye when flushing. Loosely bandage both eyes and seek additional medical help.

Teeth

Knocked out teeth-

Partially removed teeth should be pushed back in.

Completely removed teeth

1. Control bleeding by rinsing the mouth and applying gauze to the socket.
2. Retrieve the missing tooth by handling the crown only, rinse with saliva or milk. (do not use water, skim or powdered milk)
3. If you cannot make it to a dentist in less than 30 minutes, try to reinsert the tooth while traveling.

• Broken teeth or fillings- Clean the area with warm water. Apply a tooth-numbing agent if needed. Apply dental wax to the exposed end of the broken tooth if needed.
• Broken jaw- Stabilize the jaw by wrapping a bandage under the jaw and over the head.

Excessive Blood Under Nails

     If a toe or fingertip has been crushed, blood may pool under the nail and creates painful pressure. The pressure can be relieved by heating a nail or paperclip and melting a small hole in the nail. Clean and apply dressing afterwards

Protruding Organ 

     Cover exposed organ part with a moist dressing that will not stick or fall apart when wet. Cover dressing with a towel to maintain warmth. Stabilize the area loosely.

Caregiving Tips on Internal Threats

Diabetes

     Our brain requires a constant supply of glucose as fuel to operate. Our digestion system is set up to convert most things we eat into that fuel. Diabetics have an impairment that prevents them from processing glucose properly. There is always a potential of having too much glucose in the blood stream and not enough in the brain or that their medication has worked too well and there is not enough glucose in the blood or the brain. This impairment leads to diabetic emergencies that can be life threatening. Suspect a diabetic emergency if you witness the sudden onset of a combination of these symptoms:

Staggering, poor coordination, nervousness, anger, confusion, pale color, sudden hunger, excessive sweating, trembling, fruity-smelling breath, rapid heartbeat, blurred vision, or eventual unresponsiveness.

Care for Diabetic Emergencies

     Measure their blood glucose and respond as follows

If the blood glucose readings are under 70mg/dl they are too low or hypoglycemic.

• Treatment is to eat 15 grams of sugar (2 tsp. or ½ can soft drink or the equivalent of orange juice) wait 15 minutes. Repeat if symptoms persist. If symptoms still persist, seek immediate medical care.

If the blood glucose readings are over 240mg/dl they are too high or hyperglycemic.

• Treatment is to give rest, fluids, and medication. If reading continues to increase or is over 350mg/dl, seek immediate medical care.

If the blood sugar cannot be determined, give 15 grams of sugar and wait 15 minutes for improvement. If none is seen, seek additional medical treatment.

Fainting

     Fainting is usually caused by low oxygen to the brain that can result from a variety of conditions. If a resident faints, check for breathing problems and additional injuries. Raise the victim’s legs six to 12 inches and loosen tight clothing. Supply fresh air and a cool, wet cloth if needed. Have the victim get up slowly and give them a cool drink. Monitor for continued dizziness.

   If the resident is on blood pressure medication check if their blood pressure is too low. If it’s okay then monitor the patient. Report the fainting to the doctor. Train the resident to get up in stages. Set up, move to the edge of the seat and then stand up slowly. If the resident stands up all at once gravity will pull the blood away from the brain and they will get dizzy and faint. It is a common occurrence in the elderly and residents who take blood pressure meds.

Seizures

     Seizures are abnormal firing of brain cells that results in sudden falling, unresponsiveness, rigid or arching of the back, and jerky muscle movements. The goal of therapy is to prevent further injury and to aid in the recovery of normal mental function after the seizure.

Care for Seizures

• Remove any potentially harmful objects that are nearby.
• Cushion the victims head.
• Loosen tight clothing.
• Roll the victim on their side.
• Help orient the victim as the seizure ends.
• Keep curious onlookers away. (Seizures are embarrassing.)
• Do not put anything in their mouth or try to restrain any movement.
• Seek additional medical help for seizure lasting more than five minutes, continued seizures, or if victim has other medical conditions.

     When I was a Scout Master, I took my boys to summer camp. We had a bon fire program and the presenters mesmerized my scouts with images and shadows that danced and flickered across their eager faces. Unfortunately, the flickering also triggered a seizure in one of my boys. There were several well-qualified first aid responders there in an instant. The boy soon recovered, and I took him back to the tents. With a whole camp full of curious boys and one very embarrassed seizure victim, I soon found out that crowd control, appropriate information dissemination, and privacy matters are very important seizure treatment considerations. 

Caregiver Tips for External Threats

Poisons

     Poisons are any substance that harms the body or causes death. The signs of poisonings are nausea and vomiting, stomach cramps, diarrhea, burns, odor, or stains in or around the mouth, drowsiness or dizziness, and poison containers nearby.

Treatment is dependent on what was ingested. Call the poison control center at 1-800-222-1222 for guidance. If they are unavailable, call 911. Save any vomit and suspected poisons that are nearby. Do not give any water unless told to do so. Do not induce vomiting. There is no evidence that it helps and may cause more damage as the poison comes up.  Lay the victim in the recovery position. Treat the victim for shock and monitor breathing.

Poisonous Plants

     Certain plant oils can cause a delayed severe allergic reaction in susceptible persons coming in contact with them.  Poison oak, poison ivy, and poison sumac are the most common. Reactions typically occur within 24 to 48 hours but can start to show six hours after contact. Watch for rash, itching, redness, blisters, and swelling.

A certain diagnosis is difficult because of the delayed effect. If poison plants are seen in the area and if contact is suspected:

• Change clothing. Handle soiled clothing with care or gloves.
• Wash the contact area with plant oil dissolvent (commercial products are available at a pharmacy, Technu products and ivyblock) or flush the area with large amounts of water. Scrubbing the affected area with soap usually just spreads the oils to other parts of the body.
• Apply numbing creams or sprays, hydrocolloidal oatmeal preparations, hydrocortisone or calamine lotion.
• For those with a larger portion of the body affected, use oatmeal bath preparations like
• Seek medical attention if ingested or smoke from burning plants was inhaled.
• OTC antihistamines might slow or mute the reaction.

Animal and Human Bites

Consider all human and animal bites infectious, and seek further medical attention. Clean the wound the same as for a bleeding wound. Use extreme caution in handling the offending animal. It is safer to notify the police or an animal control specialist and let them collect the animal for rabies examination.

Insect and Spider Bites and Stings

     There are many insects and spiders that have been known to bite or sting humans. Often the victim does not even know they were bitten until a reaction starts to occur.   First aid is to clean the wound with soap and water or rubbing alcohol. Place a cold pack over the area to delay the effect of any venom and ease the pain. Take note of any venomous species seen in the area and monitor for serious signs and symptoms. Watch for muscle stiffness or cramps, headache chills, fever, heavy sweating, dizziness or vomiting, difficulty breathing, severe site reaction or blister, and anaphylactic reactions. Seek medical attention immediately if these occur.

• Fire ant bites are very painful. Do not pop the blisters that form. The pain may be helped by applying a baking soda and water paste.
• Ticks should be removed using tweezers very slowly. Grasp the tick as close to the body as possible and gently pull, using just enough force to lift the skin but not break the insect. After the tick has been removed, wash with soap and water or alcohol. Monitor the bite for one month for a rash. If one appears, seek medical attention. Other serious symptoms that may appear are muscle and joint aches, sensitivity to bright lights, and paralysis that starts with leg weakness.

Caregiver Tips for Heat Emergencies

     Medical heat emergencies occur when the body’s cooling mechanisms get overwhelmed and body temperatures exceed normal functioning levels (105 degrees).  It can happen over a period of days (dehydration) or occur more rapidly (overly hot weather conditions).  Certain medications can aggravate the situation for example water pills and other diuretics like caffeine.  The goal of therapy is to ensure proper hydration and cool the core body temperature so that vital systems may function. The elderly and infirm are more susceptible and have less ability to sense when warning symptoms occur. The elderly just don’t feel thirst like they used to. During a hot summer or on field trips they will have to be monitored more closely. Regularly scheduled drink breaks would be a good idea.

Heat Exhaustion

     Heat exhaustion is the first sign that the body’s cooling mechanisms are being overwhelmed. It can be brought on by a combination of dehydration and a hot environment. The symptoms are sweating, thirst, fatigue/exhaustion, nausea, headache, shortness of breath, and rapid heart rate. A quick dehydration test is loosely pinching the skin on the upper part of the hand. If it snaps back into place everything is okay. If a peak remains then the skin is dehydrated. The older one is the less effective this test is.  

Care for Heat Exhaustion

• Place the victim in a cool environment and remove excess clothing.
• Give cool drinks. Sport drinks with electrolytes are best, but lightly salted water or nutritional supplement drinks can also replace missing electrolytes. Continue to maintain proper hydration.
• Wet sponge the victim and fan them. (artificial sweating)
• If no improvement is seen within 30 minutes, seek additional medical help.

Heat Stroke

     Heat stroke is a more serious condition where the victim’s cooling mechanisms have failed and harm to vital systems are occurring. It can be seen as extremely hot and or dry skin and altered mental status ranging from slight confusion to agitation and fainting.  The goal of therapy is to get additional medical help immediately and cool the body down.

Care for Heat Stroke

• Call 911 especially if mental status has changed or the patient stops sweating.
• Place the victim in a cool environment and remove excess clothing.
• Add water to the skin and clothing and fan vigorously.
• Encourage small amounts of fluid intake.
• Raise the legs to help from feeling faint.
• Place ice bags wrapped in wet towels around the neck, armpits, body trunk, and groin.

*Special Notes for Heat Emergencies

• Rest is required for the remainder of the day for victims.
• Heat stroke victims may become angry and uncooperative, which is a sign of the loss of mental control.
• A cold shower with or without clothing might be appropriate in emergencies.
•  

Conclusion

   The residents in your homes count on you the caregiver for their comfort, health and tranquility, just about everything they need. No other health profession has so many expectations placed upon them. As the residents point of first contact with the health care system and as their advocate you either have to take care the problem yourself or know how to connect to with rest of the health care continuum to solve ANY the issue that may occur.   Being professional in your caregiving efforts helps with your burdens. It also entails being prepared for any emergency that may occur. It is your job to know what steps to take in the smallest to the largest of emergencies.  From a certain point of view that makes you the most important health care provider in your residents lives. Good luck in fulfilling that role.

References:

1. Hypoglycemia (Low Blood Glucose). American Diabetes Association June 1, 2015 http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html
2. Choking. Wikipedia the Free Encyclopedia, April 15 2017. https://en.wikipedia.org/wiki/Choking
3. First Aid. English Wikibooks September 19, 2007 https://upload.wikimedia.org/wikipedia/commons/1/1d/First_Aid_for_Canada.pdf
4. First aid. The Mayo Clinic. http://www.mayoclinic.org/first-aid
5. First Aid & Emergencies. WebMD. http://www.webmd.com/first-aid/default.htm
6. First Aid Merit Badge Manual. Boy Scouts of America. http://www.scouting.org/filestore/Merit_Badge_ReqandRes/First_Aid.pdf
7. Rod Brouhard, EMT-P. OSHA Compliance for First Aid in the Workplace. VeryWell. July 10, 2016https://www.verywell.com/osha-compliance-for-first-aid-in-the-workplace-1298830
8. Best Practices Guide:Fundamentals of a Workplace First-Aid Program. U.S. Department of Labor Occupational Safety and Health Administration, OSHA 3317-06N, 2006. https://www.osha.gov/Publications/OSHA3317first-aid.pdf
9. Medical and First Aid. U.S. Department of Labor Occupational Safety and Health Administration. https://www.osha.gov/SLTC/medicalfirstaid/

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A Caregivers Perspective on an the

Patient’s Bill of Rights

Author: Mark Parkinson RPh:  President  AFC-CE

Credit Hours 1- Approximate time required: 60 min.

Educational Goal:

To present an alternative utilitarian point of view of the Patient’s bill of rights. 

