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Behavior Management, A Deep Dive
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Exam
Introduction to Care Plans
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Introduction to Care Plans
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 1 - Approximate time required: 60 min.
Educational Goal:
Tell In-Home caregivers how to use Care plans.
Educational Objectives:
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 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.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
Introduction to Care Plans
There has been a growing recognition of the need for better communication and planning in caregiving. To address this issue, many medical professions have started to implement a program of formal care plans that provide a framework for how care is provided. Government oversight has recognized the value of these efforts and has started to mandate the use of care plans. So, could you benefit from a Care Plan for your residents? Hopefully, by the end of this lesson, you will be able to answer that question for yourself. Let us start off with- what is a care plan?
Definition – Care plan
The Centers for Disease Control and Prevention defines a Care Plan as:
“A care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments.
Care plans can help:
Care plans can be especially helpful if you care for more than one person.”
You can see the CDC care plan form here. https://www.cdc.gov/caregiving/media/pdfs/Complete-Care-Plan-Form-5081.pdf
There are many different types of care plans. They can be simple to very complex. It all depends on what is needed and who needs to be involved.
Other examples of care plans are here; just click the links.
https://printblame.com/health/nurses/nursing-care-plans/
https://inkpx.com/templates/6olv/printable-simple-minimalist-student-nursing-care-plan-template
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I know what some of you are thinking.
Oh really!? Are you so sure about that? Let’s take a closer look, shall we?
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Care plans are another caregiver tool that will help you be more professional and, if used correctly, make your job easier. Worth it? In my opinion, yes- worth it! So let’s get after it. Care plan, ready, set, go! |
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Let the Purpose Guide You
There is no “One Size Fits All” format for Care plans. In my research, I found a dizzying variety in the formats and content in the examples I saw. Then it struck me, the Care Plans were different because each had a different purpose. Naturally, a Nursing Home care plan would be different from a Nursing care plan. Similarly, a Nursing home care plan with a large staff of different medical professionals that need coordinating would be different from an Adult Foster Care home with just a few employees. So the first step in writing your care plan is determining the purpose of your care plan. What are you trying to accomplish with it?
Building a Care Plan
So what caregiving and business elements are important to you? If nothing comes to mind, start asking yourself some questions.
To sum all of the above up, where’s the need, and how do you build your care plan to meet that need? Here are a few examples
Reporting Tool
Need- You have a resident who has a complicated medical condition(s). The Doctor or Home Health Nurse has to have frequent reports to judge the effect of therapy.
Steven Johnson
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Health Problem |
Goal of Care |
Intervention |
Out Come |
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Sedentary lifestyle due to pain in the legs |
Increase mobility and decrease the level of pain |
Control Diabetes, Establish a regular exercise program, and develop a pain medicine regimen |
Diabetes is controlled but pain continues at levels 6-8. Patient refuses to get up and move about. |
Patient File Tool
Review the CDC form again by clicking here.
chrome- extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/caregiving/media/pdfs/Complete-Care-Plan-Form-5081.pdf
Fair warning, there will be some quiz questions about what's on the form.
Here is a shortcut suggestion. Can you take your current patient information filing system and make a few tweaks to turn it into a Care Plan? For instance, instead of just recording basic information, add some forward-looking sections as they have in the CDC form.
Mary Ann Webster
In a few sentences, tell people what you want them to know about you.
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I have an allergy to strawberries. I like to take walks. I need to watch church services on Sunday. I have fallen twice while going to the bathroom at night. |
Baseline and Outcome Tool
This could also be called a Goals and Outcome Tool. The idea is to gather data about a patient's behavior or condition. Then, with the help of the doctor or other medical professional, determine what therapies and outcomes are desired. Next, track the progress toward the goal. This could also be used for non-medical aspects like overall contentment. In these cases, you would get the help of family members or church groups. Since you are tracking outcomes, it would be helpful if you could measure something. For example, on a scale of 1-10, 10 being the best, how content do you feel?
Training Tool
The main caregiver quickly establishes a routine that works well. But when a new hire or substitute caregiver gets involved, then a care plan is a very useful tool in getting them up to speed quickly. When I ran my own Adult Foster Care homes, we had a laminated chore list that the employee would check off with a grease pencil. A whiteboard would do just as well.
To make such a care plan manageable, you could divide the different components into the categories of
If you include the resident in developing this list, you get to personalize the care plan to fit individual needs and wants. Good for business if the desires of the customers are asked for and taken care of.
A Living Document
Care plans are not a “one and done” event. There is a need to continually review and update the plan as circumstances change. Besides, no one gets it perfect the first go around. There is always a way to do things better. Always be on the lookout for how to make the care plan more useful and effective. That is how you make your job easier and make your business more competitive. Always plan for improvement.
Make Your Own or Buy One Premade
In my opinion, it is always better to make things up yourself. That way, you can customize things to meet your needs. But I know just how hard it is to write up something from scratch. If you're new to the concept of care plans, it could be easier to use someone else’s form. Then adjust it as you become more familiar with the concept of care plans. If you want to see what is out there to copy or buy, go to your computer and search for, Nursing Care plan templates or Nursing Home Care plan templates. Next, narrow the search by looking at the field on the screen just below where you just typed and change the settings from “All” to “Images”. Look around, there are plenty of choices out there that are free or purchased cheaply. Also, there are some really good ideas on what to include in your care plan.
Using a Care Plan
Writing up a care plan form and using a care plan are two different things. It’s going to take some practice. As you travel up the learning curve, you will gain a deeper understanding of the principles of good caregiving. As you stick with it and pay attention to what works and what doesn’t, you will become a more skilled caregiver. I believe you will find that you will travel up the learning curve faster if you implement the care plan using a 5-step outline. Assessment, Identification, Goals, Execution, Evaluation.
Care planning starts with gathering information about the client. In a nursing home, they would have an interdisciplinary team meeting. Foster Care providers don’t have the luxury, so you are going to have to be tenacious about gathering the important information. This is also a good time to practice excellent customer service skills. By including the client and their family in this process, you are showing that you really care about the resident and are truly concerned about them. I suggest you make a form up and reuse it for every new client. That way, you don’t have to reinvent the wheel with every new resident.
This step involves identifying what needs require attention. Let the purpose of your care plan help guide your efforts. Depending on those purposes, you could include doctor’s diagnosis, nursing assessments, dietary restrictions and requirements, socialization needs, and religious practices.
You could just copy what the doctor says the goals of therapy are, but you would be missing out on a great opportunity. A patient has the right to review and refuse any medical effort. By including the resident in this goal-setting session, you are showing that you are more than a babysitter. You are becoming their advocate. Someone on their side who is looking out for their interests. You will find that the resident and their family become more cooperative, more grateful, and more loyal to you as a friend. Establishing that personal relationship is worth every effort you make. It’s caregiver gold.
Be thorough and methodical in the execution of your care plan. Include it in your daily routines. Write it up as job procedures. And for heaven's sake, keep good records of outcomes.
Simply put, are the goals being achieved? Do the goals need to be adjusted? Do you have to strap on your armor and do battle with the doctor? As a good caregiver, it’s your job to be an effective patient advocate. As a good business person, it would be beneficial to let the client know that you are going to battle for them. Being an effective communicator is key here. This is also the place where you can determine if you are improving as a caregiver. Are your skills and the skills of your staff improving?
Care Plans as a Protection
As a final note. When something goes wrong, who does everyone look at first? You of course. You're left scrambling to avoid trouble. The harder you scramble, the guiltier you look. The care plan and its documentation can keep you out of hot water. It also helps keep employees and substitute caregivers in line. That’s how the big boys at the nursing home and hospital operate. Why not you?
Conclusion
So, what is your answer to my first question? Could you, your staff, and your residents benefit from using care plans? Can you see how useful a tool they are in caregiving and business? You get to know your residents better. It is a way to systematically improve what is most important to you and your clients. It helps you not forget anything important. It enables you to be better at caregiving and appear to be more professional to those around you who matter. It also helps you prove your case in any dispute and gets any government regulator off your back. In my opinion, it’s something you have to get good at.
Good Luck in those efforts, Mark Parkinson, BsPharm
References:
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Food Handlers and Food Poisoning in Foster Care
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 1 - Approximate time required: 60 min.
Educational Goal:
Provide food handler training for Foster care homes.
Educational Objectives:
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 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.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
Food Handlers and Food Poisoning in Foster Care
The Problem- Food Poisoning
Your residents are under attack
Your residents are constantly being assaulted by an evil army of noxious little critters that want to invade their bodies, start to multiply, and eat them from the inside out. The medical term for them is pathogens. Normally, a healthy body can defend itself against this evil army. Unfortunately, there are members of that evil army (a whole host of bacteria, viruses, parasites, and fungi) that have figured out how to get past our defenses by hitching a ride on the food we eat. Once they are inside us, they can cause all sorts of problems. There are more than 250 food-borne illnesses that we can be afflicted with. Collectively, we tend to call them all food poisoning. Fortunately, adult foster care providers can stop these invaders cold by following a few simple rules in food preparation.
But first--------
What does food poisoning look like?
According to the CDC, “The most common symptoms of food poisoning include diarrhea, stomach pain or cramps, nausea, vomiting, and fever. Signs of severe food poisoning include bloody diarrhea, diarrhea that lasts more than 3 days, fever over 102°F, vomiting so often that you cannot keep liquids down, and signs of dehydration.”
The CDC also states
“See a doctor if you have any symptoms that are severe, including:
Complications of food poisoning
Again from the CDC
“Most people have mild illnesses, but some infections spread by contaminated food are serious and even life-threatening. Some people may need to be hospitalized, and some illnesses lead to other health problems, including:
For some people, these health problems can last for weeks or months after recovering from a foodborne illness. For others, they never go away.”
Where does food poisoning come from?
This is probably the most important part of this whole CE. Food poisoning can come from anywhere. Not only from restaurants and food vendors, but also from grocery stores’ produce section and meat markets. Even from the cleanest of home kitchens. You must assume those nasty little critters are everywhere. If you think about it too much, you can turn yourself into a germaphobe
Higher Standards
A lot of food poisoning cases are mild, and symptoms go away by themselves. Our body has some pretty good defenses in place. Even if a few of the enemy army manage to get inside us, they are usually killed off quickly by a healthy body's antimicrobial resistance. But we are not taking care of healthy bodies, are we? Your residents’ immune systems are compromised. That is why Adult Foster Care health professionals are held to higher standards of food preparation and storage than the average home. Your residents need your vigilance to remain well and be infection-free. Count on county licensors inspecting your kitchen and food storage areas and asking pointed questions about your food handling techniques. It’s just part of the job.
A few final points about where food poisoning comes from
All food-borne microbes will end up in your stomach acid, and that will be the end of most of them. But there are a few of those nasty critters that can survive the acid bath, and you need to know about them. Some of the names you will readily recognize.
