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Assessing The Elderly For in Home Needs
There will eventually come a time for most people to take care of a loved one at home. In the health care world today the shift from hospital and nursing home care is to the private home setting. Increased insurance rates with diminishing confidence and trust in the system is influencing changes in the health care system. There maybe many incidences where there is no option for home care due to the high level of care needed and the availability of care providers. However, there will be many elderly persons that can function at home well with the assistance of either a custodial aide or simply a companion. Identifying the needs of the individual in this situation is critical to the safety and well being of that person.
The first step in isolating the needs of the person needing assistance is doing a basic assessment of the person in question. Mental acuity remains as the first and paramount requirement of the assessor. Many elderly people are as alert as the assessor, or appear to be. The appearance of alertness can easily be confabulated by anyone who is trying to appear more alert than they really are. Many people will not tolerate a mental acuity assessment as they don’t want to appear mentally failing. Therefore the common denominator used in this assessment is not only applied by the assessor through direct contact but also input from others that are familiar with the individual. Frequently these others are family members whom have been close to the person and can identify changes in mental awareness. If this input is limited the assessor will have to spend more time, and at different hours of the day. Many people that seem aware and alert at 10am, can be disoriented and confused later in the day and at night. Without a recent prior history and input from outside companions and family members an accurate mental awareness assessment could take several days. Assessing the person for appropriateness through out a 24 hour period is truly the only way to properly assess the person. Appropriateness certainly can be calculated by most people that are appropriate. If that sounds confusing, consider the simplicity of the basic exchanges of the activities of daily living. The fact that somebody can’t see or hear very well doesn’t mean they’re not aware and alert. Managing those reduced senses is the priority of the assessor. The limited visual acuity can be assessed not only by asking the person about their vision but spending the time with that person while doing the activities of daily living. Certainly a common sense approach to a problem that may not appear to be a problem until the stove ignites a fire because somebody can not see a cloth pot holder sitting next to a red hot burner. Although the visual assessment is fundamentally discovered through trial and error of daily living the elderly seek independence and may not share their poor vision with the assessor.
The mental acuity assessment remains the assessment that takes the most time. It truly can be as convoluted as the world can be confusing. However, time and patience are the tools required to come to a conclusion to help identify the needs of the elderly. How does one assist the confused and elderly to remain independent and in their own surroundings? The mildly confused person may in fact be similar to the pediatric child of 6 to 10 years. They need supervision but perhaps not around the clock. Frequently the elderly are concerned about their friends and contemporaries. Having these people nearby that can visit and assist in the care is a huge plus. Communication is a must and the ‘life alert’ programs which are easily available can cut into a budget. Although these services are dependable and available in most areas their costs can start about 50.00/mo. Without prior insurance planning these services are generally self pay and a fixed income is frequently limited. A nearby relative or a friend is equally as good, however a mobile phone would be a must, and pinned on speed dial and carried continually.
Timed daily visits are critical to help assist the in home elderly person, and perhaps at meal times. This basic need may not be that easy to fulfill. Most communities have daily meal delivery programs that are accessed through county senior centers. In advance let me say at one time these were very effective but lately these programs have taken big hits in funding at all levels. They still exist but unrealistic delays are now an every day occurrence. The frozen TV diner once considered to be a joke often times can deliver safe, economical and nutritional meals. I can not stress enough the importance of meal availability and the safety assessment on its preparation. It is one of the top priorities in the needs of the in home elderly. It maybe in fact the main reason for most nursing home admissions. This need is critical and should be reassessed with the mental awareness assessment and evaluated frequently.
Another need commonly considered by professionally trained persons is the elimination need. Many elderly people have incontinence issues that may not be repairable through medical or surgical treatments. However, it is not uncommon for a person to attempt repair again and again with little success. Urinary bladder catheters are a very common treatment for the elderly incontinent person. Although relatively basic care is required the urinary catheter is commonly neglected and problems arise via infection and replacement delays. These catheters should be assessed for output flow, urine quality, and cleanliness. Urine quality can be assessed simply by looking at the amount of urine in a 12-24 hour period. The amounts can vary but the standard acceptance is about 30cc/ hour [1 oz.]. Less is not uncommon and more is not uncommon. Very little with dark urine is symptomatic of dehydration, and or, poor kidney function. Urine volume and quality discussions can be lengthy, but remember foul smelling and cloudy urine is in need of addressing. Persons with urinary catheters should all be under the care of a physician and problems should be reported in a timely fashion to the physician.