Educational Objectives:

Present the patient’s bill of rights as a communication tool that needs to be better utilized by care homes.

Suggest alternative wording to the tradition wording of the patient’s bill of rights. 

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

A Caregiver’s Perspective on the

Patient’s Bill of Rights

Adult foster care homes are a business in which the borders on the individual’s rights tend to blur. It’s easy to start your business thinking you will respect the rights of each and every resident in your care. But when you’re in the caregiving trenches day after day, it becomes easier for caregivers to cross the line. Corners get cut, caregivers get burned out, patients get difficult to manage, and the rights of individuals become forgotten.

Government officials understand the pitfalls and pressures of caregiving. That is why the Patient’s Bill of Rights was written and its principles enforced. It is the government’s job to ensure that the rights of all individuals are not forgotten. That’s what we the people hired them for: to protect everyone’s rights.   

Caregivers in adult foster care homes are in a special situation in regards to the rights of individuals. By establishing a business in your home and being eligible for government reimbursements for services (Medicare and Medicaid), we agree to give up some of our individual rights. We agree to have the government control some of our actions, and we agree to choose the rights of residents over our own.

I remember when the Patient’s Bill of Rights started to be enforced in my care homes. It got my patriotic dander up. I was angry. This was MY home, MY life, MY rights. I was raised by ultra-conservative spud farmers from Idaho who taught me not to let the government take away any of my rights. I was young, reactionary, and stupid. Over the years, I have come to realize that I got it all wrong.

Take a closer look at the Patient’s Bill of Rights. It’s more than a list of dos and don’ts. It’s a guide to good caregiving, it’s the doorway to excellent customer service, and it’s a gold standard for business practices.  Instead of being restrictive, it’s a shield. It prevents bad thing from happening to you, your residents, and your business. It’s time to take another look at the Patient’s Bill of Rights from a wiser point of view.

Looking from a Different Point of View

I advise you to review the Resident’s Bill of Rights not from the perspective of an administrative rule the government is forcing you to comply with but rather as a caregiver tool - a tool that will make you a better caregiver and make your care business healthier. Do it right and your residents and their families will be happier customers. Doing it right leads to easier caregiving and a stronger business.

The following are excerpts from the Oregon Department of Human Services publication A Guide to Oregon Adult Foster Care Homes, page 7. I have written a few of my thoughts on how to use these to make you a better caregiver and healthier business. Hopefully they will inspire you to see the Patient’s Bill of Rights as the potent caregiver tool that it is so you can make your own career-improving observations.

 The Resident’s Bill of Rights

When you move into an adult foster home, you do not give up any of your civil rights nor any rights as an Oregon citizen. Caregivers must respect your privacy, dignity, independence and your right to make choices. Each adult foster home must post the Residents’ Bill of Rights in the home and discuss those rights with each resident at the time of admission.

My Notes:

When a resident moves in, the orientation / welcome speech includes all of the thoughts above except rewrite it to sound more like a quality of care guarantee.  Something like:

Welcome to our home. We want it to feel like your home, too. You will not have to give up any of the rights and civil privileges that you have become used to as an Oregon citizen. We as your caregivers guarantee your privacy and independence to make choices and will do everything in our power to maintain your dignity.  We are going to post this promise of your Resident’s Rights for everyone to see. If you have any questions or concerns, just ask us. Or you can have anyone else check up on us. We want the whole world to know how we are striving to take care of you and your rights.

(I give you permission to copy any or all of “My Notes” for your own or business use.)

All residents have the right to:

(a) Be treated as adults with respect and dignity;

(b) Be informed of all resident rights and all house policies;

My Notes:

We guarantee that you have the following rights:

(a) We will treat you as an adult; that means you will be treated respect and dignity.

(b) We will make sure you understand all your resident rights and all our house policies so that you will be comfortable and secure here.

(c) Be encouraged and assisted to exercise constitutional and legal rights including the right to vote;

(d) Be informed of their medical condition and the right to consent to or refuse treatment;

(e) Receive appropriate care and services and prompt medical care as needed;

My Notes:

(d) We will inform you of any medical condition that comes to our attention. We will work for you in dealing with them. If you do not want or are concerned with any treatment, we will work as your advocate to find another treatment that you are not opposed to. We believe you have the right to refuse any treatment. 

(e) We guarantee that you will receive all needed care and services as soon as possible.

(f) Be free from abuse;

(g) Complete privacy when receiving treatment or personal care;

My Notes:

(f) You have a right not to be abused from any person or business. If you feel threatened or taken advantage of from any source, tell us or someone else. We will be your advocate in protecting you. If you feel we are abusing you, please let us know so we can correct and improve our methods. If you feel uncomfortable talking to us directly, please talk about it with someone else.

(g) Just like in your own home, we will maintain your privacy when you receive personal care and treatments.

(h) Associate and communicate privately with any person of choice and send and receive personal mail unopened;

(i) Have access to and participate in activities of social, religious and community groups;

My Notes:

(h) We want you to feel you can associate and communicate with any person you choose to, and we will help provide the means to do so. We will deliver your mail to you unopened as soon as we receive it.

(i) We will help you have access to and participate in social, religious, and community activities.

(j) Have medical and personal information kept confidential;

(k) Keep and use a reasonable amount of personal clothing and belongings, and to have a reasonable amount of private, secure storage space;

My Notes:

(j) Your privacy is very important to us. We will not knowingly reveal any personal or medical information to unauthorized personnel without your permission.

(k) We want you to feel free to bring in with you any personal clothing and belongings. It will make the transition easier for you. You can bring as many things as there is room for, and we will do our best to keep your belongings safe and secure.

(l) Be free from chemical and physical restraints except as ordered by a physician or other qualified practitioner. Restraints are used only for medical reasons, to maximize a resident’s physical functioning, and after other alternatives have been tried. Restraints are not used for discipline or convenience;

My Notes:

(l) We want you to be safe and secure here in our home. We have set things up so you will be free from chemical and physical restraints of any kind except those that are deemed medically necessary by a qualified medical practitioner. As your advocate, we will ensure that any restraints ordered by your doctor will only be for your safety and physical wellbeing. They will be used only after other alternatives have been tried. We promise that restraints will never be used as a punishment or for our convenience.

(m) Manage their own financial affairs unless legally restricted;

(n) Be free from financial exploitation. Providers must not charge or ask for application fees or non-refundable deposits or solicit, accept or receive money or property from residents other than the amount agreed to for services; 

My Notes:

(m) You will be able to manage your own financial affairs to the full extent of the law.

(n) We want you to be free from financial exploitations. You will never be charged for hidden fees or non-refundable deposits. We will not ask for or accept any money or property other than what we have both agreed to for our services. We also want to protect you from others who would financially exploit you. If you feel threatened or coerced in any way by anyone, please tell us and we will help you make things right as long as you live with us.

(o) A written agreement regarding services to be provided and the rates to be charged. Providers must give at least 30 days’ written notice before a rate change and before any change in their home’s ownership;

(p) Not to be transferred or moved out of the adult foster home without 30 days’ written notice and an opportunity for a hearing. Providers may transfer residents only for medical reasons or for the welfare of the resident or other residents, or for nonpayment;

My Notes:

(0) We will provide a written agreement for the services we will give you. Our rates will be clearly written. We will let you know at least 30 days in advance of any changes to our agreement.

(p) We further promise never to transfer or move you out without at least a 30-day notice unless it is medically necessary, or for the safety and welfare of the other occupants of the home or for nonpayment. You have the right for a hearing regarding the transfer.

(q) A safe and secure environment;

(r) Be free of discrimination in regard to race, color, national origin, gender, sexual orientation or religion;

My notes:

(q) We feel you have a right to feel safe and secure, and we will do everything in our power to make it that way.

(r) You have a right not to be discriminated against. We do not care what race, color, national origin, gender, sexual orientation, or religion you are. You will be treated equally and fairly by us.

(s) Make suggestions or complaints without fear of retaliation; and

(t) Be free of discrimination in regard to the execution of an advance directive, Physician’s Order for Life-Sustaining Treatment (POLST) or do not resuscitate (DNR) orders.

My Notes:

(s) We want to be continually improving. We want you to help us by making suggestions. Rest assured that we will never retaliate for any complaint you have about anything.

(t) We respect the choices you make. We will honor and obey any advance directive, Physician’s Order for Life-Sustaining Treatment (POLST), or do not resuscitate (DNR) orders.

The Caregiver’s Perspective

In order to survive and thrive, adult foster care homes have to be able to turn restrictions into advantages. Seeing the resident’s rights as a guide to quality caregiving is one way to do that. It also helps you set a performance standard for training purposes, and it can be a real marketing asset if cooperated with instead of fought against.  One note of caution before you post your own version of the Resident’s Bill of Rights: Check with your local government agency. Even if the agency won’t allow any modification, you can still be creative when you explain the Bill of Rights to your residents.

Conclusion

The Resident’s Bill of Rights is more than just a list of dos and don’ts. It’s a standard of caregiving and a resource that can be used to elevate your care home to the next level. I suggest that instead of fighting against it or brushing over it, creatively embrace it. Use it to make your caregiving career all that much better.

As always, good luck in your caregiving

Mark Parkinson

References:

1. Residents' Rights. The National Long Term Care Osbudsman Resource Center. http://ltcombudsman.org/issues/residents-rights
2. Resident’s Rights: An Overview. The National Consumer Voice for Quality Long-Term Care. March 2007. http://theconsumervoice.org/uploads/files/long-term-care-recipient/ResidentRights.pdf
3. Adult Foster Home General Information. Rouge Valley Council of Governments, Senior and Disability Services. http://www.homecarechoices.org/adultfh1.htm#Bill of Rights

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Revisiting House Rules

Author: Mark Parkinson RPh:  President  AFC-CE

Credit Hours 1- Approximate time required: 60 min.

Educational Goal:

To expand the perspective of Adult Foster Care providers about the writing and use of house rules. 

Educational Objectives:

Explain about the opposing expectation of residents, caregivers and licensers and how to use the house rules to align them.

Provide suggestions on how to write house rules for broader purposes. 

Explain that house rules are actually a statement of company policy.

Provide additional sources of information about writing company policy.

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Revisiting House Rules

The unique feature of our industry is that you provide medical care out of a regular home. It gives you a competitive advantage over other types of medical care by tapping into the resident’s and their family’s sense of home.  It also creates the perception that the job is easier and more relaxed for caregivers.

This may be strength, but it is also a weakness. Expectation for the caregiver’s home to be like the resident’s own home is very high. At the same time, it is oh so easy for caregivers to forget their house is no longer a home - it’s a business. A business set up to meet the needs and expectations of paying customers.

Adding to that complexity is another layer of government standards of caregiver behavior that must be complied with and will be inspected for regularly. It is no wonder that things get a bit tangled and frustrations occur over time.  

What we are really talking about is a conflict of expectations. The caregiver, resident, and government licensor all have divergent perspectives and expectations on what should occur in the care home. When all three align, things run smoothly. When they don’t, problems start to occur.

Bringing all three expectations into harmony is the difference between a good home and a poorly run home. But how do the good homes do it? How do they get everyone on the same page and keep all three perspectives in agreement the answer lays in the three Cs: Clear Consistent Communication.

Easier said than done, right? I can’t even remember what I said to my wife a week ago, and I’ve been married to her for 30-plus years. How is a person supposed to communicate consistently and clearly with customers and government officials day after day, week after week, year after year?

There is a communication tool that can accomplish just that: Your House Rules. What? I thought I heard you collectively moan, “That’s not a communication tool. That’s just something the government makes me do.” Go on, you can admit it. Some of you only think about house rules when a customer moves in and when the government licensers shows up. Think about that for a minute. House rules and communication with the customer and the government, hmm.  Yes, that’s right. House rules is a tool that you use to communicate clearly and consistently with customers and government licensers year after year. But if you’re only using it a couple of times a year, you’re not get much use out of it.