Final quote from the CDC
“Some germs can make you sick within a few hours after you swallow them. Others may take a few days to make you sick. This table provides details about the symptoms caused by different germs, when they usually start, and common sources for those germs. Search the table for symptoms you are having.
|
Germ |
Symptoms and When They Start |
Common Sources |
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Staphylococcus aureus (Staph food poisoning) |
Nausea, vomiting, stomach cramps, diarrhea 30 minutes to 8 hours |
Foods that are not cooked after handling, such as sliced meats, puddings, pastries, and sandwiches |
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Vibrio |
Watery diarrhea, nausea, stomach cramps, vomiting, fever, chills Within 24 hours |
Raw or undercooked shellfish, particularly oysters |
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Clostridium perfringens |
Diarrhea, stomach cramps that last for less than 24 hours 6 to 24 hours |
Meat, poultry, gravies, and other foods cooked in large batches and held at an unsafe temperature |
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Salmonella |
Diarrhea (can be bloody), fever, stomach cramps, vomiting 6 hours to 6 days |
Raw or undercooked chicken, turkey, and other meats; eggs; unpasteurized (raw) milk and juice; raw fruits and vegetables; many animals, including backyard poultry, reptiles and amphibians, and small mammals |
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Norovirus |
Diarrhea, vomiting, nausea, stomach pain 12 to 48 hours |
Leafy greens, fresh fruits, shellfish (such as raw oysters), contaminated water, infected people, touching surfaces that have the virus on them |
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Clostridium botulinum (Botulism) |
Difficulty swallowing, muscle weakness, double or blurred vision, drooping eyelids, slurred speech, and difficulty moving eyes 18 to 36 hours |
Improperly canned or fermented foods, homemade alcohol (pruno) |
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Campylobacter |
Diarrhea (often bloody), fever, stomach cramps 2 to 5 days |
Raw or undercooked poultry, raw (unpasteurized) milk, contaminated water, pets (including cats and dogs) |
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E. coli (Escherichia coli) |
Severe stomach cramps, diarrhea (often bloody), vomiting Long-term effects: Around 5–10% of people diagnosed with E. coli develop a life-threatening health problem called hemolytic uremic syndrome 3 to 4 days |
Raw or undercooked ground beef, raw (unpasteurized) milk and juice, raw vegetables (such as lettuce), raw sprouts, and contaminated water |
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Cyclospora |
Watery diarrhea, loss of appetite, weight loss, stomach cramps, bloating, increased gas, nausea, fatigue 1 week |
Raw fruits or vegetables and herbs |
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Listeria (invasive illness) |
Fever and flu-like symptoms (such as muscle aches and fatigue), headache, stiff neck, confusion, loss of balance, and seizures Pregnant women: Infections during pregnancy can lead to miscarriage, stillbirth, premature delivery, or life-threatening infection of the newborn. Call the doctor right away if you have a fever and feel more tired and achy than usual. 2 weeks |
Queso fresco and other soft cheeses, raw sprouts, melons, hot dogs, pâtés, deli meats, smoked fish, and raw (unpasteurized) milk |
The Solution- Fighting to gain control
First line of defense
You, the food handlers, are the first line of defense against food poisoning. You and your residents won’t get sick if you are never exposed to sufficient enough quantities of germs to make you sick. That is the second most important concept of this lesson. In a homestyle kitchen, you can never eliminate germs, but you can greatly limit the amount of those nasty critters you are exposed to. That is the goal of food handler regulations of the state. Most are based on common sense techniques designed to control the growth and or exposure to food poisoning-causing microbes. If you find them inconvenient or annoying, remember that higher standards thing we talked about earlier. It’s just part of being a health care professional.
Let’s put this in a framework you are familiar with. You are accustomed to the concept of universal precautions to prevent patient and caregiver exposure to potentially harmful substances. Take those basic techniques and apply them to protecting foodstuffs. You are never 100% sure if the food you are handling is contaminated or if what you are doing will contaminate the food. You just assume that what you are doing is hazardous and take precautionary steps for protection.
Protecting the food from you
Let’s face it. You and the actions you take are THE major determinants of contaminated food. You have to control the environment where the food is and use good personal hygiene habits.
The kitchen, you, and the clothes you wear must be regularly cleaned. You must control your hair when cooking. Trim your nails or wear gloves if you want to have long fingernails. Be aware that jewelry and watches are where germs can hide. Aprons, oven mitts, hot pads, dishrags, and sponges must also be regularly cleaned or replaced. Disposable gloves are your friend. Their use easily solves many potential problems. Bandages must be covered with disposable gloves. But gloves can also get contaminated. (see the upcoming video) When in doubt, get on a new pair. Don’t forget to clean food storage areas on a regular basis, that includes the fridge and freezer.
When you touch any contaminated area, wash your hands before touching food. Duh, right. We already know that. Just as a reminder, wash hands:
Here is a quick, entertaining video reminder of why hand washing is important.
No pets in food prep areas. Especially birds above food and cats on counters. If you see a rodent or insect, take action quickly. The one you see represents multiple ones you can’t see. A good mouse killer is a cornmeal, sugar, and baking soda combination. The cornmeal and sugar draw them in; the baking soda kills them. Mice can’t burp or fart. The gas just builds up and kills the pest.
Garbage cans in kitchens having lids and liners are a good idea.
Caregiver sickness is a challenge for AFC homes. The worker can’t go home; they are at home. But you can get someone else to cook or order out. If you have to cook because there is no one else, use the universal precaution methods. Glove up and mask up. Cough and sneeze into a tissue, paper towel, or elbow. Wash more frequently. Clean and sanitize handled items.
Cleaning and sanitizing are not the same thing. Cleaning is the removal of grease, oils, and debris. Sanitizing is reducing the number of germs to safe levels. You cannot count on washing and scrubbing to kill off all the germs. You have to take additional steps to sanitize the food prep area.
You must apply a disinfecting or sanitizing chemical to kitchen surfaces. Then allow it to sit on surfaces long enough to be effective. There are several choices for kitchen sanitizers. The old standby is 1 tablespoon of bleach in a gallon of water. Leave on surfaces or soak items needing to be sanitized for at least 10 seconds.
Protecting you from the germs in food
Most, if not all the food you buy is clean but not sanitized. Under the right conditions, the germs in and on your food will multiply until they reach the numbers that can make you sick. The food handling goal is to kill them off and or keep them from multiplying to dangerous levels. Your main tools to accomplish this goal are controlling exposure to germ sources and the temperature of the food.
Temperature
Temperature has a direct effect on any microbe living on or in the foods we eat, especially perishable foods. Cold and freezing temperatures below 41°F reduce the metabolism of organisms, thus inhibiting their growth and reproduction. High heat (above 165°F) will outright kill the germs. Between 41°F and 165°F is called the Danger Zone, where bacteria thrive and multiply. The longer your food stays in the danger zone, the more unsafe it will be to consume.
Now you know why adult foster care homes have to have a thermometer in the refrigerator. The proper place for it is in the warmest part of the fridge, which is the front. That ensures that the rest of the fridge is below 41°F and out of the danger zone.
Freezing does not sanitize your food. When the food thaws and the temperature enters the danger zone, the microorganisms will wake up and start to grow again. The proper food handling principle is to reduce the amount of time perishable foods stay in the danger zone to the shortest time possible. The safest way to thaw food is in the refrigerator or in the microwave.
The same principle applies to the other end of the danger zone. Temperature probes inserted into the perishable food showing temperatures above 165°F ensure that the germs have been killed off. But that is not the end of the food poisoning concerns. Some germs produce chemicals that are toxic to humans. For example, the bacteria Clostridium botulinum secrete the botulism toxin, which heat will not destroy. Thus, it is still possible to get food poisoning from properly cooked foods if that food has stayed too long in the danger zone. So you still have to be concerned with how much time the perishable food remains between 41°F and 165°F.
There is no way for you to visually determine if food has become dangerous from being held too long in the danger zone. It is recommended for safety reasons that “Foods left in the Danger Zone for more than four hours must be discarded.” (Oregon Food Safety Your Self-Training Manual)
Cross Contamination
If food that is ready to eat is exposed to a germ source, it is possible that those germs will grow and cause food poisoning, even if the food has already been cooked. This is called cross-contamination.
Watch this video
Other common cross-contamination sources are;
Preventing cross-contamination is not difficult if you are aware of all the potential germ sources around you while handling food.
Proper Food Storage
The final item to cover is how to safely store foodstuffs. Remember, you are trying to protect your food from potential germ sources, toxic chemicals, and danger zone temperatures.
Conclusion
We are surrounded by and are constantly under attack from an army of microbes that can cause us harm. The foods we eat are a potential weak point in our defenses. You, the professional care provider, are the first line of defense against these food-borne pathogens that can cause incidences of food poisoning.
Food handlers must have good hygiene habits and practice thorough hand washing techniques. Cleaning and sanitizing is a two-step process to protect you and the food from contamination. You need to assume that germs are everywhere and take precautions against potential cross-contamination. You must keep perishable foods out of the danger zone temperatures as much as possible. Foodstuffs have to be properly stored or disposed of in order to prevent foodborne illness.
As always, good luck in your caregiving and this time, food handling efforts.
Mark Parkins BsPharm
References:
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Behavior Management, A Deep Dive
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 4 - Approximate time required: 240 min.
Educational Goal:
Provide behavior management techniques options for In-Home caregivers.
Educational Objectives:
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 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.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
Behavior Management, A Deep Dive
Adult Foster Care providers have a very demanding job because of the insidious and dreaded Nevers.
You Never get to step away from the job. You Never get to go home after work; home is work. You Never get to leave troubling and grouchy customers behind because you live with them 24/7. Even when you do get to get away, like grocery shopping, you Never get to step away from the worry. “Is there going to be a five-alarm mess to deal with when I get home? On any peaceful, calm day, a resident's troubling behavior can turn your world upside down. In order for you to survive long-term in this profession, you have to gain behavior management skills and gain them quickly. In order to gain those skills, we first have to cover a few important principles.
Thee Most Important Principle
As we grow to adulthood, we learn the social norms of how to interact with other people. Those social norms help us interact with others with a minimal amount of conflict.
For example, when working with a teenager in a group setting and the kid thoughtlessly says some stupid remarks. You can call out his name a little louder than usual and give him that look. You know the one. You can expect a normal kid to respond with, “Oops, sorry,” and things get back to normal. We have learned that if we act in a certain way, we can influence others to react in a predictable way. It comes so predictably that we take it for granted that interactions with others will always work out the normal way.
Unfortunately, our residents aren’t normal. If they were normal, they wouldn’t need us to take care of them. You cannot always get the predictable response you want. Those social cues and demands that we use just don’t work when the resident’s physical and mental state has been altered in some way. What that really means to us caregivers is that when the residents don’t act like we want them to, our normal methods of getting them to change behaviors will not work. This is thee key principle in In-Home caregiving.
