When the strongest start to fail.

One of the saddest things as a nurse, is seeing the proud, strong, independent, become more confused, dependent and weaker. Sometimes nothing can be done to "fix" the problem, Symptoms can (and should) be managed. Emotional support is a necessary part of the picture.
The family should be supported. Sometimes they lash out at staff, not because staff has done anything wrong, but, because they (the family) are feeling angry, helpless and just not dealing well with the guilt, stress, etc. that they are feeling. It is a time to be patient with the family, without letting them disrupt the nursing floor.
Hospice, although not essential in a skilled nursing setting (for actual care), can make the difference with emotional support and advice with symptom management. Sometimes a doctor is more willing to treat pain, nausea and other symptoms more aggressively when hospice is involved.
Staff do become emotionally involved with people they take care of day after day. They grieve, too, as a patient becomes weaker, losing their battle with chronic illness and an aging body.
It is a hard time for all.
It is a time to support each other, and to be kind to all involved.

Depression

Depression is the most undiagnosed ailment of the elderly population. (Don't take my word for it - do a search online for depression in the elderly.)
It isn't always expressed as sadness.
Sometimes you will see anger and/or irritability.
Some people don't eat. Others want to eat all the time.
Some people sleep more - others, less.
Some people withdraw from the people around them. Others have an unending list of ailments and complaints.
There are simple tests that can be done to determine signs and symptoms of depression. Staff observations are often crucial.
It is expected, that there will be a period of adjustment in a new setting, like a nursing home. But, when the mood affects quality of life, there are interventions needed.
Moving into a nursing home means there are new things added to the losses that we all have in our lives - loss of autonomy, privacy, giving up your home, your belongings, the pattern of your life. Sometimes it means giving up a beloved pet.
It may require someone like a licensed clinical social worker coming in to listen to your loved one. Sometimes medication is needed. Some doctors order a psychiatric consult (that doesn't mean their patient is crazy).
The important thing is to find the right combination of interventions, and help the resident feel better, and more in control of their lives.
It doesn't mean the nursing home is the wrong place to be. It means your family member needs help and support to cope.
Depression is not a "normal" part of aging.

Pain

Pain can be expressed in many ways, not just verbally.
If someone grimaces or is protective of a body part (called guarding) this is a symptom of pain.
Irritability, changes in mood and/or behavior also can indicate pain symptoms.
If you are in pain, do you want to eat? Interact in your usual manner?
If someone shows discomfort when repositioned, they were probably in pain before the repositioning.
Look at the whole person, not just the words they say. Families are often taken aback when pain management (sometimes just Tylenol scheduled at regular times) is started. Some people feel that it is "unnecessary".
But, ask yourself this - is life good when you are in pain, even a low level of it?
No one should deal with constant aches and pains. It is not "just a part of getting older".

Making the nursing home a real home

What makes someone (like your mom or dad) feel at home when they aren't "home" ?
A nice cover for the bed (make it something that you will have no trouble cleaning if you do their laundry) in a warm, but light material (fleece seems to be very popular these days) is a start. The facility will provide a bedspread, but, it will be about as individual as a hotel bedspread. Your parent can have their own.
Is there an afghan that they liked to use at home?
What about family pictures? A favorite picture? One of the most memorable I've seen was the romantic kiss of a pair of newlyweds. They were married many years, and the bride, now widowed, still grew misty when discussing that happy moment. It gave her a chance to share a happy memory and gave me a glimpse of a happy marriage, and the woman she had been when younger.
The facility pillows are, well, institutional. I always travel with my own pillow, and maybe your loved one has a preference, also.
A warm, easy to put on robe, sweaters, lap robes. Warm socks are always great!
A popular item in the nursing home these days is the new flat screen TVs. The facility probably has size and weight restrictions, so check before buying one. Keep in mind that even in a private room, space is limited. A remote control is a must, so that mom (or dad) can control the TV. It is there for their benefit, not the staff's. If you find it tuned in to shows your family doesn't watch, ask them who tuned in to the program. If they need help tuning in to THEIR favorite programs, let the RNAC (Registered Nurse Assessment Coordinator), Unit Manager, Social Services, and other staff know what their wishes are.
Residents are encouraged to wear their own clothing. Everything should be clearly labeled, even if you are doing the laundry. Facilities usually offer a labeling service. Firmly attached labels like you can purchase for summer camp, etc. are also good. The labeling must be where it isn't visible on the outside of the garment when being worn, for dignity reasons.
Velcro, snaps and other alterations can make most clothing easier to put on. Elastic waistbands help, too.
Expensive jewelry can be lost (or stolen).
Cash and other tempting items of value should be limited. Discuss this with admissions and/or social services. Facilities have stern policies about theft, but, there will be alot of people in and out of the room.
Eyeglasses and dentures should be engraved.
If your parent has a habit of hiding their hearing aide under their pillow, it is wise to share this information with staff. Too many hearing aides end up in the laundry, when a bed is stripped. Dentures, wrapped in a napkin on a tray can end up in the garbage. Staff are trained to watch for these items, but even with vigilance, things get lost or damaged.
Think about what makes your loved one comfortable, ask them what they would like and be realistic about durability and space restrictions. Their room is their home, and should look like it is.