Here’s a story for you that illustrates my point. In my garage is a big fancy box that contains a practically unused table saw. I have to admit; even though I bought it I have never used it. I did loan it to my neighbor, and he used it. Then he packed it back into the box and there it has sat ever since. I don’t ever use it because I don’t want the hassle of putting it together, and I tell myself, “You don’t know how to use it anyway.” So there it sits, a big fancy box that I lug around with me year after year, move after move.  What a waste. I wonder how many times my life would have been easier if I had unpacked it and learned how to use it.  On a wall somewhere in your home pinned to board is a big fancy communication tool. It’s just sitting there, practically unused.

Why don’t you take it down and let’s take a gander at it. You have had training from the state on what must be included in each house rules. That training emphasizes the minimum requirements and leaves the rest of the details up to you to figure out. In my opinion, that minimalist training has unintentionally limited the focus of the document, which in turn has limited its usefulness and made it harder to use.  So let’s work on some of the details to make it a more functional tool that is also easier to use.

What you are actually looking at is a statement of company policy or how the boss wants things done. It should contain all the rules and procedures that the business owner wants everyone to adhere to, not just the minimums. Each house rules will differ from all others, just as each foster care business is different from all others.

Generally though it should:

1. Instruct the resident about what to expect for payment and any limitations they have while staying at your home.
2. Tell the employee what the owner wants them to do and how to act.
3. Include any government regulations that everyone must adhere to.

The larger the organization, the more extensive the company policy should be, especially if the employees spend a significant amount of time on their own without the boss supervising them or if there is a large turnover of employees. Smaller organizations can get by on less.

Important Note*

I’m not going to attempt to tell how to make the perfect one-size-fits-all house rules because there isn’t such a thing.  I will tell you some tricks, tips, and ideas that I think will help you craft your own company policies. It’s going to be up to you to write a more useful house rules for yourself. Don’t think that just because you’re not an owner you’re off the hook. Employee caregivers also can help with ideas and feedback that will help the owner in this difficult task.

Tip One: It’s a living document.

Writing the house rules is never really done. You should be open to revising it whenever needed.  I suggest the following process of revision.

• Review significant incidents. Things like accidents, complaints, customers moving out, and inspection deficiencies. View these events as opportunities to improve.
• Figure out the root cause of the issue, not just what happened but why it happened. Get feedback from employees, inspectors, and customers.
• Determine what could be done to prevent the occurrence in the future.
• Write the first draft of the revision and then get feedback on it, especially from government inspectors. This will prevent future problems with the revision and possible inspection deficiencies.

Tip Two: It’s a tool to use constantly.

Just don’t pin it to the wall, make copies of it and:

• Put it in the employees’ manual. If you don’t have one, make one.
• Turn it into a self-inspection check-off list.
• Use it as an agenda outline for employee meetings.
• Use it in employee training.

Tip Three: Write it so it is usable.

If your house rules are awkward or difficult to use in any of the above, change the wording. Just as with process, it is going to take many revisions until you get it right.

• Make the policies realistic for the size, style, location, and clientele of your business.
• Don't be condescending or patronizing. Imagine being a staff member reading them. Would the policies or their language upset you?
• Place the items into shorter sections that are easily revised.
• If an action is mandatory, use “must” in the language. Avoid the use of “should” and “shall” as it implies that it’s optional if the occasion warrants it. Try to limit the use of “will” to occasions that describe a future action and not as a synonym for “must.”
• Use wording that is positive in tone.
• Avoid being gender-specific. Use “they” instead of “he or she.”
• Make the rules easy to follow.
• If your house rules become too lengthy, consider breaking them up. One version is to be used when residents move in. The other is to be used when training new employees.

Tip Four:  Don’t go it alone.

Writing company policy is hard. Get help.

• Go to the library for a book on how to write company policy.
• Search the internet; it may cost some money to get the good stuff.
• Get input from employees, government licensees, and home health nurses. Go to adult foster home provider meetings and ask around.
• Get copies of other house rules. Include looking at nursing homes, retirement centers, and even senior centers. Those institutions may not call them house rules. They may be known by other names like company policy.
• Send the first draft to a proofreader. It will cost but not much. There are plenty of willing and able people on the internet that will review your documents. Go to the website Fiverr. I personally use http://www.proofpositivepapers.com/. She charges a penny a word.

Tip Five: Be goal oriented.

Determine what goals are important for your business. Write the document so that it enables you to accomplish those goals. Write it and use it with the goal of becoming the best functioning care business out there. To help, I suggest you ask the following questions.

• Will this document help get and retain customers?
• Will this document help make and retain good employees?
• Will this document satisfy government licensees so that there will be no inspection deficiencies?

Tip Six: KISS

Keep it simple stupid (MIT’s language, not mine). Write only what is needed. Write for the broad situation, not the specific incidence.

Write a policy:

• If there might be employee confusion on how to behave. (dress code, telephone use, limitations)
• If guidance is needed on how to act. (emergency procedures)
• If consistency is needed. (smoking policy, progressive discipline, safety rules, privacy rules, telephone and computer use)
• If the issue behind the rule can apply to everyone. One employee or resident’s poor behavior should not require a policy that will affect all other employees or residents.

Tip Seven: Get approval beforehand.

Don’t forget to get final approval from government licensees of your finished and polished house rules before you post it. Get approval on any future revisions. Be patient and keep in mind the following:

• Be courteous to the government officials. They don’t exactly have a lot of extra time on their hands.
• Tell them that you’re just trying to be cooperative and compliant with the rules and regulations.
• Identifying problems with the house rules before they are implemented takes less time and effort on everybody’s part than changing them after and an inspection deficiency notification.

Benefits

It may take some extra work, but a well-written house rules that is consistently reviewed and put into practice is worth the effort.

• Employee training and discipline will be easier. Employee morale will improve, and turnover will decrease. Owner’s action will be more consistent and less confusing to others.

• Residents and their families will know what to expect and be more content. That leads to fewer complaints filed that need to be investigated.
• You can’t be there all the time to make sure that things operate correctly but your company policy can.
• If you have included the government licensor you will have gotten approval on how you operate in advance. That means there will be fewer deficiencies at inspection time.
• A living document means you will constantly improve, and those improvements will stick. Caregiving will get easier. If there is a bad issue happening, adjust the company policy to avoid it the future.

Conclusion

Clear, consistent communication is the certain way to align the expectations of resident, owner, employee, and government licenser. A well-written and appropriately used house rules is the assured path to the three Cs.

A good quality care home will use them to get the employees to act a certain way, get approval from the state in advance, and fine tune the business to be more appealing to customers and employees. Wise owners will evaluate problems that have occurred and revise the house rules or company policy to prevent future problems from happening.

It may require more work, but it will be worth it. Get assistance if you need it. I hope that the above tips have helped.

As always, good luck in your caregiving

Here are few sources that provide more insight and examples that I found on the internet. Do your own Google search.

http://www.spadacarehomes.com/wp-content/uploads/2015/08/SH-PoliciesProcedures_01012015.pdf

https://www.thebalance.com/how-to-develop-a-policy-1918870

http://www.adrielcarehome.com/documents/HouseRules.pdf

References:

1. Module 1, Introduction to Adult Foster Care for Individuals with Developmental Disabilities. Developmental Disabilities Adult Foster Care Training Manual, Oregon Department of Human Services. http://www.oregon.gov/DHS/PROVIDERS-PARTNERS/LICENSING/IDD-FOSTER-HOMES/Documents/AFH%20Training%20Manual.pdf
2. Leslie Contreras Schwartz. Guidelines For Writing Policies and Procedures. Smallbusiness.chron.com. http://smallbusiness.chron.com/guidelines-writing-policies-procedures-1803.html
3. Nicole Long. How do I Develop a Policy & Procedures Manual?. Smallbusiness.chron.com. http://smallbusiness.chron.com/develop-policy-procedures-manual-2903.html
4. User Guide to Writing Policies. University of Colorado. https://www.cu.edu/sites/default/files/APSwritingguide.pdf
5. Oregon Administrative Rules, Chapter 411, Div.50. Oregon Department of Human Serviceshttp://www.dhs.state.or.us/policy/spd/rules/411_050.pdf
6. Susan M. Heathfield. How to Develop a Policy. The Balance .com. July 23, 2016 https://www.thebalance.com/how-to-develop-a-policy-1918870

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 Basics of Blood Pressure 

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Basic of Blood Pressure

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Basics of Blood Pressure

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 3.5 - Approximate time required: 210 min. 

Educational Goal:

To provide Adult Foster Care providers with information that will help them understand blood pressure and cooperate with hypertension therapy.

Educational Objectives:

1. Instruct about the basic concepts that deal with blood pressure.
2. Tell how blood pressure is measured
3. Discuss Sphygmomanometers and home blood monitoring
4. Explain Hypertension
5. Explain Hypotension

Procedure:           

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

Disclaimer      

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Basics of Blood Pressure

The blood transportation symptom is the body’s super highway. It flows away from the heart in the arteries to the smaller arterials then finally to the tiny capillaries in every part of our body. It transports most of what we need to live. It also carries back from the body’s tissue the waste products leftover from the body’s metabolism. Blood flows from the capillaries to the venules to the veins and then the heart.  The beating of the heart is what initially drives the blood through the system.  Blood flow is also aided by body movement and controlled by muscles wrapped around the arteries.  The flow is shunted to where it is needed by the contraction and relaxation of the muscles around the blood vessels in various parts of the body. The arterial system is kept under pressure. Without blood being under pressure, our body could not get the materials it needs to live. In fact, how much pressure the blood in under is a key indicator of health.

All that is well and good, but I know what some of you are thinking: Why should I even care? What good is this subject to a residential care provider? I’m not planning on performing any surgeries or major medical therapies anytime soon. What good is knowing about blood pressure in my caregiving profession?

I think the key word there is “profession,” as in medical professional. You have to decide whether you just a glorified babysitter and housemaid or something more? I believe that you are something more. Having more patient contact than any other medical profession, I know you have the potential to be one of the most potent members of the health care team.  Your potential will only be fulfilled when you start acting like a medical professional. That means that you have to start thinking on a higher level of medical professionalism. That means you got to stop dinkin’ around with the caregiving traditions passed down from your grandmother and replace them with evidence-based proven methods of care.

In the past, hearsay and old wives tales dominated medical practice, but today’s modern medicine is based on evidence and confirmed by measurements.  Gone are the days of guessing whether something works - replaced by knowing something works by measuring the vital signs of the patient. Vital signs are the key indicators of a healthy life - heartbeat, body temperature, respiration, oxygen saturation, and blood pressure. If you are going to work on the same level as the rest of the medical team, you have to understand your client’s vital signs. In a practical sense, knowing what’s going on vs. guessing what’s going on makes your job a whole lot easier.

What is blood pressure?

Blood pressure is the strength of your blood pushing against the sides of your blood vessels in the circulatory system.  Your blood’s pressure rises with each heartbeat and falls when your heart relaxes between each beat.  How much pressure the blood has at any given point is affected by several factors. It is affected by total blood volume, how thick the blood is, and how much resistance to flow there is. Blood volume and thickness are easy to understand, but resistance to flow needs a little explaining. Unlike a rigid straw for drinking your favorite drink, the blood vessels are very elastic. They easily expand as the blood is pushed along with each heartbeat. The initial pressure caused by the heart is maintained longer because less of the force is lost due to pushing against rigid sides. If there were obstacles in the blood vessels blocking the flow, the pressure would be used up pushing against the blockage.  Before the blockage the pressure would increase, behind the blockage the pressure would fall.

How much pressure is there?

How much pressure there is depends on where and when you measure. There is always some pressure in the circulatory system because of the volume of blood that is maintained by the body. The pressure changes as it moves through the system.  It is highest just after a heart beat in the major arteries next to the heart. The pressure is used up as it pushes against smaller and smaller vessels until it reaches the leaky capillaries. As you might guess, the pressure is lowest in the veins of the body.