Understanding it will be the difference between success and burnout, thriving or failing. If you don’t get a handle on this one principle, you’re heading for unrelenting episodes of frustration and major amounts of stress that will lead you in the end to quit. Remember the example of the misbehaving teenager. If it were a developmentally disabled teenager acting inappropriately, raising your voice and giving them “the look” would accomplish nothing. Using that tactic would only lead you to shout louder and want to physically make them behave. This in turn, gives both you and the child a lot of stress and frustration.
A Different Way
To help you get a better understanding of what I am talking about, let’s have a look at the basics of how social norms work in resolving abnormal behaviors. When different individuals interact with one another, it is expected that everyone will look after themselves and not disrupt the lives of others around them. If a person acts in a way that disturbs another person, the offended person will give social cues or a verbal request to change their behavior. Simply put, “Knock it off. You're bothering me.” It is accepted as a social norm that the offender is responsible for figuring out what they did wrong and changing their actions to get back in harmony with the offendee.
This works pretty well at resolving issues. But what happens when the offender is handicapped in some way? They are hampered in either recognizing what they are doing wrong or are unable to change, even if they understand what they are doing. The result is that stress is created, and the problem escalates.
In a care home setting, it is reasonable to assume that all of your residents are handicapped in some way that may interfere with their ability to adjust their behavior. Experienced caregivers know that they need to do things differently from the social norm. They know that they need to become familiar with the handicaps that may interfere with behaviors and help to resolve issues that may come up. You, the caregiver, are to become the facilitator of the social harmony of your home.
Issues that can lead to Problematic Behaviors Experienced in Care Homes
Maladaptive Coping Mechanisms
Maladaptive behaviors are bad habits that residents use to cope with stressors in their lives. They initially relieve the situation for the resident but ultimately cause more problems and stress for everyone.
Melissa Porrey LPC, NCC states in an article from the website Verywell health. “Maladaptive behaviors can take many different forms, but broadly fall under seven categories:
Source: https://www.verywellhealth.com/maladaptive-behavior-8640911
Causes of Maladaptive Behaviors
In the same article, Melissa Porrey further states, “Maladaptive behaviors often arise from a combination of psychological, social, environmental, and even neurological factors. Some of these include:
| Medical Conditions |  |
There are many illnesses, disorders and injuries that can affect the function of the resident’s brain. These can lead to changes in awareness, movement, and behaviors. They can cause a normally acting resident to suddenly misbehave. No amount of corrective actions from the caregiver will remedy the situation until the underlying condition is addressed.
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Central nervous System issues |
Brain bleed (hemorrhage) Brain tumor Hepatic encephalopathy Fluid build-up in the brain Seizure Stroke Traumatic brain injury |
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Metabolic disorders
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Dehydration. Hypothermia. Hypoxemia (Low blood oxygen) Hypoglycemia (Low blood sugar) Hyponatremia (Low sodium levels in the blood) Hypocalcemia (Low calcium levels in the blood) Hypothyroidism (Underactive thyroid) |
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Drug side effects |
Antiseizure medications Anticholinergics (a group of drugs that control involuntary muscle movement) Corticosteroids Sedatives Sleeping pills Overdose or withdrawal of addictive substances |
|
Infections |
UTIs Encephalitis Meningitis Pneumonia |
Loss of Mental Capacity
Any condition or combination of conditions that reduces the ability of the brain to function properly will understandably lead to problematic behaviors. Often, the resident is unaware that they are causing problems. Expecting normal behaviors or reactions to caregivers' demands is unrealistic because they have lost the mental capacity to do so.
These conditions include
Pre-existing personality and psychiatric illnesses
Being Developmentally Disabled
Diseases that affect the Brain (Alzheimer's, Parkinson’s, Cirrhosis, Chronic drug Abuse, Age-related conditions)
Reduced vision problems that can cause hallucinations
Here is a good YouTube video that shows you what that might look like.
Disclaimer- I have no financial connection to any of the videos used in this lesson. I did not produce them. I found them in YouTube's public domain. Please forgive the commercials. They enable me to give you the material for free. If you want to look further into the presenters' programs, contact them directly using the information provided or look in the comment section below the video.
Loss of the Ability to Communicate Properly
The resident who cannot communicate properly will naturally be under more stress. This inability to communicate leads to unmet biological and emotional needs. The only way to get what they want is to act out to get your attention. If there is additional cognitive decline, the resident will act out without knowing why they are agitated. For example, there might be a pain issue or a need to go to the bathroom that leads to aggressive or inappropriate behaviors.
Here is another excellent YouTube video dealing with issues related to loss of language skills. The presenter explains the biological cause of some bad behaviors related to dementia. Please excuse the bad language; it is appropriate in this example because you might face it yourself someday. It’s a long video, but trust me, it’s worth it. There will probably be a test question or two from the video.
Acting on the Principle: Stop and Look Deeper
The takeaway from all of the above is that there could be many reasons for bad behavior in your residence. There is a genuine possibility that they may not be able to help themselves from acting badly. There is also the distinct possibility that the patient may not be able to correct the disruptive behaviors once they happen. There are too many factors that may not be under their control. In care homes, the occurrence of these circumstances is so prevalent that In-home caregivers must learn a new way of dealing with problem behaviors. As you probably have already experienced, the old social norm ways of correcting bad behaviors just lead to worsening conditions. In-home caregivers must learn a new way of handling problem-causing situations.
Let’s call this new way the Stop and Look Deeper method. Stop and think before reacting. Look deeper into what may be causing the conflict.
This may seem like a daunting task, given all the different things that could be happening. In reality, it’s not that hard. All you have to do is get to know your residents well enough to be able to see the situation from their point of view, while taking into account all their handicaps. Some may call this empathy; I just call it well-informed good caregiving.
So, in the Stop and Look Deeper method, the first step is to never assume that the resident can change their behavior just because you ask them to. The second is to always ask yourself, Why are they acting abnormally, before responding. Now, this does not mean to start treating the resident as if they were incapable of handling themselves. What it does entail is that you know what issues may arise in advance and be ready to head them off before they become a problem. It also requires you to always be ready to help your resident adjust their problem behaviors using the tools in your caregiver toolbox. We’ll cover that later.
The Second Principle: Aggravating Circumstances
An agitated resident is one of the most concerning abnormal behaviors that In-Home caregivers have to deal with. We try are best to suppress the bad behavior but our efforts seem to be pouring fuel on the fire. The situation quickly escalates to one of those 5 alarm messes that we so dread. In desperation, caregivers give up and reach for sedating medication that seems to take forever to calm the patient.
The paradoxical truth of the matter is that most of the time, trying to suppress the agitation only aggravates the situation, causing more agitation. When we give up and reach for sedating drugs, the underlying cause is still remains. So you have to fight with the patient to take the drug, which makes the situation worse. Then you have to endure the five alarm condition even longer, waiting for the medication to kick in. And what about the side-effect concerns you have to deal with? It hardly seems worth it. I hope it is self-evident by now that if you just concentrate on suppressing the agitated behavior, everyone ends up being frazzled way more than you ever wanted. So the second principle to learn is that you have to understand what agitation really is and avoid the things that make it worse before you try to control the resident's bad behavior.
Acting on the Principle: Respond to the Stressor, not the Behavior
Everyone experiences agitation sometimes in their life. Think back to when you were agitated. What helped you more? 1. Someone telling you to calm down and shut up, or 2. Someone listening to your concerns and helping you resolve them? Well Captain Obvious, I’ll think I’ll take option 2. So the first step in controlling the agitated behavior is to find out what is triggering the agitation in the patient in the first place. This may seem like another Captain Obvious question, but is it really? Do residents always know what’s bothering them? Hardly. Even if they knew, can the resident always communicate with you clearly when they're upset and agitated? In care homes, the answer is almost always No.
So what is a caregiver supposed to do, turn into Sherlock Holmes? Elementary, my dear reader….Yes. First, you have to understand what agitation is and what triggers it. Then look for those triggers in the surrounding environment and try to control them. The next step is you have to investigate the actions and the responses of the resident. Doing both steps will help you gain the clues you need to help them in a way they will understand and cooperate with. Then the bad behavior resolves itself. No 5-alarm fires, no need for sedating drugs. The end result- quicker and easier resolutions.
What Exactly is the Agitation Response
The exact biological mechanisms that produce agitation are not fully understood yet. There are many chemical pathways involved that affect the amygdala portion of the brain, which may, in turn, create the agitation response. Generally speaking, though, agitation is an automatic protective response to a stressor. The body is notifying the brain that something is wrong. The brain then starts ramping up the body, getting ready to act to relieve the stress. The more stress that is experienced, the more agitated the patient becomes.
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Internal signs of agitation |
Outward signs of agitation |
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Irritability Tension Mental distress Restlessness |
Being uncooperative Clenching fists or wringing hands Difficulty focusing Excessive talking Fidgeting Hostility. Inner restlessness Lack of impulse control Pacing Violent or disruptive behavior
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The levels of intensity usually start out as mild occurrences in response to some unfulfilled need or experienced stressor. Because of the automatic nature of the response, patients may not even notice the symptoms of agitation that are starting to occur. If the need remains unfulfilled, the agitation continues. But if conditions in the environment or caregiver reaction add to the stress, the agitation escalates to a moderate condition, and then continues to severe. In severe cases, the agitation response usually overcomes rational thought. The only thing that matters is relieving the stress. Caregivers find it extremely hard to reason with the patient from then on. It’s like all portions of their brains have turned off except for the parts dealing with the stressor.
So the caregiver has to go into that place and pull them back from the brink. (Well cover those techniques later on as well.) |
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Aggravating Circumstances
Let’s have a conversation about what may trigger the agitation response in our residents. Once you become familiar with them, you will know what to look for. Knowing what to look for is half the battle won.
Lower the Trigger Thresholds
Because chemicals and brain structures are involved, there are many drugs and medical conditions that can produce agitation symptoms. Making the patient more susceptible to reocurring episodes.
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Medical Conditions
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Medications |
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Delirium Dementia/ Alzheimer’s Infections (like UTIs), especially in people over 65 Electrolyte imbalances Hyperthyroidism Physical trauma, especially head trauma After Seizures Substance intoxication or withdrawal (alcohol, nicotine, marijuana, hallucinogens, and opioids) Toxins (poisoning) Autism spectrum disorder Anxiety disorders Bipolar disorder Depression Schizophrenia
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Medications with caffeine
Corticosteroids
Amphetamine/dextroamphetamine (Adderall) Dexmethylphenidate (Focalin) Lisdexamfetamine (Vyvanse) Methylphenidate (Concerta, Ritalin) Asthma Medication
Thyroid Medication, Seizure Drugs and Parkinson's Disease Medicine |
It may seem like a long list, but that does not make it difficult to handle. It is just a matter of holding up the list next to your resident and seeing if they have factors that increase the risk of agitation. Once you determine they are at increased risk, there is less likelihood of being taken by surprise by agitated behaviors. You can be better prepared to act quickly to keep the agitation in the mild stage.