Falls

No one wants your family member to fall.
Having said that, unfortunately, people do fall. What can be done? Interventions (ways to prevent a fall) are as varied as the members of the IDT (interdisciplinary team). Confusion is a big cause. A simple, treatable UTI (urinary tract infection) can dramatically increase confusion in the elderly.
A mat on the floor can prevent injury when someone rolls out of bed. But, the benefit must outweigh the risk if your family member might trip on it when walking.
Siderails can actually cause more injury, so they are not used as often as they once were. They do not keep someone safely in bed.
Alarms are sometimes used to alert staff when a resident is forgetful about requesting assistance and is at risk for falling. They are disturbing to some people, and may not always be appropriate.
Sometimes body pillows or bolsters help a resident understand the boundaries of the bed.
Dycem (a slip resistant material) can help someone not slip off their pressure redistribution cushion ( also called a gel cushion, foam cushion, etc. depending on the type).
Toileting schedules help not only continence (staying clean and dry) but, can help a resident not feel as anxious about getting to the bathroom in time (which is sometimes the reason individuals give when asked why they tried to go into the bathroom without asking for, or waiting for help). Identifying a person's pattern for toileting needs is a big part of the process. You can help with the process if you know that your parent (or other loved one) always goes in the bathroom right after meals, during the night, etc.
Is there a time of day that your loved one is more likely to be restless, or has fallen in the past?
A team approach (and you are a part of that team), a knowledge of a resident's habits, meeting basic needs are all a part of.
A pharmacist reviews your family member's medications, to watch for possible drug interactions.
These are only a few of the many interventions that may be used.

Restraints

There was a time, when I first went into nursing, that we used restraints (aka lap buddies, posey restraints, etc.) on pretty much anyone who fell, tried to get up without assistance, climbed out of bed, etc. in a nursing home. But, fortunately, the regulations and views changed over the years and we started to try to find better ways of keeping people safe. Why? Because restraints aren't really safe. First of all, they aggravate people more than calm them. Imagine someone putting a cloth belt on you, and telling you that you had to wait for assistance to do anything you wanted (like go to the bathroom). Then, imagine waiting, and then waiting some more.
You start to feel claustrophobic from not being able to move very much, and you pull at it. Then, you try to slide under it (or climb over it). What if you get partway out and get stuck? Or choke yourself? Or fall with even more force than you would have, because you've been fighting the restraint so hard?
Now, imagine that you can't always tell someone what you want (or need), so they treat your behavior with a medication, so that you quit trying to climb over or under the restraint.
Now you're groggy, more confused, and everyone is doing this TO KEEP YOU SAFE.
Sounds awful, doesn't it?
Most long term care facilities/nursing homes, don't have restraints anymore, or a very few. Staff tries to be more vigilant. Medications are reviewed (and reduced) more. Clever interventions like regular TOILETING (imagine that) actually reduced the number of falls and injuries.
Which is why, if you saw them tie your parent to the bed, in the hospital, you won't see it in a nursing home (or rarely).

The Blame Game

The quickest way not to get anywhere productive, is playing the blame game. It may be one nurse blaming another, or "it was an agency person", or "it was the other shift". Give me a staff person any day, who looks you straight in the eye and says "I'm so sorry. What can we do, to make things better?".
So instead of looking for the culprit responsible for whatever has raised your ire, which accomplishes little, let the nursing (or housekeeping, or maintenance, or whomever) take their own internal measures by :
A) Making sure the right person knows there is a problem. How do you know who the right person is? When in doubt, tell the Unit Manager (or Nursing Supervisor). Not to worry - if another department goofed, they know who to refer it to.
B) Let them know exactly what (when, etc.) the problem is, why it is a problem, etc.
C) Now, at this point, it is not out of line to ask "what are you going to do, to make sure it doesn't happen again?"
D) A telephone call the next weekday to the person in charge (of the unit, or the facility) is not only a good thing, but, will make sure you get follow-up.
What can I tell you won't (and shouldn't) happen. One staff member should not identify another staff member or shift as "responsible". Disciplinary actions should not be discussed with you.
What should be? The problem should be clearly identified. The corrective action should be in place. The appropriate staff/discipline should know what is expected of them.
Who is responsible to make sure that happens? The person in authority who you went to in the first place, their boss, and various other levels of the power structure. Social Services (the Social Worker) and Nursing (the Unit Manager, Supervisor) should be involved.
What does the blame game (yelling, etc.) accomplish? Usually very little other than people not hearing your message, only your noise. They won't think you are more involved, more supportive, or more loving.
Being polite, firm and tenacious always works.
Your family member deserves good care.