   Pressure is also determined by where and when the blood is needed. As mentioned earlier, a layer of muscle surrounds the arteries that are used to manipulate where the blood flows. This muscle layer plus other factors are used by the body to alter your blood pressure when needed. If the body is too cold, the blood and its heat are maintained in the core of the body. If it’s too hot, it is pushed out to the skin where it can release the excess heat easier. If the body is working hard, the blood pressure is increased to push the blood out to the muscles where it is needed the most.  If you get scared or nervous, the blood pressure increases so that you will be ready to “fight or flight.”  There is also a 24-hour circadian rhythm, and the body’s blood pressure drops at night when you’re supposed to be sleeping. The bottom line is that blood pressure is extremely variable, going up and down as the result of many factors.

How Is Blood Pressure Measured?

Unless specifically stated otherwise, blood pressure measurements are always taken of the arterial blood supply. Blood pressure readings are given as two numbers (ex. BP 120/78). The numbers are measurements of what happens to blood pressure as the heart is beating.   The top number is called the systolic and represents the highest pressure just after the heart beats. The lower number is the diastolic and measures the pressure between beats when the pressure is the lowest. The units of measurement are mm Hg, which stand for millimeters of mercury. 

Historically, blood pressure was gauged by how far up a tube it could push a quantity of mercury. Most B/P machines no longer use mercury but the measurement continued.   

Blood pressure (BP) can be taken any where there is a pulse, but the numbers change depending on where you take the measurement. The standard placed to take BP readings is just above the crock of the elbow right over the brachial artery. The farther away from this area, the measurements are taken the less standardized the results will be. You might have heard that the farther away from the heart the BP is taken, the less accurate the readings are. It would be better to say the less standardized the measurements are. When taking B/P readings, it is important to report where the blood pressure is taken, for example a wrist or finger blood pressure machine.  

 Blood Pressure Machines- The Sphygmomanometer

The sphyg what?   The word is a combination of Greek and scientific terminology meaning pulse pressure meter. You can call it a blood pressure meter or cuff.  There are two types of sphygmomanometers, manual and digital.

Manual- Auscultatory (to hear)

Manual systems are actually two devices used together. One is an inflatable device that is either a manually or an automatic machine pump-filled cuff. The second is a stethoscope for listening to the blood rush through the artery.

 The operating principle is easy enough to understand. You wrap the cuff around the arm and place the stethoscope over the artery. Then you inflate the cuff until the atrial blood is cut off. You then gradually release the cuff pressure until you hear through the stethoscope the blood start to gush through the artery with every beat of the heart. That is the systolic or highest blood pressure. You continue to release the cuff pressure until you can’t hear the gushing anymore. That is the point of diastolic blood pressure.

As you can imagine, manual blood pressure machines require skill to use, but they are the most accurate. Unless they have been trained and have regular practice, foster care providers should probably skip using manual devices.

The aneroid (a dial pressure reader) is easier to use but still requires trained skill. The dials also require periodic calibration.

Digital- Oscillometric (electronic calculation)

The easier-to-use but harder-to-understand BP machines are the automatic digital readers. They are basically an electronic pressure sensor. More explanation than that isn’t necessary.  There is a complex math formula involved that I know you wouldn’t care about.

Each model has its own instructions, but they all follow the same basic steps as the manual type. Inflate, release the pressure, and read the systolic and diastolic points. Most will also give a read out of the heart rate.

 The difference between the various models is how many bells and whistles you want. Ranging from the simplest (and cheapest) hand-inflated cuffs to push-one-button-and-done models. Some of the newer models can be connected to an iPhone so that the BP readings can be sent to the doctor.

The most common models are designed to be used on the arm or wrist, and all are not as accurate as the manual types. They also require calibration from time to time, which also affects accuracy. As an in-home caregiver, getting the most accurate reading is not that big of an issue. You let the doctor worry about getting the most accurate reading. Your biggest concern should be reducing variability by getting the most consistency in your readings.

Caregivers taking home BP measurements   

Regardless of the BP machine caregivers use, the most important factor in my opinion is consistency of use. Have you ever noticed how blood pressure is taken at a doctor’s office? They take blood pressure readings the same way every time.  The patient is always sitting in a relaxed position. The same bare arm is most often used etc. The doctor and his staff have been trained to take blood pressures that way to try to control how variable the patient’s blood pressure can be. Just standing up can increase the blood pressure and give a falsely high reading. 

In-home caregivers should adopt this same level of professionalism. When you take blood pressure readings, you should do it the same way every time. If there is a change (for example time of day, left arm vs. right), the change should be recorded along with the BP measurement.

Because you can’t always control the situation, caregivers should not be overly concerned with individual readings. Sometimes the pressure readings spike unusually high or low. If you’re concerned over such spikes, wait awhile and take another reading. In my opinion, where Caregivers should concern themselves with patterns that happen over time. If you see a gradual increase (or decrease) or consistently odd read out over the course of several measurements, that is the time to notify the doctor.

What is a normal blood pressure?

I might have given you the impression that BP measurements are all over the place all the time. Going up and down like a ball at a basketball game. Well in the short term, sometimes it can go up and down, but for the most part the body has homeostatic mechanisms that keep thing pretty much the same.  When the body is operating normally, the overall average is what is considered normal.

Medical science has not figured out all the control factors that affect blood pressure homeostasis. We do know about the following.

• Baroreceptor reflex- specialized stretch-sensing cells. When blood pressure increases, it makes these cells stretch. They in turn send signals to the brain to decrease the blood pressure.
• Renin-angiotensin system- It increases the blood pressure by constricting the muscles around the blood vessels. It kicks in when there is a drop in blood pressure due to total volume loss.
• Aldosterone- A hormone that helps the kidneys retain salt. Water follows salt so liquid blood volume increases, raising blood pressure.

Our bodies put a lot of effort into keeping the blood’s pressure the same. The brain, nervous system, hormones, muscles, and organs are all involved. All these factors work to bring the body’s blood pressure back to what it thinks is normal. That brings up another point, what’s normal? Describing what is normal in humans is always difficult. Each individual’s reaction to their environment and all the internal control factors of the body make it very complex. The best we can settle for is a range of readings that helps determine what is normal and what is an indicator of ill health.  The general consensus is that a normal blood pressure is systolic 90-119 Hgmm and diastolic 60-79 Hgmm. The more fit you are, the lower the numbers become.  What we understand as normal also changes with age.

For those readers who take care of children, the blood pressure ranges for children are:

Source: Pediatric Age Specific UCLA Health System

 It’s time for another caregiver reality check.  Another “that’s all well and good but what’s in it for me” moment. 

Caregiver Moment

As a care provider it is not your job to decide what is normal. That’s the doctor’s job. But the more blood pressure readings you take for a patient, the more you will be able to tell what’s an average reading is for that resident. You’re not looking for information that will lead you to diagnose a disease state. You’re looking for red flags that tell you that something needs attention by other medical professionals. If you’re being a medical practitioner yourself and not just a babysitter, you will catch problems sooner and get them resolved quicker. See how that could make your job easier?

We’re not talking about a lot of extra work or cost either.  One $50 automatic-inflate digital model placed on the arm of the residents as they settle in after breakfast, say around 10:00 (when all the morning chores are over) a couple of times a week isn’t much extra work.

When Things Go Wrong

The human body is an amazing thing. The God that made us gave us a wonderful self-regulating creation that can pretty much maintain itself despite all the variables around us. But our bodies are not perfect yet. We’ll leave that process in God’s hand for now. In the here and now, things can go wrong and cause problems.  Diseases break things, birth defects handicap us, harmful substances gradually poison us, and bad habits play havoc. We can compensate with drugs, but drugs have side effects that can interfere or they can work too good.  Even if we avoid all of the above, eventually things will just wear out. That’s the way we we’re designed. It’s all part of the greater plan for us to eventually move on to bigger and better things.

When things do go wrong, that’s where you come in to help. But how can you help if you don’t know what’s going on.

High Blood Pressure

Chronically high blood pressure in the arteries is called hypertension (HTN).  It is a long-term disease state where the homeostatic mechanism of the circulatory system has worn out, is broken, or is being interfered with. The body is built to handle higher pressure in the arteries for short periods of time, so initially we don’t feel a thing. But if the hypertension continues long enough, things start to breakdown. The excessive pressure on artery walls can damage blood vessels as well as organs. The higher the blood pressure and the longer it goes uncontrolled, the greater the damage becomes. Hypertension over time is a major risk factor for hypertensive heart disease, coronary artery disease, stroke, aortic aneurysm, peripheral artery disease, chronic kidney disease, and eye problems. Uncontrolled high blood pressure may also affect the ability to think, remember, and learn.

According to the National Institute for Health (NIH), about one in three adults have high blood pressure. African American adults have the highest rate of almost 44 percent.  High blood pressure rates increase with age. The condition is more common in men than women, but after menopause, women’s rates start to increase. Lifestyle has a significant effect on hypertension, resulting in higher rates in lower socioeconomic classes.

Classifying High Blood Pressure

High blood pressure cases have two categories based on the cause of the condition. Primary or essential HTN is the result of a complex interaction of different genetic weaknesses inherent in all of us and the environment that we live in. For example, some individuals are more sensitive to the harmful effects of a high-salt diet than others. Secondary hypertension results from a more identifiable cause. Kidney disease is the most common cause of secondary hypertension (the kidneys are a focal point of blood pressure homeostasis). 

Just how high the high blood gets is also an important consideration. The gold standard for the classification of the severity of hypertension cases was set down by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).

Diagnosis

Traditionally it was recommended that a diagnosis of hypertension be made by the doctor after three separate sphygmomanometer measurements at one-month intervals. The American Heart Association recommended at least three measurements on at least two separate health care visits. There is a problem with that method, a phenomenon call white coat hypertension.

When we get nervous, our blood pressure goes up. Certain people get nervous around doctor offices, so these patients would always give falsely high reading all the time. It wouldn’t matter how many measurements were taken if they were taken in a clinical setting. As a result of these difficulties, greater emphasis has been placed on multiple blood pressure readings taken at home. 

Caregiver Moment

Hmm, that will be right down your alley after reading this CE article.

During the diagnosis process the doctor will also look at the patient history and list symptoms he or she discovers. For instance, primary hypertension tends to develop gradually with no apparent cause. Secondary hypertension tends to appear suddenly and cause higher blood pressure. The various conditions that can contribute to secondary hypertension are

• Obstructive sleep apnea
• Kidney problems
• Adrenal gland tumors
• Thyroid problems
• Certain defects in blood vessels you're born with (congenital)
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers, and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines
• Alcohol abuse or chronic alcohol use

Risk Factors

The practice of medicine is not only about taking care of problems that have occurred but preventing diseases from happening in the first place. The trick is to identify those who are at most risk and then reduce or eliminate causative factors before high blood pressure occurs.

This is a good place to introduce you to the term prehypertension.  According to the JNC7 classification regime above, those with normal but consistently slightly high BP readings are in a warning zone called Pre-hypertension. It is a time where there is no evidence of disease yet but conditions are ripe and may lead to it later on. It is a good indicator that your health is heading in the wrong direction and you should start turning things around by paying attention to the risk factors that contribute to hypertension.

According to the Mayo Clinic, risk factors for developing hypertension are:

• The risk of high blood pressure increases as you age. Through early middle age, or about age 45, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• High blood pressure is particularly common among blacks, often developing at an earlier age than it does in whites. Serious complications, such as stroke, heart attack, and kidney failure also are more common in blacks.
• Family history.High blood pressure tends to run in families.
• Being overweight or obese.The more you weigh, the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls.
• Not being physically active.People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
• Using tobacco.Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow, increasing your blood pressure. Secondhand smoke also can increase your blood pressure.
• Too much salt (sodium) in your diet.Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Too little potassium in your diet.Potassium helps balance the amount of sodium in your cells. If you don't get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
• Too little vitamin D in your diet.It's uncertain if having too little vitamin D in your diet can lead to high blood pressure. Vitamin D may affect an enzyme produced by your kidneys that affects your blood pressure.
• Drinking too much alcohol.Over time, heavy drinking can damage your heart. Having more than two drinks a day for men and more than one drink a day for women may affect your blood pressure.
• High levels of stress can lead to a temporary increase in blood pressure. If you try to relax by eating more, using tobacco, or drinking alcohol, you may only increase problems with high blood pressure.
• Certain chronic conditions.Certain chronic conditions also may increase your risk of high blood pressure, such as kidney disease, diabetes, and sleep apnea.