Investigation Starts the Intervention
There are so many variables that can create tension or strain your residents that it’s not very effective to assume you know what’s going on before you intervene. When incidents of agitation start to occur, just like the famous detective Sherlock Holmes, you have to start the investigation by gathering the clues. Once you have gathered enough evidence, your interventions will be much more effective. And just like a detective, your investigation will be much more efficient if you start with the usual suspects.
Internal Stressors
Any need the resident has that goes unfulfilled strains the patient and becomes a stressor. Diminished abilities like the inability to communicate, cognitive impairment, or vision loss make it harder to take care of those needs. That adds to the patient’s frustration. The greater the disability, the more frustration is felt, and the greater the agitation that is manifested. Therefore, recurring needs like pain relief, hunger, bathroom breaks, boredom, depression/sense of loss, mania, allergies, worry, and loneliness become the “usual suspects” when you start your investigation.
External Stressors
Having to deal with things we don’t like is an automatic stressor. In addition to that, the brain only has a finite amount of ability to process input from its surroundings. Exceeding that limit is also a stressor. When disability further reduces the ability to process input, everyday things like colors, patterns, noise, commotion, and odors become the “usual suspects” to start investigating. And don’t forget changes in the environment, routines, or people interacting with the resident can readily set a person on edge. So ask, what has changed that is causing the agitation?
Caregiver Caused Stressors
Unfortunately, one of the usual suspects that causes agitation is the Caregiver themselves. Isn’t it ironic that the one person in the room who is trying to reduce the agitation may inadvertently be adding to the stress of the situation? Don’t feel too bad about though. No one comes into this business fully trained. You have to gain experience on the job or get some training in another medical field. Some of the things I have noticed In-Home caregivers doing that stress out the residents are;
Treating the resident like a child or a problem that is annoying the caregiver.
Reacting too loudly, too positively, too quickly
Saying one thing and acting another.
Not listening to the patient, disregarding what they are saying or dismissing their concerns out of hand.
Acting against them, not for them. Not seeing things from their point of view.
Making the patient feel that the rules are more important than the patient.
When you lose your cool, everything you do, good and bad, becomes an aggravation, making things worse.
All of the above can be really irritating to a stressed-out patient. They can negate any good that you are trying to do. The usual result is instead of calming the patient, you quickly escalate the agitation to higher levels.
Let’s do a practice exercise. Put on your Sherlock Holmes hat on and look at this video. List the items that you see that may be contributing to the patient's agitation.
I listed the stress of unresolved pain, Nicotine withdrawal, the stress of being in an unfamiliar hospital setting with uncomfortable clothes on, and people who are strangers telling her what she can’t do. The caregivers are not really listening to her. Telling her that hospital policy is more important than her needs. They say they are trying to help but their body language says they are there to control here. What did you come up with?
Being Sherlock
There are better ways to handle agitated residents that don’t lead to 5-alarm fires. Let's call it the Supportive Sherlock Holmes method. Instead of trying to suppress the agitated behavior, you concern yourself more with what is needed. Instead of acting, you begin by investigating. What is causing the issue? Is the resident at greater risk for higher levels of agitation? Is there something in the environment that is aggravating the agitated patient? Does the resident have a need that needs attention? Are my actions helping or making things worse? Once you begin to be Sherlock, you will notice that events stay under control more easily. You will have less surprise 5-alarm fires to put out. Your stress level drops, and you don’t get burned out. Much better, yes?
Behavioral Management Techniques
There is no one best way to handle behavioral problems. It is a matter of learning several techniques that fit your style of care and using them as the situation requires. I like to use the analogy of tools in a caregiver's toolbox. Some tools you’ll use almost every day. Others only as needed. The following are techniques for you to consider adding to your toolbox.
Discreet Assessment
Behavioral management has two distinct phases: assessing and acting. Investigating the causes is essential but doing it the wrong way can aggravate the situation in so many ways. Use tact and discretion to avoid making the problem worse.
Now you're ready to act wisely, and the resident sees you as a helper, not as a judge and jury or a foe.
Professional Armor
You are the professional caregiver here. It’s your job to calmly take care of your patients. It’s not the patient's job to make you feel good. You are ultimately responsible and in control of the home. Use that professionalism as a layer of armor so that nothing gets under your skin. It will help prevent you from responding emotionally and becoming a stressor.
Patient’s Perspective
Your residents are patients. They have conditions that handicap them and prevent them from perceiving the world as you do. They cannot come to where you are mentally and or socially. You have to go to the world that they exist in. If a person has a wheelchair, you don’t give them tasks that require standing or walking. You alter the conditions so that they can accomplish the task while sitting in the wheelchair. In behaviorally handicapped patients, the same adjustment of conditions needs to be done. But in these cases, you are altering your communication style and the content of what is said to fit the world that they live in.
For an example of what I am talking about, watch this video about Dementia patients wanting to go home.
At first, this concept is difficult to understand conceptually. Unlike a physical handicap, you cannot readily see mental and or social impediments. But once you comprehend that they are almost communicating in a different language. (similar to the one you use, but based on comprehending circumstances differently), interacting with them becomes easier.
This caregiver tool requires practice on how to use it effectively. It may feel like you are lying or manipulating the resident. Socially, you are conditioned to see this as a bad thing. That is not what you are trying to do. You are not conning them; you are acting as an interpreter. You are presenting concepts in a way they will understand. In the video example above, telling the patient that they can’t go home because of exterminator fumes is actually telling them it would be emotionally difficult for them to see that you can never go back to the way things used to be. I like the label of therapeutic fitting the presenter used. You are helping the handicapped patient fit into the real world in a verbally therapeutic way. Once you become proficient in this communication therapy, other caregiver tools become more effective.
Positive Paradigm Approach
Another caregiver tool that makes other tools more effective is having a positive attitude toward everything you do as a caregiver. The human psyche has two sides. A rational side that deals with facts, logic and outcomes (The thinking side) and an emotional side that deals with feelings. We start out in life with feelings being prominent. As we learn to think for ourselves, the rational side becomes more and more prevalent. The rational side ends up governing the actions we take. When the thinking side is compromised in some way, the emotional side takes over and governs the actions we take.
That is why those residents who are mentally or emotionally handicapped are more easily triggered.
In addition, emotions color our interpretation of the facts. Negative emotions only see the trials of events and facts; positivity sees the opportunity in situations.
Positivity affects behavioral management in four ways.
De-escalation
In the middle of a 5-alarm situation, the resident is in a crisis mode or escalating towards it. The emotional side of the brain has taken over and is not listening to reason. If a caregiver tries to intervene by using rational arguments, the resident will likely resist them and be agitated by your attempt to help. The very effort to solve the situation can escalate the situation into further conflict. A De-escalation is needed before trying to resolve the problem.
Effective de-escalation is accomplished in several general steps.
Talking first about the feelings being felt provides an avenue of release for the pent-up emotions. It validates the emotions, confirming that you understand why they are acting out. It also forces the rational side of the brain to start thinking in terms of facts and conditions. Often, the patient doesn’t even know what they are feeling until you give them a label. It also shows the resident that you are really trying to understand, and there is no more need for aggressive behaviors to get your attention.
Helpful Hints
Once you see the resident is more in control of their emotions, you can proceed with other tools from your caregiver toolbox.
Substitution
In Substitution, caregivers suggest an alternative to fulfill the need that provides an advantage over what is currently being sought by the resident. (You’re giving them choices in what they can do, not dictating what they can’t do.) It could be a favorite physical object or an alternative idea or method.
For example:
Helpful Hints
Here is an example of substitution
Redirection
In redirection, you are trying to make a clean break from the problem behavior by diverting attention to another activity. The alternative activity has to be distracting or entertaining enough to divert the attention of the resident. This tool can be used like a magician to pull away the focus of the resident away from what you are doing behind their back, or it could be used like a traffic cop turning the flow of the action in a new direction.
Diverting Attention
Diverting the residents' attention away from problem topics and situations may seem like a Captain Obvious thing, but I find this tool is harder to pull off than other techniques. In my opinion, it should only be used at the early stages of the problem. Since diversions do not address the underlying stressors, when tensions are higher, those efforts may be interpreted as overt manipulation and actually cause more conflict. I recommend you watch this video; she has some really good techniques that you could use in your care practice.
To help you be more effective in problem-solving, I suggest you have a variety of preplanned distraction activities prepared that address common concerns of the resident.
Replacement Behaviors
Of course, the most effective therapy is to solve problems in advance. For recurring problems with known solutions, altering long-term behaviors to meet needs is worth the effort. Long-term behavioral changes have to be internally motivated and can be facilitated with caregiver support.
Supportive caregiver actions:
Periodic assessment will be required. Compare what you think is going to happen with what is actually happening. Take note of what works and what does not. That list will be helpful to you in other circumstances.
Reinforcement Activities (Yes, I am using behavioral modification tools on you.)
Take note of the different techniques that are used in the following video.
How could you adapt the techniques used in this video to your care home?
Here’s another good training video
Conclusion
Trying to modify troubling behaviors in our residents the same way we interact with the general public is not a very effective way to handle troubling situations. Relying on drugs is often too slow and comes with additional side effects to deal with. In my experience, there are better techniques for handling problem behaviors.
At first, it may seem like you're lying to, manipulating, taking advantage of your residents. But as you become skilled in their use, you will see that you are, in fact, benefiting your residents and keeping them happy. Happy residents equals easier caregiving.
And as always, Good luck in your caregiving efforts. Mark Parkinson BsPharm.
References:
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Arthritis and Neuropathy Pain
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 1 - Approximate time required: 60 min.
Educational Goal:
Give suggestions on how to handle complaints of chronic pain caused by arthritis or neuropathy.
Educational Objectives:
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 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.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
Arthritis and Neuropathy Pain
This CE was requested by one of our subscribers.
Here’s the scene: You get your client up in the morning. She starts complaining of not sleeping well and moaning about her legs or hands hurting. Then she is cranky for the rest of the day, making your life miserable as well. Sound familiar? What is an In-home caregiver to do? Here are a few things I would do. But first, let’s get everyone up to speed on what’s most likely causing the problem: arthritis or neuropathy. Both are tricky to take care of, and caregivers need a good basic understanding of what is going on in the body of their resident in order to manage things effectively.
Arthritis- What is it?
Arthritis literally means joints inflamed. I love how knowing medical terminology makes understanding things that much easier. The inflammation is causing the pain your client is feeling, and the pain is the body’s way of saying to the brain, “Notice me, something is wrong, pay attention”.
So what is going wrong? According to the Arthritis Foundation's website
“Arthritis isn’t a single disease; the term refers to joint pain or joint disease, and there are more than 100 types of arthritis and related conditions. People of all ages, races and sexes live with arthritis, and it is the leading cause of disability in the U.S. It’s most common among women, and although it’s not a disease of aging, some types of arthritis occur in older people more than younger people.”