URINARY CATHETERS AND THEIR MANAGEMENT
Care of the urinary catheter revolves around keeping it clean, especially where it enters the body. Washing the entire catheter with mild soap and water will help reduce urinary tract infections and allow the care giver to assess the catheters’ proper positioning and integrity. The catheter should easily slide in towards the bladder and have restrictions to be removed. An inflated balloon keeps the catheter in place and any pulling or tension on the catheter should be avoided. The changing of the catheter is variable and averaging every 3-4 months per routine catheter is acceptable. However, not all catheters are routine and require more frequent changes, or less. These types of assessments should be made by knowledgeable personnel. Many a urologist will recommend cranberry juice daily to reduce the possibility of infection. It doesn’t hurt to follow this rule, 4-6 ounces/day would be the standard. The care of urinary catheters should be by the direction of the attending physician who may have additional treatments for the management of the catheter. Be sure to check any recommendations and physicians’ orders before implementing catheter care. Although cleanliness does not have to be ordered by a physician. Many people will opt for a catheter as avoiding to wear diapers. Long term catheter placement causes the bladder to loose tone and is unlikely to return to its original tone, reducing its ability to ever return to normal control. The cost compassion related to incontinent briefs? Incontinent underwear can run 80-100$ a month. A catheter is much less but one will be constantly required to maintain a drainage system wherever they go.
The use of incontinent products such as adult diapers and bed pads are common sources for needs in incontinent treatment of the elderly. Maintaining safe and healthy skin with these products takes diligence and common sense, and yes dollars. Assessing urinary incontinence in the alert person can be accomplished fairly accurately by asking the person when their period of high volume is. Does the bladder empty fully? Is there any ability to sense the need to urinate? Does the urine have a foul odor? Are there any discomfort complaints? Urinary incontinence is a frequent occurrence with many elderly people which can be manged with diligence to the time, volume and patient knowledge of existing conditions. Stress incontinence is frequently seen in the elderly female, much more than the male. Laughing, lifting objects, coughing and sneezing maybe a common cause for stress incontinence. Surgical intervention of the bladder frequently is successful, but like all surgeries may in fact fail or cause additional problems. Many urologist will considered medication and specific exercises applied for the treatment of stress incontinence before considering surgery. Perhaps wearing a lite volume incontinence brief maybe that part of life one will have to accept and manage the incontinence of urine by remaining as dry and clean as possible. Many briefs of many different quality and prices are available on the market today. Total incontinence of an elderly person can put out as much as 1-2 liters a day of urine. There are new products on the market that can keep the skin dry and still close to a liter of urine. Wellness Briefs claim astronaut technology. Saves money in the long run, but the brief stays on longer. Longer brief times may allow bacteria the chance to grow unless closely monitored and treated. Barrier creams for almost all incontinent persons is highly recommended. Light cleansing with baby wipes before application is a must. The barrier cream should be applied with special attention in the groin grooves as well as between the buttocks and perineal area. This type of skin care is a must and needs to be monitored with increased importance with the diabetic person. The diabetic person will often excrete sugar in the urine and rapidly promote either skin infection or groin rashes. Knowing hourly outputs, which time frame will put out what amount of urine, will help the person and the care giver to allow for a cleaner and drier person. It will also reduce costs. Applying a washable bed-pad at night will help reduce costs, but doesn’t necessarily keep the person dry. Managing incontinence of urine in the elderly is an ongoing assessment with a focus on volume, time, urine quality and cleanliness.
Fecal incontinence in the elderly is much less seen, but not uncommon. The treatment and management of cleanliness and control is not unlike urine incontinence, however, constipation is not an uncommon side effect seen when managing fecal incontinence. If that sounds confusing it means liquid stool may appear to be fecal incontinence but in fact is liquid stool being leaked around impacted stool. This problem should be approached by experienced personnel. Most elderly people are very bowel elimination conscious and will have a wide assortment of treatments for their bowel elimination routine. Most elderly persons are less active and will have altered bowel patterns that hopefully they themselves have had some success managing. The altered mentally aware person will need one to one assessment over several days to make an accurate assessment. The regularity of the bowels is highly variable dependent on activity, medications, oral intake, and prior exposure to laxatives.
The psychological effects of aging and losing independence and perhaps financial stability will probably provoke some degree of depression in this person. The degree of this depressive state is certainly variable but often times the more alert and aware person seems more vulnerable. Let by itself to grow within the depressed mind of the elderly depression can take over and create ‘the will to die.’ I suspect from my own clinical experiences this factor is seen most frequently in long term facilities such as nursing homes. Although also seen in the private setting once the person has made up their mind to die there maybe little you can do to stop that. Keeping a house bound, dependent person happy and healthy seems dependent on close relationships with loved ones visiting on a regular basis. It all may go to the personality and general make up of that person that determines how they’ll handle this portion of their life. There are volumes composed by scholars of all kinds to give guidelines and predictions and I would say from first hand experience much thought for this person seems focused on the value of their life past, but also the close ties to friends and family. They need support, at least most commonly.
There will never be enough said for instructions in the assistance of persons in need of nursing and personal assistance. The requirement for good care begins with common sense and the inner belief that the care giver can make a difference in the recipient’s life. The creation of a sense of well being comes from the milieu of well being itself. Meaning the care giver has the desire to give good quality care and more importantly garnishes satisfaction from helping and caring for others. Many times family members are generally a good source for this type of care but not always. The cost of professional care comes into play for those that are on a fixed income. Senior Medicare is limited to about three two hour visits per week. These visits can be very effective when managed properly and alternated amongst visits with family visits. The key to success will almost always depend upon proper timing related to the activities of daily living. Especially noting meal times. Assisting at mealtimes and the hours of sleep is essential.
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