Why does someone stop eating?

There are many reasons that someone might stop eating. In long term care (aka nursing homes), the interdisciplinary team (all the people involved from all disciplines - nutrition, social services, nursing, infection control, activities, the doctor and anyone else on the team who can add insight) , the Resident (aka patient) and their family needs to be involved. Are they depressed? In pain? Is there a urinary tract infection (or any infection) that is affecting their appetite? Is medication making everything taste "bad" or "funny"? Are they weak? There are so many reasons someone stops eating. Sometimes their disease processes are affecting them in ways no one has realized. With input from everyone (and not everyone will agree on what they see), the doctor can order testing and physically assess the patient.
A sore mouth, ill fitting dentures - the causes are many, and not always easily found. But, with observation, persistence, and the input of many different perspectives, the cause can often be found.
Sadly, sometimes the body systems are failing, and the body is responding by decreasing appetite. It isn't something that can always be fixed - but, sometimes (more often than not) a cause can be determined, and interventions will be effective.
People don't stop eating just because they are getting old. Never accept that as a reason.

I want to go home

I think a parent begging or demanding to "go home" pushes more emotional buttons than most adult children could ever imagine.
The reality? Even with lots of emotional and physical support, it can be almost impossible to keep someone at home who needs 24 hour a day care and supervision. If you are doing it mostly (or totally) alone, you are asking more of yourself than anyone else could ever expect of you.
If we can help your loved one become stronger, healthier, able to help care for themselves (in whole or in part) then it can work, when that goal is reached. Many people do go home, and with support from home healthcare, bureaus of the aging, and family, do manage for the rest of their lives, to be "home".
But, what if they don't get better, or stronger? How many staff does it take, to put Mom to bed at night? Take her to the bathroom? Transfer her from bed to chair?
Watch your parent in therapy. Watch how trained staff meets their needs.
Can you do this? Twenty four hours a day?
I know your mom (or dad) took care of you. But, you did not weigh over 100 pounds (and dead weight is not just an expression). You did not have fragile, aging skin that tore with the slightest pressure, or become a draining sore without the proper positioning and cleansing.
I've seen the results of families, exhausted and frustrated.
Try to be as kind to yourself, as you would be to someone else.
Because, home may just not be the best place, at least for now, for them to be.

Tip for the day

Medicare can cover 100 days. However, there are strict rules for skilled Medicare coverage, and very few people receive 100 days of coverage. There is an appeal process, if you don't agree with the facility about coverage, and when it ends. This MUST be explained to you (or your loved one if they are legally capable) and contact information provided, at the time of the "cut notice". You will only have a short time to file a verbal appeal, and the determination is usually made quickly (about 24 hours). If the facility is following all the rules for Medicare, you probably won't win an appeal. But, some people do get continued coverage (usually for a short time). Nursing homes are expensive (usually well over two hundred dollars a day), so don't count on 100 days of coverage.