Types of arthritis
The most common types of arthritis are:
Osteoarthritis- Some call this a wear-and-tear disease, but it’s more than that. Bones in affected joints weaken, and the connective tissue that holds the joint together and covers the ends of the bone deteriorates. Inflammation occurs as a short-term protection against the damage, but chronic inflammation further damages the joint lining. If osteoarthritis continues, eventually much of the joint tissue will be gone. This results in a very loose joint and painful, debilitating bone-on-bone grinding. The body tries to compensate by growing bone spurs around the joint to give the joint some stability. They show up as a lumpy, thickened joint. It is the most common type of arthritis, usually felt in the hands, knees, hips, neck, and lower back. It can happen at any age, but it happens most often as you age. After age 50, it is more common in women than in men.
Rheumatoid arthritis (RA)- It is an autoimmune disease where the body’s immune system is overactive and attacks some of the tissues in the joints. The disease begins with inflammation in the synovium (joint capsule lining the joint space). Immune cells start to gather in the synovium, leading to swelling and thickening of the joint. These immune cells release further chemicals that damage the bone, ligaments, and tendons, causing the characteristic deformities seen in rheumatoid arthritis. The deformities are painful, limit movements, and cause weakness. The autoimmune response is typically seen first in the small joints of the hands and feet on both sides of the body. The inflammation can spread to other areas of the body. Many people with RA get very tired (fatigue), and some may have a low-grade fever. Anyone can develop RA. It typically develops between the ages of 30 and 60. Children and young adults who have RA usually start to show symptoms between the ages of 16 and 40. Women are three times more likely to develop RA than men.
Arthritis is a progressive disease that has no cure. If left untreated, it will only get worse. For the most part, the damage caused by arthritis is irreversible. The goals of therapy are to 1. get a proper diagnosis, 2. slow the progression down, and 3. manage the resulting pain. Early diagnosis is very important in retaining function and managing the pain.
In-home caregivers must pay attention to red flag warnings in the complaints of their residents. You are not diagnosing; you are just suspecting and then asking the right questions of the doctor. If the resident is fatigued, has a low-grade temperature, has swollen knuckles, the pain is felt on the left and right, and the pain or stiffness in the morning lasts longer than 45 minutes to an hour. Start asking questions about rheumatoid arthritis. If the pain is in the fingers, just at particular joints, takes the resident less than 30 minutes to get going in the morning, suspect osteoarthritis. If the pain lasts for more than 6 months, then it's time to see a doctor, regardless of what you suspect. If they already have a diagnosis, then you, as the patient’s advocate, can request the services of a number of specialists who can help you keep your client well and comfortable, and the insurance may pay for the extra care.
Arthritis Specialists Resources
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Rheumatologist |
RA specialist but often is skilled in all arthritis diseases. |
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Orthopedist |
Doctor of Osteopathic Medicine (DO). They can also operate as a regular family physician. |
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Orthopedic Surgeon |
Joint replacement |
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Pain Specialist |
Excellent resource in managing chronic pain |
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Chiropractor |
Check the insurance before you go |
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Podiatrist |
Good resource for all things feet-related |
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Home Health Nurse |
Great resource for getting doctors to cooperate, and can help get care delegations done |
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Occupational Therapist |
Helps with activities of daily living. Knows all the latest and greatest tips and tricks |
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Physical Therapist |
Helps improve movement and function, reduce chronic pain, and prevent future injuries through various treatments and exercises. |
Neuropathic Pain
The other culprit that might be causing discomfort in the extremities of your resident is neuropathic pain. To understand neuropathy, you first have to understand what pain really is. The feeling of pain is just the brain interpreting nerve signals that stress or damage is occurring. If the brain is preoccupied, asleep, or knocked out, the nerve signals are ignored, and there is no pain felt. However, if the nerve is stimulated and it sends signals to the brain, even though there is no tissue damage, pain is still felt. That is what is happening in cases of neuropathic pain. Something is causing the nerves to fire when there is no reason to.
The nerve malfunction can be triggered by multiple factors and can occur anywhere along the nervous system. Even in the brain itself. Common causes are excessive alcohol consumption, diabetes, nerve compression by a tumor, lack of vitamin B-12, trauma, infections like HIV-AIDS, and strokes. Neuropathic pain can be felt as burning, aching, shooting, stabbing or electric shock sensations. It is frequently intense and worsens at night and is often felt in the lower legs. Sensitivity to stimuli is also heightened to the point where a light touch, like feet being covered by sheets in bed or a cool breeze, can cause severe pain. If one of your residents is showing these patterns of behaviors, it might be time to start asking the doctor the right questions so a proper diagnostic exam will be done.
My Suggestions for Caregivers
Pain management in these conditions can be very challenging for in-home caregivers. Your residents are paying you to make them feel content and comfortable. When they aren’t, there is an expectation that you will do something about that. They want you to make the pain go away. Here are a few ideas that can make that happen.
Manage patient expectations
Help the resident get realistic expectations through patient education. Empathetically remind them often of what is actually going wrong and what everyone is doing about it. Also, remind them of what has worked and not worked in the past.
Manage residents' mood
There is a strong relationship between mood and how much pain is felt. Be positive and provide a supportive environment, and the resident will respond. With the doctor's help, actively fight depression. Provide plenty of distractions to divert attention away from negativity.
Get a variety of PRN meds to choose from
Life is variable; some symptoms may show while others fade. Also, the body has a tendency to get used to a pain medication, so it becomes less effective over time. It’s good to have multiple pain therapy tools available to handle changing conditions. Changing up the prn med response can help maintain their effectiveness.
Suggestions to ask the doctor for.
Narcotics (Hydrocodone, Tramadol, Oxycodone). Patients always want to reach for the opioids first. Frequently, that’s all they know. They think that’s the good stuff. Unfortunately that’s not always the case. Narcotics do not take care of inflammation, the root cause of many pain problems. Also, they often are not that effective in managing neuropathic pain. I suggest using them as second-line therapy, what to reach for when other things don’t work.
NSAIDs (Ibuprofen, Naproxen) In my opinion, these are what you should reach for first. By definition, they take care of inflammation. Again not as effective in neuropathic pain.
Acetaminophen (Tylenol) Does not take care of inflammation but does work in the central part of the brain where pain signals are interpreted. An effective alternative when you want to change things up.
Topical meds- lotion, creams, and patches. These are great for changing things up. The massage effect when applying is also therapeutic. If you get approval for self-administration, these agents can give the patient a sense of being in charge of their own therapy. Which is good for their morale.
Lotion up the limbs
Applying lotion helps reduce skin irritation nerve stimuli. Massaging the lotion in can also feel really good. It’s an activity of daily living that can double as therapy that does not require a prescription. If you’re doing it a lot though, it is still wise to inform the doctor.
Push for extra help
Don’t be afraid to request the doctor to approve the use of specialists. Contact the resident's insurance to see what is available on their policy. You might be surprised by what a couple of calls can do. If you do get extra help, make sure they go through you as the primary caregiver and major patient advocate.
Reduce the stimuli
Keep the home environment calm and peaceful. Aromas go a long way in calming sensory stimuli. Pay attention to what elements trigger a pain response, then manage them to reduce exposure to pain stimulus.
Plenty of rest, exercise and proper diet
Healthy habits are scientifically proven pain management techniques. Regular exercise and walks are diverting and good for emotional control and improved morale.
Hot and cold packs and heating pads
Alternating hot and cold packs are a proven chronic pain therapy. The cold and heat give the brain something else to think about besides the pain. Heating pads also do this. In addition, ice has a numbing effect and heat stimulates blood flow and promotes healing. This is also a therapy that the patient can control.
TENS
Transcutaneous Electrical Nerve Stimulation is an electrical device that sends an electrical current through an area of peripheral tissue. It is also an effective tool in managing pain. In a care home, it will require doctor's approval to use and someone to do a delegation before you can use one. Insurance will require a prescription but some units are cheap enough to just buy one over the internet.
Symptoms Journal
Start keeping a record of symptoms and the circumstances around their showing. It will help you identify triggers, recognize patterns, monitor therapies for effectiveness and side effects, and give the doctor more data to use in determining and managing therapies. It seems like more work, but it can save you a ton of work in the long run.
Conclusion
Chronic pain issues in your residents are also a pain in the neck for you, the primary caregiver. It's difficult and frustrating when you can’t make the problem go away. But there are ways that can help you manage the situation. Don’t be afraid to push the doctor a little. Get plenty of tools in your caregiver tool box, and you will manage things just fine.
As always, Good Luck in your caregiving efforts, Mark Parkinson BsPharm.
References:
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ADHD and Amphetamines
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 2 - Approximate time required: 120 min.
Educational Goal
Explain what ADHD is and how amphetamines are used in its treatment.
Educational Objectives
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.
ADHD and Amphetamines
This CE is a request from a subscriber. Yes, we do those.
ADHD is a murky topic that everyone has heard about but generally few have a good comprehension of what it is. Because of this, myths and misunderstandings have grown around the subject. The term ADHD has been misused so often that a hazy stereotype has built up around it in our culture. I am going to do my best to demystify your understanding of it in this lesson.
What is ADHD
ADHD stands for Attention Deficit Hyperactivity Disorder. It is a spectrum of neurodevelopmental disorders. In my opinion, disorder may be too strong a word; it's more like a condition than a disorder. What that means in everyday language is that parts of the brain are formed differently at birth from those of other people. The result is that those who are on this spectrum think, act, and react differently from social norms to varying degrees. Those who have it are unusual because their brains are just wired differently.
What Happens in ADHD
ADHD is “characterized by symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation that are excessive and pervasive, impairing in multiple contexts, and developmentally inappropriate.” Source: Wikipedia
This may seem a bit confusing. Everyone at times is subject to not paying attention, can’t sit still, and jumps into activities without much thought about the future. We all have our spurts of a disordered mind, then things get back to normal. It is part of being human. However, as far back as 1902, some doctors noticed there were young boys who could not seem to control their hyperactivity. It affected all aspects of their lives, not just a few items here and there, and the condition persisted over time. No amount of discipline or adult supervision could make the boys “behave”. They were always active to the point of disruption. It was as if they had no internal off switch. That is what everyone notices, even to this day, to the point of it becoming the stereotype of the ADHD sufferer.
Over time, psychologists have noticed that hidden behind all the activity were other abnormal behavioral patterns that did not seem to have an off switch. There were things like- not being able to pay attention, acting on impulse, always being disorganized, being blind to time, excessive daydreaming, absentmindedness, lack of control of emotions, and other mental aspects that were not under normal controls. It was also observed that there were those who had these types of symptoms who did not suffer from the out-of-control hyperactivity at all.
Today, those who are diagnosed with ADHD are placed into 3 subgroups.
Predominantly inattentive symptoms. (31% of cases)
They can’t pay attention and/or are easily distracted. This category is sometimes called Attention Deficit Disorder or ADD (No H).
Predominantly hyperactive, impulsive symptoms. (7% of cases)
This category is the stereotypical ADHD. It is comprised mostly of males (researchers don’t know why yet). You will also notice that in spite of the stereotype, such cases are in the minority.