Source http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/risk-factors/con-20019580

Treatment

The goal of high blood pressure therapy is to achieve blood pressures below 140/90.  Treatment for high blood pressure depends on the cause of the problem. In secondary HTN, the cause is identifiable so that is where the doctor concentrates his efforts. In the more common primary HTN, the cause is unknown and is most likely an accumulation of several factors. In such cases, standard medical practice starts by having the patient make lifestyle changes that bring under control contributing risk factors.  If more help is needed, a methodical use of medication is introduced, adding additional medicines until the patient’s blood pressure is under control.

Fortunately in the case of hypertension, small lifestyle changes in many areas can have a cumulative effect, which means several small improvements can make a big difference.  For example, in one study, obese teenagers who went on a salt-reduced diet dropped 10 Hgmm in blood pressure after just two weeks. In another example, exercising one hour a day only three times a week can lower blood pressure. It little matters how you reduce your blood pressure. If patients can achieve the goal of less than 140/90, they will realize the long-term benefits.

Caregiver Moment

What that means to care providers is because they control the lifestyles of their residents to a great degree, they can have a huge impact on hypertensive patients. If you regularly monitor B/Ps in the home, you can find out what changes work the best for each resident. It also gives you the benefit of more easily gaining the cooperation of hypertensive residents as you show them the up-to-date progress they are making.

Lifestyle Changes

Lifestyle changes are the first line of therapy in hypertension. The lifestyle changes that care providers can help make that affect high blood pressure are:

• Reduce weight- for overweight residents as little as a five-pound weight loss can start to lower blood pressure.
• Being more active- A 30-minute brisk walk on most days is recommended. In my own care homes, I found that making activity part of the daily routine was the easiest way to start and maintain an exercise regime. I have seen the use of stationary bikes and stepper machines work equally well. Giving the residents active chores to do helps with their health, (as well as relieves their boredom).
• Ban the use of tobacco and alcohol in your homes.
• Decrease salt and increase potassium. An easy-to-implement approach is to replace salt shakers with salt-substitute shakers. You can easily buy products like Mrs. Dash, No-Salt, and Morton Salt Substitute and place them on the table and by the stove. The last two are potassium chloride instead of sodium chloride (salt).
• Stress-free environment- Be aware of the sights, sounds, and feel of the home. Routine is the key to less stress. Periods of relaxing music can go a long way. Another trick is the use of scents in the home. Lavender has a calming effect. Who doesn’t like the smell of cinnamon, even if it is just cinnamon water boiling in a pot on the stove?
• Control contributing conditions like keeping blood sugars under control for diabetics, maintaining blood oxygen levels for those with breathing problems and sleep apnea sufferers, and supporting chronic anxiety suffers.

Food and Eat Healthy

Of all the lifestyle factors that affect blood pressure, eating a good diet is the one thing that is most under the control of in home care providers.  Even though most of you are not licensed dietitians, you can still cook healthy meals.

Eating healthy starts with buying healthy. You cook what you purchase, so buy lots of fruits and vegetables, low-fat dairy products, and whole grains. Cooking from scratch is easier to control nutrient values than cooking prepackaged convenient food. You will usually find that cooking from scratch also saves you money.

I think I just heard a collective moan from all the cooks. I know what a big deal food preparation is to an adult foster care home. After planning the menus for over a decade for my homes, I found the secret path to an easier way to cook healthy. It’s all about the recipes. Planning the recipes in advance tells you what to buy, what to have on hand, and how much time it will take and how to cook healthy. Planning the menu through recipes makes everything easier.

Where do you find the right recipes? According to my research, the proven blood-pressure-lowering diets are a Mediterranean-style diet or the DASH diet. Just look them up online, and you’ll find tons of good recipes.  DASH stands for Dietary Approaches to Stop Hypertension and was developed by the U.S. National Heart Lung and Blood Institute. 

The National Institute of Health (NIH) published an excellent lower-your- blood-pressure guide, which included the following:

 The DASH Eating Plan

The DASH eating plan shown below is based on 2,000 calories a day. The number of daily servings in a food group may vary from those listed, depending upon your caloric needs.

* Serving sizes vary between 1/2 cup and 1 1/4 cups. Check the product’s nutrition label.

† Fat content changes serving counts for fats and oils: For example, 1 tablespoon of regular salad dressing equals 1 serving, 1 tablespoon of low-fat salad dressing equals 1/2 serving, and 1 tablespoon of fat free salad dressing equals 0 servings.

You can find the whole pamphlet here.

http://www.nhlbi.nih.gov/files/docs/public/heart/hbp_low.pdf

Start your recipe search here: Dash Diet. Keep the beat recipes. https://healthyeating.nhlbi.nih.gov/pdfs/Dinners_Cookbook_508-compliant.pdf

Medication

When lifestyle and diet changes are not enough to reach the target BP rate, clinicians can turn to a wide variety of drugs to help manipulate the circulatory system to lower the patient’s blood pressure.  Doctors will usually start off with a lower dose of a single drug (monotherapy) then increase as needed to reach the target BP rate. It is not uncommon to have the patient taking several different medications at the same time (polypharmacy). The drugs will not “cure” the hypertension, just help control contributing factors. If the medication was discontinued, the hypertension would likely return if no other control efforts were made.

Diuretics

Diuretics are commonly called water pills. They work on lowering blood pressure by increasing the amount of salt that is excreted by the kidneys. Water follows salt. If there is too much salt in the blood, then there will be too much water as well. This extra volume is thought to contribute to higher blood pressure. Diuretics help lower the salt content of blood, and the excess water volume follows the salt out in the urine. Diuretics also cause the blood vessels to relax and widen, also contributing to lower blood pressure.

Common examples of diuretics are: Chlorothiazide, Hydrochlorothiazide (HCTZ), Metolazone, Furosemide (Lasix), Amiloride, Spironolactone, and Triamterene.

Special Considerations

• Diuretics should be taken in the morning so that having to go to the bathroom frequently will not be so disruptive to the patient’s lifestyle.
• Some diuretics cause an increase of potassium to be excreted in the urine. The patient might also have to take potassium supplements.
• The patient should be monitored for dehydration.

Beta Blockers

Beta blockers are nerve signal blockers. They work by preventing the norepinephrine and epinephrine (adrenaline) neurotransmitter chemicals from binding to beta receptors on nerves. This prevents the nervous system from telling the muscles around the blood vessels to contract.  Wider blood vessels results in lower blood pressure (vasodilation).

Common examples of beta blockers are Acebutolol, Bisoprolol, Propranolol, Atenolol, Labetalol, Carvedilol, and Metoprolol.

Special Considerations

• Unfortunately there are beta receptors throughout the body. Some tell the muscles to constrict while others are related to other effects. Whether these side effects become a problem is very individualistic. Patients should be monitored for dizziness upon standing, breathing problems, blurred vision, constipation, and headaches.

ACE inhibitors

Angiotensin converting enzyme inhibitors or ACE inhibitors lower blood pressure by reducing the activity of a key enzyme in the chemical pathway the body uses to increase blood pressure. Think of as removing a domino in the domino chain the body uses to increase its blood pressure naturally.

Common examples of ACE inhibitors are Benazepril, Captopril, Enalapril, and Lisinopril.

Special Considerations

• Certain populations are sensitive to developing a dry cough that will not go away when on ACE inhibitors.
• Kidney impairment especially when used with an NSAID pain killer and a diuretic.
• They may also increase the pain felt in inflammation.

ARBs

Angiotensin receptor blockers, or ARBs, are drugs that modulate the same chemical systems as the ACE inhibitors, just in another place.  They are also commonly referred to as the sartans. They are most often used for ACE inhibitor patients who develop the dry cough side effect.

Common examples of ARBs are Losartan, Candesartan, Valsartan (Diovan) Irbesartan (Avapro), and Telmisartan (Micardis)

Special Considerations

• It is rare, but some ARB patients are still troubled by a dry cough.
• ARB patients should be monitored for muscle cramps, muscle pain, back pain, and insomnia.

Calcium Channel Blockers

 Calcium channel blockers or CCBs inhibit calcium from entering cells which is a major “Start or Go” signal for certain cell functions. They lower blood pressure in primarily four ways.

1. Vasodilation- Relaxing the muscle layer around the arteries (vascular smooth muscle layer)
2. Reduce the force of the contraction in the beating heart. Less force equals lower blood pressure.
3. Slow down the heart beat rate.
4. Block the kidney from producing a hormone (aldosterone) that is involved with raising the blood pressure.

CCBs are particularly effective against large blood vessel stiffness, one of the common causes of elevated systolic blood pressure in elderly patients.

Common examples of CCBs are Amlodipine (Norvasc), Felodipine, and Nifedipine.

Special Considerations

• Common side effects of CCBs are headache, constipation, rash, nausea, flushing, edema (fluid accumulation in tissues), and drowsiness.
• Caregivers who take care of residents on CCBs should occasionally measure their ankles and lower legs and monitor for a red, hot- looking face (flushing), and unusual tiredness (slow heart rate).
• Monitor heart rate. A normal adult heart rate is 60 – 100 beats per minute. Most digital blood pressure meters also read heart rates.

Alpha 1 Blockers

Alpha 1 blockers, or alpha-adrenergic blocking agents, work similar to the beta blockers just at a different receptor site in the nervous system. Blood pressure lowering is accomplished through vasodilation.

Common examples of Alpha 1 blockers are Doxasosin (Cardura), Terazosin (Hytrin), and Prazosin (Minpress).

Special Considerations

• The body’s homeostatic mechanisms may initially try to counteract the drug’s effect. It may take a while to see the full blood-pressure- lowering effect.
• Alpha 1 Blockers can cause the resident to get dizzy if they stand up too quickly. A way to manage this side effect is to take the medication at night before bed.
• Some drugs in this class can also cause nasal congestion.

There are many other classes of drugs that can lower blood pressure but are not commonly used for that primary purpose.  For these medications, lowering blood pressure could be considered a side effect, which the doctor may certainly take advantage of. 

Concerns of Hypertension Therapy

There is always the potential to go too far in the drug manipulation of the body’s blood pressure system.  There are also the body’s homeostatic mechanisms to contend with and the dynamic effect the environment has on the blood pressure system.  Hypertension therapy requires constant monitoring of the patient and dedicated follow through. 

Getting Used to Therapy

There is always a transition period in all new medicinal therapies. Caregivers must use patience in the first couple of weeks. Minor problems that occur might go away by themselves as the body gets used to the new drug. If the problems get worse or don’t go away, notify the doctor.

Professionals always have measurements when notifying the doctor. It is not good enough to report: My resident is acting funny. It is much better to report: My resident has an average 138/85 BP taken at 10:00 a.m. for the past two weeks but has experienced a dry cough five days out of the last seven.  In my opinion it is always worth the added effort of monitoring and recordkeeping to keep a patient healthy. Healthy residents are always easier to take care of, and professionalism always brings huge rewards in the long run.