My mother's face in the mirror

The one thing I can guarantee in life - one day (if you live long enough) you will look in the mirror and say to yourself "Who is that? Is that me? That looks like my mother (or father, depending on gender)." It is not so much a "light bulb moment" as one of those "how did that happen?" moments.
Lines suddenly appear where there didn't seem to be any before. Hair grows in interesting places. Hot flashes provide indoor heating to most of us lucky ladies (most men deny any life altering changes like our hormonal joys, but, I tend to think otherwise - picture some of the commercials airing these days).
I'm sure we could have some fun with thoughts along those rife with possibilities topics, but, first let me introduce myself. I am of a mature age (still young enough to be amazed how long ago I graduated from high school, still have a daughter in college). I am also what I like to call a "late bloomer". My first great joy in life was being a mother to three daughters. But, somewhere down that path, I finally figured out what I wanted to be "when I grow up", and that was, and is, a nurse. I have been a nurse for 16+ years, first an LPN and then earning my degree, and becoming an RN.
That's when the journey got really interesting. I thought I would want to work in pediatrics or obstetrics (didn't). What I found I love, in many different forms, is geriatrics. I love working with the elderly. They are interesting and endlessly complicated as a group, and as individuals. Geriatric Psych was a locked Med/Surg unit with IV's, transfusions, and every psychiatric and medical issue you could name. Don't even get me started about the psychiatrists! I was there after working in long term care for a few years (nursing homes).
Then, when I got the itch to try something new (and during the day, so I could see my kids more), I went to work for hospice.
The short story about hospice, is not only the many useful things I learned about pain management, etc., but, that working with the dying was more about life, than death.
That was when I learned that it is the journey, not the destination, that is important, while we are so busy living our lives.
I visited people in their homes, helping them with the day to day struggle of living with a sure knowledge of how short life is. There were many symptoms that people had to deal with, when they are dying. Most of them can make life very unpleasant. But, there are many medications and resources to help control those (it's called symptom management, and with alot of team effort, it usually works). I am sure, somewhere out there are heroic nurses singlehandedly slaying dragons for their patients. Fearless and without support from anyone else. Never met one, although I've heard the stories. My experience is that it takes a team of caring professionals (not all nurses and doctors, either), to successfully manage and support a patient (in any environment). When being on the road 12 hours at a time, day after day, got too much, I went to work at the inpatient unit. I was the only nurse for nine patients, with an aide to help with the physical stuff (it is truly hard to lift someone around in a bed, without any help). I worked all night, because that was the only full time shift available. Interestingly enough, I spent alot of time with patients. It amazes me, still, how long night seems to someone facing their mortality. Somehow, it is safer to sleep when it is light outside. It is truly darkest before the dawn. I've shaved men's faces at 3AM as they told me stories. I've held hands of the dying and the frightened. I've learned the grace that some people live and die with, and how others fight and struggle to the last breath. I learned that there are many facets to the way individuals leave this life, just as there are so many ways to live it. A topic we can pursue, if anyone is interested.
Then I became an RN Unit Manager of a 40 bed nursing home unit that was primarily for dementia patients. While there I learned more about nursing and the many facets of management. I passed meds, did treatments, met with families - I learned alot.
But, four years later, I was burned out, looking for something different. I started working at another nursing home, not as management, but, strictly as a charge nurse/floor nurse. It took me nine months to find my way back to who I wanted to be as a nurse.
Then, refreshed (but, tired of working on my feet all the time), I trained as an RN Assessment Coordinator, including being certified in my specialty (that means extra I had to attend classes, take certification exams - ten-before becoming certified - thus adding more letters onto my signature). I complete the mandatory assessments for the residents on the 62 bed unit I work on (the government requires new assessments every 92 days on everyone in long term care). Medicare has other assessments that are required. The assessments are important, because it is how the facility receives funding (there are 108 line payment items on a full assessment). But, even more important, for the families and residents, is that this is a review of how the resident (the patient) is doing physically, emotionally in all areas of their lives. Every resident has a plan of care that details how their needs are met. That plan of care is reviewed with the resident and their family quarterly (again by regulation). This is also known as Care Plan, or Plan of Care. About two weeks after the MDS (minimum data system) assessment is done, the meeting is held. Residents and their FRP (first responsible party) are invited.
However, much more than just the review is accomplished with this meeting. Family and patient teaching is important to help (you and yours) understand changes, disease processes, and sometimes, just how the system (of the nursing home) works. I always encourage my families to tell us (team members, individually and together) their concerns and worries as they occur. Three months is much too long to wait if there is an issue about care.
The team consists of myself, the social worker, the dietitian, activities aide (one of the most important concerns in the facility, if you are bored!), sometimes the unit manager or a occupational or physical therapist if they are on therapy. Other people who are part of the team, but, who rarely attend, are the infection control nurse, nursing administration, housekeeping, nursing assistants, the hairdresser, the business office,maintenance (there are alot of people on the team). I've always thought that housekeepers, nursing assistants and the hairdresser are a priceless source of information about the residents. Unfortunately, they are very busy people who don't have time to attend the meetings, but, I frequently ask their opinion both before and after care plan meetings.
My favorite role as the RNAC (Registered Nurse Assessment Coordinator - the medical field LOVES acronyms), is family and patient teaching.
My grandmother was a teacher and I'd like to think that my strength in this area comes from her. She was my first and greatest role model.
Which brings me back to the mirror - is it her face I see? My face? Or is it my mother's face in the mirror?
I hope you will join me as we look into life's mysteries and any questions you would like to have a dialog about, relating to the one thing we are all doing - getting older.
I don't proclaim myself an expert in long term care, but, I have alot of knowledge - and I'm willing to share.
As I develop this blog, I will include tips, guidance, etc.
I can also be found on Twitter (lizziebetliz).
My friends call me Cindi.