Have a combination of both symptoms. (62%)
Females aren’t as likely to have hyperactive/impulsive symptoms. They have their own stereotype of being a daydreaming, bubbleheaded blond.
Within each category, there is also a spectrum of indications associated with ADHD. Presentation of symptoms is very individualistic. Some are very disruptive, while others are barely noticeable. For most, the signs appear in childhood and continue into their teens. There are rare cases where a brain trauma or toxic poisoning may have caused the symptoms of ADHD to appear. As those with ADHD grow into adulthood, some aspects of the condition may lessen as the mind matures or adaptive behaviors are gained. It may appear that they have grown out of their symptoms, but the condition remains.
Not all AHDH traits are disruptive. Positive traits can also be heightened by ADHD, like creativity, boldness in action, and noticing things others don’t. ADHD can turn these aspects into superpowers that can lead to much success. Other aspects remain disruptive though, and are the cause of much misery and depression. For example, difficulty focusing, failure to follow instructions, careless mistakes, losing items, interrupting, impatience, and overreacting emotionally. Despite all their efforts to have a normal life, they remain different from those around them, and before being diagnosed, they don’t know why.
Watch these two videos to get a better understanding of what it's like to have ADHD.
Just to make things even more complicated. Two-thirds of children have other disorders that hide the symptoms of ADHD. Like anxiety, depression, autism, and learning disabilities. Adults have higher percentages of divorces, have job difficulties, and have higher rates of substance abuse. There is an increased risk of suicide across all ages.
Why Does ADHD Happen - Pathophysiology
Medical science has not been able to determine the exact cause of ADHD yet. What the research does show is:
One out of four ADHD individuals has a parent with the same symptoms. The majority of the rest (74%) have other extended family members who show the signs of ADHD. Siblings of children diagnosed with ADHD are 3-4 times as likely to have the condition.
Executive Function
To appreciate the pathology of ADHD, you first must understand what mental executive function is. Executive function is a collection of mental abilities that enable us to act appropriately. They enable us to organize our thoughts so that we can plan actions and work on achieving goals.
Executive function skills
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Working memory |
Core skill |
The ability to hold and use information to follow instructions, solve problems, and make decisions. (related to short-term memory) |
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Cognitive Flexibility |
Core skill |
The ability to switch between different tasks, adapt to change, and think creatively. |
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Inhibitory control |
Core skill |
The ability to control acting on impulses. Related to thinking before acting and staying focused by ignoring distractions. |
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Planning and Prioritizing |
Related skill |
Be able to figure out what steps are needed to complete a task and determine what is most important. |
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Task initiation |
Related skill |
Starting a task without procrastinating or getting stuck at the beginning |
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Time management |
Related skill |
Meeting deadlines, estimating how long a task will take, and being able to keep track of the flow of time. |
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Problem Solving |
Related skill |
Analyzing a situation, finding solutions to problems, and the ability to consider other options |
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Self-monitoring |
Related skill |
Being able to evaluate your own behavior and make adjustments as needed |
Neurotransmitter Synaptic Control
The ability to use our executive function is driven by the flow of neurotransmitter chemicals across the synaptic junctions between the brain neuron cells. Let me explain how this works.
At its simplest, each thought and action we have is the result of a combination of nerves firing or not firing. An electrical impulse will travel down a neuron ending in a part of the cell that contains bubbles of chemicals called neurotransmitters. The bubbles, called vesicles, are held close to the outer surface, adjacent to the junction with another nerve cell. The electric signal will make some of the bubbles pop, releasing the neurotransmitters. This changes the mix of chemicals held in the space between each nerve cell, called a synaptic junction. This results in either a buildup of electrical charge on the connecting nerve synapse or an inhibition of an electrical charge buildup. When an electrical charge threshold is passed, the nerve will “fire”, sending the electrical signal down the neural pathway.
The neurotransmitters are then sucked back into the nerve cell via channels and repackaged into vesicles. This rebalances the chemical mix back to normal. Thus, resetting the nerve's ability to send a signal. There are over 100 different neurotransmitter chemicals, with more being identified by researchers. Chemicals predominantly involved in executive function are dopamine and norepinephrine. That will be important later on when we talk about treatments for ADHD.
The Brain's Wiring in ADHD and Its Consequences
In ADHD, somewhere among the many steps in the flow of neurotransmitters that are involved with Executive Function, something or things were not formed normally at birth. The brain's wiring is messed up, and we do not know exactly where. It could even be in multiple steps at varying degrees of dysfunction. What we do know is that the ADHD behaviors are not under the conscious control of the patient. The ADHD suffer does not choose to behave abnormally; it just happens because their brain is wired differently.
The consequences of the rewiring of the brain from birth are;
An important first step in learning to live with ADHD is to properly identify the disability by getting a proper diagnosis.
How is ADHD Diagnosed
Since medical science has not been able to isolate the problem causing ADHD, there is no way a doctor can give a screening test to discover it in their patients. Also, since the disability occurs on a microscopic level in the synapse, there are no imaging tests that can be utilized. However, tests may be used to eliminate other possible causes of the troubling behaviors. The main way a specialist gathers information to make a diagnosis is through questioning.
The doctor or psychiatrist has to obtain and evaluate a history of the patient's behaviors to determine a diagnosis of ADHD. Patient histories are usually obtained from multiple sources if available. Parents, teachers, school grade cards, and the like are often consulted. While evaluating the patient history, the clinician must also eliminate the possibility of other pathologies that can cause the behaviors that are being seen. In addition, the doctor or psychologist must also determine the degree of impact the symptoms have on the life of the patient. The question is not whether the symptom occurred; it is how often the problem is felt and how much the problem interferes with the patient being able to live a normal life.
The questionnaires used to obtain the needed medical history can be quite extensive, time-consuming, and involve the questioning of others who know the patient. They can take up to 1-3 hours. Additional visits may be needed.
“To make an ADHD diagnosis, providers look for these conditions:
For children, six or more symptoms in one of the two main categories (or both) over the last six months — inattention and hyperactivity/impulsivity.
For adults, at least five established ADHD behaviors in one category (inattention or hyperactivity/impulsivity) for six months.
Adults or children must have symptomatic behavior in two or more settings, like at home, school, or on the job, usually as identified by two or more observers.
The symptoms are debilitating and interfere with daily functioning.
Symptomatic behavior started in childhood, usually before age 12.
Symptoms aren’t due to another disorder. For example, the symptoms can’t be caused by anxiety or depression.”
Source: https://my.clevelandclinic.org/health/diagnostics/24758-adhd-screening
For a better understanding of the process, watch this video. I suggest that you pause the videos and have a close look at the lists presented.
Therapy for ADHD
In considering the therapy for ADHD, it is important to remember that the outward symptoms of the disability are not under voluntary control. There is no way to make the patient act in normal patterns. However, there are compensation therapies available that may enable the patient to lead a normal life. They may even facilitate the advantageous aspects of the condition so that the patient can achieve greater success in their endeavors. Once predominant symptoms are identified, therapy can be tailored to be even more effective. The goals of therapy are the management of symptoms, which is done primarily through counseling and medications.
Counseling
In counseling for ADHD, clinicians use a multifaceted approach that includes gaining coping skills, behavioral reinforcement and emotional regulation. Techniques often include psychoeducation, goal setting, skill practice and implementing techniques like Cognitive Behavioral Therapy. For children, counseling often includes training the parents to help create structured environments and teach positive discipline.
Counseling sessions often include:
Drugs
Medications that affect the dopamine pathway and or the norepinephrine pathway are effective in ADHD therapy. They boost the neurotransmitter concentration levels in the synapse, enabling proper functioning of the neural pathway.
Medication used in ADHD therapy
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Drug Class |
Names |
ADHD Action |
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Stimulants Amphetamines |
Adderall, Mydayis, Dexedrine, Vyvanse |
Increase dopamine and norepinephrine concentrations in the brain's synapses |
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Stimulants Methylphenidate |
Ritalin, Concerta, Metadate, Daytrana, Quillivant XR. |
Blocks the reuptake of dopamine and norepinephrine |
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Antidepressants |
Strattera (amoxatine) |
Increases norepinephrine levels |
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Wellbutrin (bupropion) |
norepinephrine-dopamine reuptake inhibitor |
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Alpha Agonists |
Guanfacine, Clonidine |
Stimulates Alpha-2 adrenergic receptors in the brain leading to improved attention and reduced hyperactivity |
Medication Management Concerns
In ADHD, just as symptom presentation is varied and individualistic, so also is the drug therapy. A medication is selected, then monitored for effect and side effect tolerance. The dosage has to be started low, then dialed in for optimum effect. If the drug does not have the desired effect (or more likely, has side effect concerns), then the process starts over with a new medication. Monitoring for effect will be key and is primarily done by the patient and caregivers. Even with the best of management, 20% of patients do not respond well to drug therapy.
Because of the abuse potential of stimulants, extra precautions need to be taken for safety reasons. For example, you can only get a 30-day prescription with no refills. Also, medications given at school may have to be supervised by school personnel. There may be others who will want to obtain the medication as an academic performance enhancer or for recreational use. Given in unsupervised larger doses, they may become addictive.
Along with the addiction potential, there have been many other concerns over the long-term use of the medications used in ADHD. Fortunately, many long-term studies have shown that taken as directed, the medication has proven safer to use than aspirin. The need for medication may lessen as the brain matures, effective coping mechanisms are obtained, or lifestyle circumstances change.
Why should In-home caregivers even care about those with Attention Deficit Hyperactivity Disorder?
The ability to evaluate ourselves is an executive function of the brain. Therefore, it may be difficult for the ADHD patient to see things as they really are or judge the severity of ADHD symptoms or medication side effects. Caregivers, family members, and other support personnel (for example, teachers) may need to identify the symptoms of ADHD and monitor therapy. In addition, if there is a suspicion of ADHD, others may be needed to help the patient work through the diagnosis process. For example, showing up on time to doctor appointments and/or filling out the questionnaires.
Because of the involuntary nature of the condition and because it is an incurable condition, caregivers may also be needed to give long-term (even lifetime) lifestyle support, provide structure, give reminders, comfort when things go wrong, and give understanding and resolution when ADHD symptoms impact others negatively.
If you have a resident who is diagnosed with ADHD, your caring support and stable home structure are greatly needed. If you suspect troubling behaviors are something more, then your efforts are required to help navigate the diagnosis process and initiation of therapy. I hope this CE has helped break the stereotype and given you a more helpful view of AHDH.
As always, Good Luck in your caregiving efforts.
Mark Parkinson BsPharm
Reference:
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My Journey into the Serious Situation of Cirrhosis
Author: Mark Parkinson BsPharm: President AFC-CE
Credit Hours 3 - Approximate time required: 180 min.
Educational Goal:
Show how to care for Cirrhosis patients and how to handle difficult situations by telling the story of how my wife was diagnosed with Cirrhosis and how I handled the situation.