Therapy Going Sideways

Side effects are always an issue in drug therapy. Each drug has its own list that caregivers should be familiar with. Common to most (but not all) hypertension medication are the problems of:

1. Dizziness upon standing (orthostatic or postural hypotension)
2. Electrolyte imbalance (getting sodium, potassium, or calcium messed up)
3. Drug working too well (hypotension)

Orthostatic Hypotension

Orthostatic or postural hypotension causes the patient to get dizzy or faint when they sit up or stand. In short, it’s a problem of gravity. When we sit or stand up, gravity pulls our blood toward our toes away from the brain and other vital organs. That lack of blood pressure in the brain even for a short moment is enough to cause problems. Normally our bodies overcome that problem with an automatic response called the baroreceptor reflex or just baroreflex. There are certain nerves that sense a drop in blood pressure in key areas. They send a signal to the brain, which in response keeps the blood pressure up by tightening the muscles around the blood vessels. In essence, the baroreflex squeezes the blood back up to the brain.

Can you see the problem here? Many of the medications affect the nerve signal to the muscle layer around the blood vessels. They may lower the blood pressure but they also may interfere with baroreflex’s ability to squeeze the blood back to the brain when gravity pulls it away.  The solution is to get up slowly or raise the body up in stages. If the resident is already unsteady on their feet as is the case of the elderly or infirmed, you have a real concern on your hands. Who cares if the blood pressure is under control if the resident falls and breaks a hip?

Many things can cause dizziness and fainting. To confirm that postural hypotension is possibly the cause of the problem, blood pressure readings are taken after the patient stands. If you get significantly lower readings after standing, it’s time to notify the doctor (for example a loss of 20 Hgmm). From then on caregivers should always be close at hand or even assist the resident when standing or sitting up after lying down for a long time.  It’s well worth the extra effort to keep the resident from cracking open their skull on the corner of the table or bed stand.

Electrolyte Imbalance 

Electrolytes are the minerals and other chemicals our bodies uses in cell function and to conduct electric signals in the body. A good example of electrolyte function is how the kidneys work to get rid of the waste products in the blood stream.  Much of the blood’s content is pumped into the kidney’s tubules, including a lot of the water and its mineral salts. The kidneys then transport the salts back into the blood stream, and the water naturally follows the salts. What’s left is then flushed out in the urine.  In addition, the nervous system practically runs on the electoral charge of the sodium and potassium ion charge (Na+, K+).

Can you see the problem here? Many of the drugs used to treat high blood pressure do so by increasing the amount of salt lost in the urine. That’s how water pills work.  Also calcium channel blockers alter the way our bodies use calcium, another essential electrolyte. There is always the potential for an electrolyte imbalance.  

To prevent electrolyte imbalance, the doctor will blood test on a regular basis. But those blood tests only happen once, maybe twice a year. Caregivers should know the warning signs of electrolyte imbalance for the time in between.

Caregivers should look for the following warning signs:

• Lethargy, confusion, weakness, swelling, seizures, and depression
• Leg cramps and heart palpitations

In-home caregivers will see these symptoms long before any other medical provider, but only if they actively look for them. 

Hypotension

Hypotension is the opposite of hypertension or a case of low blood pressure.  The body is pretty good at maintaining a constant blood pressure, but there is always a chance in medical therapy that the drugs will work too well and drop the blood pressure to dangerous levels.  What BP reading is too low varies by each individual, so caregivers must look for the warning signs and act before any major damage occurs.  Generally a BP of 90/60 is considered hypotensive. Your resident will start to look like they are running low on gas because that is exactly what is happening. The blood pressure is too low to carry essential nutrients to the body, especially the brain. Look for lethargy, confusion, irritability, and stuck-in-the mud behavior.  Fortunately, this is an easy fix for the doctor, either change the drug or reduce the dose. As a pharmacist, I always thought it was very good news when a patient could reduce the amount of drugs they had to take. What I consider is the most important message in this paragraph is doctors won’t know the dose needs to be lowered if the caregiver doesn’t tell him or her about the hypotension warning signs.

More Information on Hypotension

Very low blood pressure is a dangerous event and often leads to a life- threatening condition called shock. The body’s homeostatic mechanisms work very hard to maintain an adequate blood pressure.  It has several interrelated and overlapping compensating systems to keep the blood pressure up. If one fails, then others systems can compensate. One of life’s ironies is the healthier and athletic a person is, the lower his or her blood pressure is.  So having lower BP numbers isn’t necessarily an indicator of an inadequate supply of blood pressure. A better indicator is how the body reacts when it starts to run out of essential nutrients the blood pressure supplies.

The brain is particularly sensitive to the lack of nutrients (oxygen and glucose to mention a few).  The cardinal signs of hypotension are thus related to brain function, mainly lightheadedness or dizziness. These symptoms can progress to fainting, seizures, and death.

Causes

Low blood pressure is seen is cases of hormonal changes, widening of blood vessels, medicine side effects, anemia, heart problems, or endocrine problems.  The most common cause is hypovolemia (low blood volume).  I’m not just talking about the blood. An inadequate volume of water could also be the problem. Hypovolemia is caused by excessive bleeding (hemorrhage) and could also be caused by insufficient fluid intake or  excessive fluid loss from diarrhea or vomiting.  Excessive use of diuretics and heat stroke can also lead to hypovolemia. 

Other causes of hypotension are related to troubled cardiac function. Severe congestive heart failure, large myocardial infarction (heart attack), heart valve problems, or extremely low heart rate (bradycardia), often result in hypotension.

Excessive vasodilation (blood vessels are open too wide) is also a source of hypotension.  Blood pressure medication can cause vasodilation, also nitrate preparations (nitro pills), sepsis, acidosis, and an excessive use of most inhalation drugs.

Conclusion

Caregiver Actions in Blood Pressure Issues

Wow, we’ve talked a lot about blood pressure, the highs and the lows and a few things in between. We’ve talked about how vital blood pressure is and what efforts modern medicine takes to support the body’s own mechanisms to maintain a healthy blood pressure level. 

Most blood pressure issues in care homes will be minor and easily headed off by an alert caregiver. In practical everyday terms, caregivers should look for abnormal behaviors.  If there is a concern, the prepared caregiver can confirm any suspicions by taking a blood pressure reading. Remember that one abnormal BP reading could be the machine’s fault. Wait a few minutes and take another one unless it’s obvious that immediate action is required.

And like I always say:

“When in doubt send them out- to the doctor, that is.”

Caregivers should act with medical professionalism, that means less guessing and more facts as seen in measurements. A natural result of this attitude is regular blood pressure measurements taken at home.  It will only result in healthier, happier, and easier-to-care for residents.

Good luck in your caregiving efforts.

Mark Parkinson.

References:

1. Description of High Blood Pressure. National Heart Lung and Blood Institute, National Institutes of Health Sep 10 2015 http://www.nhlbi.nih.gov/health/health-topics/topics/hbp

2.High blood pressure (hypertension) Mayo Clinic Patient Care and Health Info. Jul 7 2015 http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/definition/con-20019580        

3.High Blood Pressure Symptoms, Causes and Treatments. MedicineNet.com. http://www.medicinenet.com/high_blood_pressure_pictures_slideshow/article.htm

4. John P. Cunha, DO, FACOEP, High Blood Pressure. MedicineNet.com. Feb. 18 2014 http://www.medicinenet.com/high_blood_pressure_hypertension/article.htm

5. High Blood Pressure. Center for Disease Control and Prevention Feb. 19 2015 http://www.cdc.gov/bloodpressure/   

6. Self-Measured Blood Pressure Monitoring. Million Hearts, Center for Disease Control and Prevention, U.S. Department of Health and Human Services. Feb.2013 http://millionhearts.hhs.gov/Docs/MH_SMBP.pdf

7. Oscar A. Carretero, MD; Suzanne Oparil, MD. Essential Hypertension Part I: Definition and Etiology. Clinical Cardiology: New Frontiers, American Heart Association Circulation. 2000;   101:  329-335 doi: 10.1161/01.CIR.101.3.329 http://circ.ahajournals.org/content/101/3/329.full

8. Markus MacGill. Blood Pressure: What Is Normal? How To Measure Blood Pressure. Medical News Today. Jul. 9 2015 http://www.medicalnewstoday.com/articles/270644.php

9. Markus MacGill. Hypertension: Causes, Symptoms and Treatments. Medical News Today. Sep 4 2015 http://www.medicalnewstoday.com/articles/150109.php

10. Measuring Your Blood Pressure at Home. Pubmed Health. U.S. National Library of Medicine. Feb. 22 2012 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0041082/#conssmbp.s3

11. Katrin Uhlig, MD, MS, Ethan M Balk, MD, MPH et all. Self-Measured Blood Pressure Monitoring: Comparative Effectiveness. Effective Health Care Program, National Center for Biotechnology Information Jan 2012 http://www.ncbi.nlm.nih.gov/books/NBK84598/

12. Hypertension. Wikipedia the Free Encyclopedia. Oct. 6 2015 https://en.wikipedia.org/wiki/Hypertension

13. Blood Pressure. Wikipedia the Free Encyclopedia. Oct. 2 2015 https://en.wikipedia.org/wiki/Blood_pressure

14. Sphygmomanometer. Wikipedia the Free Encyclopedia. Aug. 24 2015 https://en.wikipedia.org/wiki/Sphygmomanometer

15. Prehypertension: Are You at Risk? WebMD http://www.webmd.com/hypertension-high-blood-pressure/guide/prehypertension-are-you-at-risk

16. Hypotension. Wikipedia the Free Encyclopedia. Sep. 29 2015 https://en.wikipedia.org/wiki/Hypotension

17. Benjamin Wedro, MD, FACEP, FAAEM . Electrolytes. eMedicine Health. Aug 4 2015 http://www.emedicinehealth.com/electrolytes/article_em.htm

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 Boning Up On Bones 

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Boning Up on Bones

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 2.5 - Approximate time required: 150 min. 

Educational Goal:

To provide Adult Foster Care providers with the background information that will help them promote good bone health of their residents.

Educational Objectives:

1. Instruct about the consequences of poor bone health.
2. Teach about the anatomy and physiology of bone.
3. List the factors that limit bone health
4. Inform about the caregivers role in preventing bone loss

Procedure:           

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

Disclaimer  

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Boning Up on Bones

It has always been my opinion that adult foster care is an under- appreciated and under-utilized portion of the health care continuum.  Whether you run a developmentally disabled, mental health, or elderly care home, the potential to impact a patient’s life for the better is poorly developed. The root of my opinion stems from the fact that so much of a person’s health depends on what happens in-between doctor’s visits. Doctors, pharmacists, and nurses have a great deal of knowledge, but no one has more day-to-day impact on patients’ lives than foster care homes. It is the day-to-day activities over the long run that really determines whether a patient stays healthy or gets ill.

There is no better example of this than bone health.  Other than the odd genetic defect, bone health is largely determined by lifestyle and dietary choices we make over our lifetime. The impact those choices make are very subtle. Bone health problems don’t happen suddenly but develop over a long period of time. The consequences of those choices are usually felt when we age.

According to the National Institute of Health (NIH), “By 2020 half of all Americans over 50 will have weak bones unless we make changes to our diet and lifestyle.”

Those of us who develop weak bones are more likely to suffer significant health issues that will dramatically affect the quality of our lives.

• Each year, 1.5 million older Americans suffer fractures because their bones have become weak.
• A broken hip makes you up to four times more likely to die within three months.
• One in five people with a hip fracture ends up in a nursing home within a year.
• Those with weak bones become frightened to leave home or engage in activities because they fear they will fall. This leads to isolation and depression.
• The fear of falling leads to a sedentary lifestyle that is a major risk factor in developing other disease states like diabetes, high blood pressure, obesity, deep vein thrombosis, and spinal disc herniation (lower back pain).
• Multiple micro fractures in the spine lead to the poor posture “hunched over” look of the elderly and compromises the comfortable feeling that good posture brings in all daily activities.

Weak bones are not inevitable, and poor bone health is not part of the part of the aging process.  The consequences of a lifetime of poor choices can still be impacted by the good day-to-day lifestyle choices we make now.

Which health profession has the most impact on the day-to-day lifestyle and dietary choices of patients?  Adult foster care does.   To make a positive impact, caregivers must know what to do. So let’s bone up on bone health and learn about what the care provider can do to maintain your residents’ bone health.

What Is a bone?

It may sound like a stupid question, but do you really know what a bone is? Most of us know bones as the hard, lifeless material leftover after a meal. That is only part of the story of our bones.  Our skeleton is a complex system of many parts. It contains blood vessels, marrow, cartilage, tendons ligaments, and nerves. It is a dynamic system that constantly functions and serves us in many ways.

Purposes of Our Bones

1. Support

The skeleton provides the framework that supports the body and maintains its shape.  For example, without the rib cage the lungs would collapse.

2. Movement

Movement would be all but impossible without our muscles being anchored to bone.  Joints between the bones enable greater range of motion

3. Protection

Our bones provide a shield to keep vital body parts protected. Imagine what would happen to our delicate parts like the brain and spine cord without bones to protect them.  Our bones and cartilage also acts like a shock absorber, taking the brunt of outside forces like falls. 

4. Blood cell production

The skeleton is the start of our blood cell development in a process called hematopoiesis. Without our bone marrow, we would not have many of the components of our blood supply.  In children, hematopoiesis occurs primarily in the marrow of the long bones, such as the femur and tibia. In adults, it occurs mainly in the pelvis, cranium, vertebrae, and sternum.

5. Storage

Our bones are a bank that stores vitally important minerals that we use in our day-to-day lives, primarily calcium and phosphorus. If we don’t get enough of these essential materials in our diet, our bodies will a withdrawal from the stores in our bones. 

6. Hormone regulation

Bone cells release a hormone called osteocalcin, which contributes to the regulation of blood sugar (glucose) and fat deposition. Osteocalcin increases both insulin secretion and sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of fat. In return, the skeletal system is greatly affected by other hormones like estrogen.

Basic Structures of Our Bones

Bone material is a matrix of flexible and solid material.  What gives our bones flexibility is a protein called collagen. It forms a flexible netlike framework. Upon this framework specialized bone-building cells deposit the compounds calcium phosphate and calcium carbonate. These mineral compounds give the bone its strength. 

The bone is composed of two types of skeletal tissue laid down in layers. The outer layer or cortex is made up of a hard compact material called the cortical or compact bone.  It accounts for about 80 percent of adult bone mass. It may look like a solid material, but look closely enough and you’ll see it is filled with microscopic columns called osteons. Each column contains living bone cells and boney material wrapped around a central canal the Haversian canal. Each osteon column is connected to each other by other canals called Volkmann’s canals. The cortical bone is covered on the outside by a layer called the periosteum layer and on the inside by the endosteum layer.

Underneath the endosteum is the second type of skeletal tissue called the cancellous bone. It is also called trabecular or spongy bone, not because it’s soft like a sponge but because it’s very porous like a sponge.  It’s so porous that cancellous bone has 10 times the surface area of cortical bone. The porous spaces of the cancellous material is filled with bone marrow and hematopoietic stem cells, which are later transformed into platelets and red and white blood cells.

The longer larger bones have a center shaft that does not contain boney material but is filled with bone marrow.

The Activity Inside the Bone

The matrix material of both types of bone tissue is an active place where minerals are constantly being laid down and removed. The work is done by three types of specialized cells, osteocytes, osteoblasts, and osteoclasts.

Osteoblasts are bone-forming cells and are found mainly on the surface areas of the bone.

Osteocytes are osteoblasts that have become surrounded by the boney material they produced. When they are encased, they cease forming new bone material and are more associated with maintaining bone function.

Osteoclasts are cells that breakdown bone tissue by secreting enzymes that dissolve the mineral portion of the bone. The dissolved minerals are then transported out of the bone via bodily fluids to be used elsewhere.

All three cell types are sensitive to chemical signaling as seen in hormones and are involved in changing bone mass due to stresses on the bone.

Bones As We Age

At first glance, bones may appear to be a solid, unchanging support system.  In reality, bones serve many purposes and are constantly changing to meet ALL the demands placed upon them.  They change considerably as we age.

Before we are born, our bones start out mostly as cartilage. This helps the body go through the many changes it faces.  Then in a process called ossification, cartilage is replaced by bony material as the body starts to grow. 

Initially, newborn and infant bones are filled mainly with cancellous bone tissue filled with blood-producing red marrow.  As the infant grows, a portion of the cancellous tissue is replaced by the more supportive cortical bone tissue.

In our early developmental years, our bones need to grow a lot. In a process called Modeling new bone material is laid down in patterns that support this massive growth.  The body is geared to direct minerals and nutrients toward the needs of growth.

 The body continues the growth process until it reaches maturity between the ages of 18 to 30 years old. After that the skeletal system shifts functions from growth to maintenance and support.

In our mature years the same bone cells continue to lay down new bone and break down old bone but the balance between the two has changed.  Growth is no longer needed so bone processes switch to Remodeling, basically a turning over of bone mass. It has been estimated that most of adults bone mass is replaced every ten years.

In the long run the skeletal system changes according to what is needed at the time.  Growth is just one factor of need. If we work hard and put stress on the bone it responds by bulking up the bone to handle the added of stress. This explains why right handed people have bigger bones in their right arm. Dentists utilize this process to change teeth. They apply braces to the teeth that put stress on the bone. The braces guide the teeth in new growth and force the remodeling of the existing bone material.

The processes of modeling and remodeling are limited by what materials we take in to replenish what is used up. You can’t make a dollar’s worth of bone with 50 cents of material acquired from the food we eat. 

The crucial points for caregivers to understand about the processes of bone growth and support can be made easier if you think of the bones as a bank vault. The body starts out with a very small bank account of minerals but has tremendous growth potential. In the beginning most of the minerals we bring into our account goes into making the bank vault bigger. After a while we stop making the vault bigger and instead make the walls of our vault stronger.  We fill up the vault with the resources that will be needed later in life. As the need arises we dip into the supplies held in our bank account.  With each meal we replenish our account with new minerals. If there isn’t enough in reserve to meet our day to day needs then our bodies start to use the materials in the walls of our vault. If we have made our vault big and strong enough then taking some from the walls won’t affect our bank vault that much. But if the walls aren’t thick enough then it will be easier to break the bank and cause problems. 

This story’s bank vault theme can be seen prominently in the metabolism of calcium. The mineral calcium is used throughout our body, especially in the nervous system and muscles. That includes the brain and heart. It is a priority of the body to always have enough calcium in the blood stream to keep things running smoothly. But only 1 percent of our body’s calcium is found in the blood.  When more is needed, it has to come from the bones.  Ninety-nine percent of the body's calcium is stored in the bones and teeth.

 Inherent Limitations

The skeletal system works remarkably well considering all the changes it goes through and how variable dietary mineral intake can be. There are some limitations, though, that can lead to breaking the bone bank.

Bone Loss Due to Age and Disease

Bone loss due to age is a normal reaction to the environmental and metabolic changes that occur as we advance in years.

1. Our daily routines change as we age. We engage less and less in activities that put bone-building pressure on our skeleton. It is a natural response to lose some of our bone mass.
2. Maintenance of the skeletal system is dependent on a complex system of hormones and other body systems. As we age or through disease these control systems start to wear down, resulting in bone mass loss. This is particularly common in post-menopausal women. On average, a woman loses 10 percent of her bone mass during the menopause transition.

Calcium Regulating Hormones

Another example of how aging contributes to bone loss is a combination of an aging body and a change in habits. Calcitriol that comes from vitamin D is used by our body to help absorb calcium from our diet. Our bodies make vitamin D when sunlight strikes our skin. Older adults tend to stay indoors away from vitamin D-giving sunlight. They also naturally feel cold easier, so they wear more clothing.  This also prevents the sun from reaching their skin.  As a result, the body can’t make enough vitamin D to process the calcium that it takes in. To maintain blood calcium levels an increased amount of calcium has to come from the skeleton. As a result, we start to lose bone mass.

Genetics

Even though there are many ways we can voluntarily build bone mass, the genes we are born with play a major part of how our bodies are built. There are those who naturally have smaller bones so they are at greater risk for bone-loss-related problems or have other inherited bone-loss factors.

At-risk groups:

• Women (menopause)
• Caucasian people of Asian descent
• Families with congenital abnormalities. Having a parent or sibling with osteoporosis puts you at greater risk, especially if your mother or father experienced a hip fracture.
• Body frame size. Men or women who have small body frames tend to have a higher risk because they may have less bone mass to draw from as they age.

Lifestyle Inadequacies

We can’t feel or sense the mineralization or de-mineralization process so most of the time we can’t tell how healthy our bones are.  There are no outward signs to let us know how our actions are affecting our bones.  The lack of outward symptoms to warn us of danger leads many of us to make unwise choices.  Many of us unknowingly start to lead lifestyles that lead us straight into future bone loss trouble.

Contributing lifestyle factors for bone loss:

• Poor diet- Healthy bones depends so much on what we eat. For healthy bones, you must have adequate amounts of calcium, phosphorous, and vitamins C, D, and K.
• Excessive alcohol- More than one drink a day for women and two drinks a day for men can cause bone loss.
• Excessive caffeine- Too much caffeine interferes with calcium absorption.
• Smoking- Tobacco also prevents calcium absorption.
• Eating disorders or just trying to be thin is closely related to an inadequate diet.
• Sedentary lifestyle- plainly put: no exercise = bone mass loss.

Drug-induced Bone Loss

Long-term use of certain medications can cause accelerated bone loss. This is a very complicated topic. I could write several hours just on bone loss due to drugs alone. Since caregivers have little impact on drug therapy decisions, we’ll just let the doctors worry about that topic for now. There are a few groups of residents who are at greater risk than others so caregivers can help compensate for bone loss.

Watch out for residents who take:

Steroid inhalers for asthma

Anti-seizure medications

Anti-hormone (testosterone and estrogen) medication used in treating breast and prostate cancer.

Stomach acid blockers (proton pump inhibitors)

This is one area where developmentally disabled (DD homes) may have greater concern than other care homes.  It is not that uncommon for their residents to be on asthma, seizure, and PPIs medications all at once in the bone-forming years.  If you have one of these special residents in your home, it would be wise to counsel with the doctor specifically about their bone health.

 Bones Big Enough for a Lifetime

Let’s take a look at the big picture. In the beginning of life, the body makes massive changes in the bone. Over time, the skeleton starts to settle down and gradually build up bone mass. Generally speaking, a reaches its peak bone mass in its 30s. After that, the body switches directions, and bone mass starts to decrease. Under normal conditions, bone loss is very slow and we have enough bone mass to last a lifetime.  Unfortunately there are plenty of issues that can go wrong. Things can happen that interfere with building up the proper amount of bone mass, so there isn’t enough mass to last a life time.  Other factors can accelerate normal bone loss to the point where the bone can no longer properly handle the stresses put upon it. Outwardly we can’t feel the bone weakness until after the bone breaks.

Osteoporosis

When a patient loses so much bone material that the skeleton can no longer support body actions, that person has osteoporosis. Osteoporosis is a disorder of porous bone. If you could see the bone under a microscope, normally dense material has become thin and the strong matrix of cancellous bone is so porous that it has become brittle.   Minor falls and normal physical stresses can lead to broken bones.  The most likely place for breaks to occur is in the cancellous (trabecular) bone tissue of the wrist, hip, or spine. Any broken bone can cause severe pain. For patients with osteoporosis, that pain may not go away even after the break heals. Osteoporosis also causes a loss in height as micro fractures cause the vertebrae to compress. Micro fractures also can lead to poor posture, (making the sufferer to become stooped or hunched), which results in chronic back pain.

Discovery and Diagnosis

Osteoporosis is often discovered by the doctor when the patient sustains a low-trauma fracture. The diagnosis is confirmed by measuring the patient’s bone mass by the use of specialized x-ray machines and comparing it to the bone density of a healthy bones. The doctor evaluates the x-ray readings [Dual-energy x-ray absorptiometry (DXA)] and compares them to an index of bone mass. They then do some statistical analysis and come up with some number-crunching values called z-scores or t scores.  Z- scores is a comparison to the normal bone density for that of person of the same age and sex. A T-score is a comparison to young adult bones.