Educational Objectives:
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 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.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
My Journey into the Serious Situation of Cirrhosis
We have all heard of the term Cirrhosis and know it’s a bad thing, but I bet you don’t know much more than that unless you have had medical training. Oh, you might have heard that it has something to do with the liver, and alcoholics get it a lot, so alcohol must be involved somehow. But beyond that, you are most likely clueless. Like I was a couple of months ago, before my wife (who has never had a drop of alcohol in her life) was told by her doctor that her liver was in the early stages of cirrhosis.
You know, being a pharmacist and before that a professional In-home caregiver, I thought I was prepared for anything that a doctor could throw at us. But at that moment, I didn’t know what he was talking about. For the first time in a long time, I struggled to keep up when he started talking about what tests and therapies were going to be needed. I was totally at his mercy and had to just sit there and listen. I didn’t even know enough to ask intelligent questions. I felt incapable of helping or contributing in any way. I didn’t like that one bit. When my wife started to cry a little bit from the fear of the unknown, I got seriously stressed out. I vowed to myself that I would get in the know so I could help. Do you In-home caregivers, sometimes feel that way when you take your clients to the doctor’s office? Kind of like being a third wheel that no one takes seriously? Well, together let’s do something about that. Follow my learning journey to get in the know about liver cirrhosis. Maybe a few pointers will rub off on yah.
My Learning Journey
I started my journey by doing a basic search of medical information sites and continued until I stopped learning new things about the condition. I found out that cirrhosis just means having a scarred liver. So it’s not so much a disease but an end-stage condition of other diseases that affect the liver. Something has damaged the liver so badly that scar tissue has built up to the point where it can’t function properly anymore.
Take a look at these pictures.
On the left is a healthy liver, smooth surfaced and uniform in color. On the right is a liver with cirrhosis.
I thought to myself, “How could this be? I know that since the liver takes care of the damaging toxins the body produces, so it has a tremendous ability to repair itself. What’s going on? Why all the damage?”
It turns out that yes, the liver can repair itself, but everything has its limits. Here’s a simplified blow-by-blow in the fight to repair liver damage.
The blue-stained area is fibrotic tissue surrounding regenerative nodules.
So on the first step of my learning journey, I found out that Cirrhosis is a chronic progressive condition where scar tissue gradually replaces healthy liver tissue. At first, the liver will be able to work around the scar tissue, and no outward symptoms will be felt. This early phase is called Compensated Cirrhosis (stage 2 liver disease). But when the fibrosis is extensive, it is called Decompensated Cirrhosis (stage 3 liver disease) and outward symptoms that start to show. They are related to the fact that liver can’t do it’s job well.
On to the second step in my learning journey.
How serious is the condition?
What Causes the Damage
Ok, it’s a given that making the liver deal with long-term exposure to toxins (Alcohol, industrial solvents etc…) can cause cirrhosis. But what about my wife, who’s a non-drinker and never worked around a lot of chemicals? I found out that the following can also put long-term stress on the liver.
Common Causes
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Alcoholic liver disease (ALD, or alcoholic cirrhosis) |
It is seen in 10–20% of individuals who drink heavily for a decade or more. 40% of cirrhosis-related deaths are due to alcohol in the US |
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Non-alcoholic fatty liver disease (NAFLD)
Metabolically-dysfunction-associated steatohepatitis |
Fat builds up in the liver and eventually causes scar tissue. Fatty liver disease can be caused by obesity, diabetes, malnutrition, coronary artery disease, and Chronic steroid use. |
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Chronic hepatitis C |
The hepatitis C virus causes inflammation of the liver, which eventually damages the organ. 20-30% of patients with chronic hepatitis C infections develop cirrhosis. Hepatitis C and alcoholic liver disease are the most common reasons for liver transplants. |
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Chronic hepatitis B |
Chronic hepatitis B also causes liver inflammation and injury. It may take several decades for cirrhosis to develop. Both hepatitis C and hepatitis B–related cirrhosis can also be linked to heroin addiction. |
Uncommon Causes
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Autoimmune diseases |
The body attacks the biliary ducts that lead to the gall bladder. This backs up pressure in the liver and causes damage. Or lymphocytes attack the liver itself. |
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Genetic disorders |
Inherited disorders can cause toxic substances to build up in your liver. These include glycogen storage disease, cystic fibrosis and Wilson disease. |
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Toxic hepatitis |
Liver damage is caused by long-term exposure to certain toxins or medications like paint solvents and common painkillers like NSAIDs, acetaminophen, and illicit drugs. |
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Hereditary haemochromatosis |
Liver damage is caused by the absorption of too much iron from food that is eaten. |
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Cardiovascular disease: |
Conditions that cause blood to build up in the liver (congestive heart failure) or that prevent blood from reaching your liver (chronic ischemia) can lead to organ damage. |
I also learned that you can be affected by multiple conditions at the same time, which naturally would speed up the liver damage. After taking several tests, the doctor told us the primary cause of my wife’s condition was her diabetes. We suspected as much but were relieved that there weren’t other liver-damaging effects to be worried about.
Signs and Symptoms
The third step in my learning journey was to cover the signs and symptoms of liver disease. Something that should be of particular interest to caregivers. Remember, it’s not your job to diagnose, but it is your job to be suspicious of conditions that are not normal. Then it is your duty to inform the doctor of your observations and tell the doctor of your concerns. You’re going to see the problem before anyone else does, if you’re observant and know what to look for.
But first, you have to know what normal looks like. In order to know that, you need to be familiar with what the liver does for the body. A subject, unless I am totally off the mark, I’m guessing you haven’t given much thought to, because I hadn’t. Here is what I found in my research.
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The Liver – Anatomy and Physiology The liver is the largest internal organ of the body. It sits just under the lungs on the right side next to the stomach. It has two main spongy lobes. Both lobes contain many blood vessels and thousands of smaller lobes (lobules) that are tiny clusters of hepatocytes (liver cells). Blood flows into the liver from two sources. 1. Oxygen-rich blood comes from the heart via the Hepatic Artery. 2. The portal vein carries blood that has just come from the intestines, containing the products of digestion. Blood flows out of the liver through the inferior vena cava. In addition, the liver produces bile that flows out through the bile ducts. About 13% of the body’s blood supply flows through the liver at any given time. |
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The functional unit of the liver is the hexagonally shaped lobules. Each lobule is supplied with blood from the hepatic artery and portal venous systems. The hepatocytes process the blood, and the products flow out of the central vein and the bile canaliculi. The liver can be thought of as a factory that accomplishes more than 500 vital functions for the body. It regulates chemicals in the blood. Creates and/or stores nutrients. It detoxifies the blood, kills bacteria, removes old blood cells, and filters out unwanted blood elements. The liver helps remove the resulting waste byproducts through the bile or blood. The waste in the bile is removed from the body through feces. The waste in the blood is filtered out by the kidneys and removed through the urine. |
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Liver functions include
Bile is a yellow-green acidic liquid that helps carry away waste and break down fats in the small intestine during digestion
Blood plasma transports blood components (red and white blood cells and platelets), and enables the transportation of nutrients, hormones, proteins, and waste products.
Advanced info
For those readers who have had medical training, here is a more advanced summary of liver function. For those who haven’t had prior training, still read it. You may not understand everything, but it will still help you get to know some of the medical phrases that come up from time to time. There will be exam questions.
“The liver is the largest gland in the body and is ideally located to receive absorbed nutrients and detoxify absorbed drugs and other noxious substances. It serves as both an exocrine organ and an endocrine organ. The exocrine functionality of the liver is mainly in the synthesis and excretion of bile salts into the common hepatic duct, as well as the conjugation of bilirubin and excretion into the gut. The endocrine functions of the liver include involvement in glycemic control via insulin and glucagon. The liver synthesizes important proteins such as fibrinogen, albumin, prothrombin, and other amino acids and modifies proteins into enzymes and peptide hormones. The liver participates in fatty acid metabolism and synthesizes lipoproteins, cholesterol, and phospholipids. Additionally, it is involved in the metabolism of carbohydrates, which includes storing glycogen and gluconeogenesis. It is also involved in the metabolism of lactic acid and converts ammonia to urea. The liver stores vitamins and minerals such as iron. In summary, the liver is an important mediator from the gut to the blood and plays a vital role in the metabolism of macronutrients, hormones, components of blood plasma, and exocrine and endocrine substances.” Source: National Library of Medicine- Stat Pearls https://www.ncbi.nlm.nih.gov/books/NBK500014/
The liver also contains many enzymes designed to interact with and alter toxins and other harmful substances. This makes them inert or more easily removed from the body. Cytochrome p450 is a cell membrane-bound superfamily of enzymes with many variants (CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A4.) These also have a major effect on the medication the patient takes. If taken orally, the medication will first enter the liver, where a portion of the drug will be inactivated or removed. This is called the first pass effect. If the liver is damaged, the first-pass effect will also be changed. Raising concerns about the dosage amounts that are needed by the cirrhotic patient. This creates an increased need for drug effect monitoring.
Whew! That was a struggle. Now where was I? Oh yes, the third step in my knowledge journey. Now that I had a good refresher on how the liver works, I was better prepared to see and understand the signs and symptoms of Cirrhosis.
If you are getting kind of lost in all the details, here is a video produced by the American Liver Foundation that might help keep you on track.
Malfunctioning Livers
You can’t feel the Liver functioning. What you can feel is the consequences of when it’s not working correctly. But your patients may not notice. It takes a long time for scar tissue to build up to the point of causing the signs of Cirrhosis. Initially, the liver will be able to compensate for the loss of function, so the symptoms will probably be mild and general in nature. The condition takes so long to develop that the patient can become acclimated to the dysfunction and does not even notice that the symptoms are getting worse.
Compensated Cirrhosis
Many things can cause these symptoms. So look for confirming signs or several signs together before sounding the alarm. Look for;
Decompensated Cirrhosis
Two advanced cirrhosis-caused conditions are very serious, and I would like to spend some time on them. If you notice them, plus other signs of Cirrhosis, I would consider that an automatic call to the doctor, even the hospital.
Portal Hypertension
The buildup of scar tissue in the liver makes it hard for blood to flow in the portal venous system. The tissues go from being like a sponge to being like a rock. This in-flow resistance creates a backup of blood and increases the blood pressure upstream from the liver.
Portal hypertension causes:
Hepatic Encephalopathy
Hepatic Encephalopathy literally means liver-caused brain function disorder. When the liver can’t clear blood toxins like ammonia and dimethyl sulfide. They build up and cause harm.
This is what my wife experienced that started this whole journey. She was so mentally dysfunctional, I thought she was having a stroke. I took her to the ER, and they determined that there was no stroke, but noticed on one of their tests that the blood ammonia levels were very high. After that, they kind of just sat on their hands. I had to get very aggressive and demanded that they find out what was going wrong. They reluctantly admitted her to the hospital. I still had to push around some poor nurses to finally get a Doctor who could connect the dots between my wife's high ammonia levels and her mental condition. They gave her Lactulose. A strong laxative of all things. I believe that saved her life.