For those of you who are interested (probably a very low percentage of readers) the most common diagnosis of osteoporosis is made with a T-score of 2.5 standard deviations below a young adult healthy bone. 

Osteoporosis is a serious medical concern. It can lead to chronic pain, disability, institutionalization, social isolation, depression, and death. It leads to 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions annually in the America. For 2005, the medical costs have been estimated at $17 billion. Hip fractures alone account for 14 percent of all fractures and 72 percent of fracture costs.

Osteoporosis costs the patient dearly and is a heavy burden on our society.  It is well worth the caregiver’s efforts to prevent it or treat it with maintenance therapy if occurs their residents.

 Caregiver’s Role- Prevention and treatment

Osteoporosis is not part of the normal aging process. It can be prevented and treated by making simple but powerful lifestyle choices and if needed medication therapies.  Adult foster care providers are in a unique position to have the most impact on lifestyle choices, more than any other member of the health care team.  It will take daily caregiving efforts and a long-term point of view from both the resident and the caregiver. The good daily actions you take now will be of benefit for years and even decades to come.

Areas of Focus

There are four areas of therapeutic focus when working toward the goal of obtaining and maintaining healthy bones. They are the same for children and the elderly; it is just matter of how much is required. Adult foster care providers are in control of three of them and have significant impact on the fourth.

They are:

• Avoid risks
• Nutritional support and healthy diets
• Plenty of exercise
• Medication

Avoid Risks

Let’s review the behaviors that increase bone loss from a caregiver’s point of view.

• Alcohol- This is a no brainer. I don’t for see any responsible caregivers serving up cocktails for their residents.
• Smoking- Just one more reason to have a tobacco-free home. This can be a bit more challenging for mental health homes. Smoking has been linked to mental illness as patients unknowingly try to relieve mental health symptoms through smoking. Properly educating mental health residents and rewarding proper choices can help break the habit. Nicotine addiction can be broken in as little as two weeks. Caregivers can help by making it uncomfortable to smoke, breaking up smoking routines, and pointing out that smoking is a very poor choice in relieving mental illness symptoms. 
• Caffeine- Another addiction that can be problematic. In regards to bone health, it’s a balancing act. No caffeine is best, but moderation in the amount of caffeine from all sources is doable for most care homes.
• Sedentary Lifestyle- If caregivers view themselves as babysitters; they want their clients to sit around doing nothing. (bad choice in my opinion) If caregivers view themselves as medical professionals, they will schedule activities (a better, more fulfilling role in my opinion). Caregivers should take advantage of community and family resources for possible resources. Assigning residents minor chores is not out of the question either. Residents like to have a purpose.
• Falls- Caregivers should regularly inspect their home and remove slip and trip hazards. Remember, even minor falls can be life threatening for residents with severe osteoporosis.

Nutritional Support

Having healthy bones depends largely on having enough bone-building materials in the first place. Caregivers must remember that bones are not unchanging tissues. Bone mineral materials are constantly being pulled away for use by the body. So replacement should be constant as well. Where does that mineral come from and how much is needed should be a prime concern for caregivers.

How Much Calcium

Getting enough calcium is a prime concern for building and maintaining bone. The largest amount of calcium is needed in the bone-building years between the ages of 9 and 18. Daily requirements reduce somewhat in the adult years but increase for women after menopause and everyone after the age of 70.

Calcium requirements

Warning- large doses of calcium can be constipating. If the problem arises, don’t reduce the calcium. Increase the resident’s fluid, fiber, and whole-body activity. Notify the doctor of persistent irregularity problems.

How Much - Vitamin D

Vitamin D is an essential part of the digestion of calcium. Without vitamin D, we can’t absorb enough calcium in our gut and maintain the bone we do have.  The bone disease rickets is essentially caused by a lack of vitamin D.

IU- International Units

Vitamin D lasts a long time in our bodies so normally there is a healthy amount floating around. Daily amounts are just topping off the tank, so to speak. If the patient’s overall concentration is down, the doctor will prescribe mega doses to build up reserves.  There is a green liquid-filled, football-shaped jell tab prescription of vitamin D that has 50,000 IU. It’s usually prescribed once a month.

There are several other vitamins and minerals that are important to bones but are too numerous to write about them all. They will all be covered with a properly balanced diet or a daily routine of vitamin and mineral supplements.  An important note about multivitamins and mineral pills: One size does not fit all. Nutritional needs change as we age, so choose age-appropriate products to get the optimal mix of vitamins and minerals.

Healthy Diets

The typical American diet lacks all the nutrients needed for healthy bones. Caregivers must make a conscious effort to make healthy meals for their residents. Milk and other dairy products are the traditional source of calcium in our diets. Three servings a day is a good benchmark to aim for. Teenage residents should get four.  Other sources of calcium are green leafy vegetables, broccoli, soybeans, and fish products with edible bones in them (sardines and salmon). You can even buy calcium-fortified products like orange juice.

In a perfect world, you could give all the bone health nutrients that your residents need from the foods you serve them. During shopping trips, you would consult packaging information on the products you buy. Then you can place the proper foods into a well-balanced menu.  Have a handy reference chart of the nutritional values of raw vegetables and fruits to easily consult when shopping. 

In the real world, that is pretty hard to accomplish.  A few tips that will help caregivers include planning a menu and making a list of the proper foods to buy before you go shopping.  Cook from scratch whenever circumstances permit. This will help avoid overly processed foods that are poor in nutrition. Whole grains are always the best. Select foods across the color spectrum. This helps ensure variety. A broader spectrum of foods helps to ensure a broader spectrum of nutrients is consumed.  Snacks of cheese, raw vegetables, yogurt, and the always-popular milk and whole grain cookies are an easy way to sneak in more nutritional foods into the diets of even the pickiest of eaters.

Plenty of Exercise

Our bones are built to respond to the physical demands we put upon them. The more stress we put on the bones, the stronger they can become.  When we work hard, the muscles and tissues around the bone send chemical signals to the bone-building cells that make them work harder. In addition, when we exercise our bones, tiny micro fractures occur. The bone-building cells repair this damage with new stronger bone. Caregivers can take advantage of these processes to build bone mass in their residents with an active lifestyle.

How Much Time

Children and teens should get at least an hour of physical activity every day. Adults should get at least 30 minutes every day. Moderate weight-bearing exercise is the best and easiest to continue over time.  Examples are walking, jogging, dancing, gardening, and household chores like vacuuming.

Tips for Caregivers

Exercise programs in care homes can be very problematic. Here are a few tips that might help.

Taking Walks

Taking walks is a perfect fit for care homes. It’s a weight-bearing exercise. It helps work on balance and coordination. It’s easy to schedule into the daily routine. It’s easy to do in groups. In addition, you get sunshine on the skin, making vitamin D. 

Low-impact Exercise

You can reduce the possibility of injury by using low-impact exercise machines. Elliptical, gliders, and steppers are low impact and give more full-body exercise. Stationary bikes require less supervision. Use timers that alert you when the resident is done so you can be there when they stop. Always be with in supervising distance. Place the equipment in front of a TV or window to help fight exercise boredom.

Check Off Charts

Using charts that exercisers must check off gives a sense of accomplishment. It also helps the caregiver supervise exercise routines and reinforce good habits.

Can't Walk

For those residents who can’t walk, try using hand weights. Exercise stretch bands can give a more full-body workout. Mini peddlers can be placed on table tops and worked by hands instead of feet.  For more exercise ideas, go to the computer and type in “chair exercises for seniors.”

 Take It Easy

The rule of thumb is start low and go slow. Establishing long-term habits is more important than quick strengthening results. Exercise does not have to be continuous for good bone health. A 30-minute routine can be broken up into 10-minute segments. The hour needed for children can be achieved throughout the day.

Doctors and Bone Health

Doctors can be a great resource for help as caregivers and their clients work on bone health. There are many classes of medication that can help in many ways. Doctors must approve any multivitamin or mineral supplement, but they are usually open to requests. It never hurts to phrase requests in the form of a question. Example- I’m concerned about Mr. Smith getting enough sunshine this winter, do you think he needs a vitamin D supplement? Consult with doctors before starting any strenuous exercise regime.

If you have any concerns, communicate with the doctor. Call them, send them an email, and write them a note. Doctors may be in charge of all things medical, but they are ultimately just a servant to the needs of your resident. In your role as a patient advocate, it’s your job to utilize every resource available to keep them healthy and happy.

Conclusion

If your clients continue in inadequate lifestyles, it is inevitable that at some future point weaken bones will break. It is a sad fact that as many as half of all women and one fourth of all men older than 50 will fracture a bone at some point due to osteoporosis. Teenagers who fail to achieve their full peak bone mass will never be able to make it up later on in life.

Fortunately, there are plenty of things you as their caregiver can do to help avoid the pitfalls of weakened bones. Whether your resident is young and building bone or older and trying to preserve as much as they can, the simple steps but long-term efforts of having a balanced diet, getting plenty of sunshine and exercise, and utilizing the doctor as much as possible will help ensure that there will be enough bone to last a lifetime.

As always, good luck in your caregiving efforts.

Mark Parkinson RPh

References:

1. Bone health: Tips to keep your bones healthy. Mayo Clinic.org. Feb 9 2013 http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/bone-health/art-20045060?pg=1          

2. Mary Anne Dunkin, 8 Ways to Keep Bones Healthy and Strong. Arthritis Foundation.org http://www.arthritis.org/about-arthritis/types/osteoporosis/articles/preventing-osteoporosis.php

3. Peter Jaret, How to Keep Your Bones Strong as You Age. WebMD. Oct 14 2013 http://www.webmd.com/healthy-aging/nutrition-world-2/bone-strength     

4. Healthy Bones Matter. National Institute of Arthritis and Musculoskeletal and Skin Disease, National Institute of Health. NIH Publication No. 11-7577(B). Aug 2012 http://www.niams.nih.gov/Health_Info/Kids/healthy_bones.asp

5. The Surgeon General’s Report on Bone Health and Osteoporosis: What It Means to You. National Institute of Health. NIH Publication No. 12–7827 Mar. 2012 http://www.niams.nih.gov/Health_Info/Bone/SGR/surgeon_generals_report.asp    

6. The Basics of Bone in Health and Disease. National Center for Biotechnology Information, Book Shelve, National Institute of Health. Bookshelf ID: NBK45504. http://www.ncbi.nlm.nih.gov/books/NBK45504/

7. Human skeleton. Wikipedia the Free Encyclopedia Oct. 16 2015 https://en.wikipedia.org/wiki/Human_skeleton         

8. Bone. Wikipedia the Free Encyclopedia Oct. 13 2015 https://en.wikipedia.org/wiki/Bone

9. Oddom Demontiero, Christopher Vidal, and Gustavo Duque, Aging and bone loss: new insights for the clinician. National Center for Biotechnology Information, National Institute of Health. Apr. 4 2012 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383520/

11. Dr. Susan E. Brown, PhD, Bone loss in menopause — how to reduce your risk. Better Bones.com Jul. 7 2014 http://www.betterbones.com/betterbody/bone-loss-in-menopause.aspx

12. Risk factors. Mayo Clinic.org http://www.mayoclinic.org/diseases-conditions/osteoporosis/basics/risk-factors/con-20019924

13. Susan K. Bowles, Pham D. MSc. FCCP, Drug Induced Osteoporosis. Pharmacotherapy Self-Assessment Program Seventh Edition.

https://www.accp.com/docs/bookstore/psap/p7b03.sample04.pdf

14. What is Osteoporosis? National Osteoporosis Foundation.org http://nof.org/articles/7           

15. Clinician’s Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation Jan. 2010

http://nof.org/files/nof/public/content/file/344/upload/159.pdf National Osteoporosis Foundation.org

16. Vitamin D Fact Sheet for Health Professionals. National Institute of Health. Nov 10 2014 https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

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