I know that was a lot of signs and symptoms to handle. You don’t have to memorize them all. You just have to be familiar enough to recognize that something is not normal in your residents. Then call the doctor with your observations and start asking the right questions. Like, how come this and that are happening together? Could it be something to do with liver function problems? I wish what I know now, I knew then, and I wouldn’t have had to be such an aggressive jerk to those hospital nurses. I think the doctors found out that they couldn’t buffalo a grouchy pharmacist and avoided me, but the poor hospital staff were stuck with cranky me.
Here is a good video about liver disease symptoms for all you visual learners out there. There will be an exam question.
Diagnostic Tests
The fourth logical step I took in my learning Journey was to find out about all the tests that my wife undertook.
Boy, there were a lot of them.
In the hospital, blood was taken several times, and a series of tests were administered on the samples. Among those tests was a Comprehensive Metabolic Panel (CMP), which includes a so-called “liver function test”.
The liver function test measures the amount of certain liver enzymes and proteins in the blood. If too much is found in the blood, then something is not right.
The Mystery of My Wife’s Test Results
I said, So-called liver function tests, because I found out in my research that a CMD is not very good at telling us how well the liver is functioning. It mainly tells us that the liver cells have been damaged to the point that these enzymes have leaked out into the bloodstream in higher-than-usual levels.
My wife’s CMD showed only that ALT and ALP were slightly higher. Everything else was within normal ranges. I guess that is why they didn’t look too hard at the Liver being the cause of my wife’s mental confusion. Because it appeared from the CMD that the liver was normal. Boy, I’m glad I pushed the hospital staff to look harder into the mystery. After getting in the know about cirrhosis, here is my hypothesis on what happened.
Our liver cells (Hepatocytes) have a tremendous ability to repair themselves. It is only after many harmful events over a long period of time that scar tissue starts to build up, and the fibrosis starts to replace healthy functional cells. So in my wife’s case, there weren’t enough damaged cells to leak enzymes and proteins to abnormal levels. But there were not enough functional hepatocytes to clear the ammonia out of her brain. With the benefit of hindsight, clearly more tests were needed.
Mini-Mental Health Test
The next significant test she was given was administered by the nurses. I think it was given because I kept demanding that they do something about her mental state. They asked her simple questions that normally people would have to think about, but can easily answer. What is the day and year? What city was she from? Who was the President? That sort of thing. Then they asked her to draw a face and a clock, complete with hands and numbers.
She answered the verbal question correctly but very slowly. But the pictures she utterly failed at. That got everyone's attention at the ER (that and my combative attitude), and she was admitted to the hospital. As we waited (very impatiently) for the doctor to arrive, the floor nurse asked her to draw the pictures again. She failed even worse. The nurse then did the Asterixis test (the one from the video where you extended your arms with the palms extended forward). She couldn’t hold the position (just like in the video). They kept both attempts at drawing and showed them to the Doctor when he arrived. The nurse also told him about the Asterixis test. That got his attention, and the doctor finally connected all the dots and ordered the laxative therapy that I believe saved her life. It took a couple of days to clear the ammonia, and she was finally able to go home functioning well mentally. Could you imagine taking a powerful laxative several times a day for several days? Yikes!
I included the story about the mini-mental and the Asterixis tests in this CE because you can do this yourself without a doctor's order, just like the nurses did. You're not determining therapy. You are just making objective observations that you can use to get the doctor’s attention.
Degree of Liver Damage Tests
Both the hospital and my wife’s doctor wanted her to go to a hepatologist (liver specialist). They are also known as gastroenterologists (gut doctors). I found a really good one who advertised himself as the “Gut Whisperer”. It was at his office that I found out just how clueless I was about the liver. He ordered several more tests that I had to do more reading up on to understand what they were for.
By this point, it was pretty much a given that there was something wrong with the liver. The important question was just how bad things were. The doctor already had the liver function test results from the hospital. He now had two more tests he could choose from.
Elastography is a test that uses painless, low-frequency vibrations to check the elasticity of the body’s organs. It measures how stretchy the tissues are. When tissues lack elasticity and are stiff, it may indicate how much fibrosis has occurred. There are two ways to perform the test.
A liver biopsy is a procedure where a small piece of the liver is extracted via a needle inserted into the organ. Then the tissue sample can be thoroughly examined under a microscope. It is the gold standard of cirrhosis diagnostic tests. Simple enough to understand, but it’s a bit more complicated when you actually have to do it.
As you would expect, a doctor who called himself the gut whisperer had his own ultrasound machine and was really good a taking liver biopsies. So those were the tests my wife was asked to do. We were relieved because even with insurance, the copay for an MRI would have been hundreds of dollars.
Doing the Exams
The doctor’s staff did the ultrasound right then and there. The sonographer (the person who operates the ultrasound machine) applied some jelly to make the wand move more smoothly over the skin and have better contact for the soundwaves. The jelly was easily cleaned up afterward. The ultrasound images were evaluated right away, confirming that there was fibrosis scar tissue in my wife’s liver. When the doctor tried to explain what that meant, that’s when my wife started to tear up, and I had my “feeling useless” episode. After some calming reassurances and explanations, we set the appointment for the liver biopsy at the hospital.
The day of the liver biopsy, she was told not to eat any breakfast (didn’t want her to throw it up during the procedure). We went to the outpatient surgery department of the local hospital. The doctor had a couple of options on how to perform the procedure. Stick the needle straight in or snake the needle down a large vein in the neck. Since my wife didn’t have a bleeding disorder or ascites (fluid buildup in the abdomen), the doctor chose the simpler straight-in method. She got dressed in a hospital gown, given a shot of anesthesia, and 30 minutes later, it was all done. It took longer for the anesthesia to wear off than for the biopsy procedure. We were given the findings of the biopsy at the next doctor visit. I told those stories, so if your residents ever must have these exams, you will know what to expect and be better prepared to help.
What the Exams Found Out
We went in for the follow-up doctor appointment.
The doctor said a few words to us and turned the case over to one of his Physician assistants. We lucked out and got a PA with a pretty good bedside manner. She told us that my wife’s condition was just over the borderline of decompensated cirrhosis. She also told us a bunch of other things, but since I was still clueless about everything cirrhosis, I left pretty confused and had to deal with a very worried wife. That’s when I got fed up with not knowing and started my learning journey.
The Grading of Cirrhosis
The next step in my learning journey was to understand what the doctor said about how bad my wife's condition was. I learned that the progression of the liver disease is based on how functional the organ remains. It is named either as a stage or its descriptive name. There are four stages.
|
Stage |
Name |
Signs of dysfunction |
|
Stage 1 |
Compensated Cirrhosis |
Liver function is still largely intact. May have no symptoms or mild symptoms such as fatigue, fatigue, and spider veins. |
|
Stage 2 |
Decompensated Cirrhosis |
Liver function begins to decline significantly. Symptoms may include jaundice, ascites, varices, and hepatic encephalopathy |
|
Stage 3 |
Advanced Cirrhosis |
Liver function is severely impaired. Complications such as liver failure, liver cancer, and infections |
|
Stage 4 |
End-Stage Liver Disease |
Liver function is almost completely lost. A liver transplant is required for survival. |
The PA told us the exams showed that my wife was at the border of stage 2, approaching stage three. Now that I understand more about what is going on, I realized she is better off than I originally thought she was.
MELD Score
The next thing the PA talked to us about, which made us concerned at the time, was the possibility of a liver transplant, since that was the only cure for Cirrhosis. As one would imagine, there is always a significant shortage of livers available for transplant. A system had to be developed for how to objectively prioritize who got a transplant when a compatible donor became available. In 2002 MELD (Model for End-Stage Liver Disease) score was approved by the United Network for Organ Sharing (UNOS) for just such a purpose. It is a numerical scale, used for liver transplant candidates aged 12 and older. Children who need a liver go to the top of the list as a matter of course. MELD uses the patient's values for serum bilirubin, serum creatinine, and the INR levels in an equation that results in a score of between 6 and 40. The higher the number, the more serious the patient's prognosis is.
|
MELD Score |
90-day risk of death |
|
Less than 9 |
1.9% |
|
10 to 19 |
6% |
|
20-29 |
19.6% |
|
30 to 39 |
52.6% |
|
Higher than 40 |
71.3% |
The PA told us my wife had a MELD score of 10. Which meant that she was almost at the bottom of the priority list. That concerned my wife. Since then, my research has shown me that the low score was actually very good news. Her liver condition is not as life-threatening as we at first feared it was. Knowing is always better than not knowing.
Now that we have a better understanding of what the Doctor and the Physician's Assistant talked to us about, we are now in a much better position to handle my wife’s condition. Which brings us to the next step in my journey, managing, not curing. Here is what I learned.
No Cure
Why can’t the doctor cure Cirrhosis? Cirrhosis is not a disease in the traditional sense. It is a condition of excessive scarring throughout the liver. There is no homeostatic mechanism to stimulate or medical treatment that reverses the formation of scar tissue. Once it is there, it’s there for good. Also, a doctor cannot remove it by surgically cutting it out because new scar tissue will form in its place. The best that a surgeon could do is reduce the size of the scar tissue. Given how extensively and finely the scar tissue is dispersed throughout the liver, there is no point in even trying. So where does that leave us?
Managing the Problem
The goal of therapy switches from eliminating the problem to not losing any more of what we got, taking good care of what is left, and compensating for what can’t be done anymore. Broadly speaking, that means reducing what is putting stress on the liver by treating the cause, maintaining proper diet and lifestyle choices, and treating any complications that may arise.
Treating the Cause
Diet and Lifestyle
Treating Complications and Side Effects of Cirrhosis
My wife and I certainly have got our work cut out for us. It’s going to have to be a team effort. Currently, we are looking into the Mediterranean Diet. The doctor also wants her to take extra Vitamin E because of its anti-inflammatory effects and a fish oil supplement to help balance out the good fats and the bad fats in the bloodstream.
In addition, my wife is tired all the time, so my job is being a motivational cheerleader. “Get up out of that recliner and Go team Go”.
Now that we have a better handle on what's going on with her liver, I feel hopeful for a good outcome. I also look forward to being healthier myself; I could stand to lose a few pounds (really more than a few). I plan to continue my learning journey as we discover what works and doesn’t work for maintaining her liver function.
Caregiver Implications
I hope you enjoyed the story of my learning journey. The goal was not only to educate you about cirrhosis but also to give you some practical examples of how to work the medical system for the benefit of your clients. You also now know to screen for those a risk for liver disease. If you catch it soon enough, the liver can heal itself before fibrosis sets in. Those with a history of drug or alcohol abuse, diabetes, obesity, and those developmentally challenged should have their livers examined.
If you do have a client who has been diagnosed with a liver disease or cirrhosis, there is going to be some extra work for you to do.
Conclusion
For those visual learners, here are two summation videos to watch. (There will be exam questions on them.)
As always, good luck in your caregiving efforts. Mark Parkinson, BsPharm.
References:
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