Advance Directives and End of Life Training

Questions and Answers about Advance Directives

More than ever before, people are being asked to take part in decisions about end-of-life care. Yet, most people still do not discuss end-of-life care at all, even if they are seriously thinking about these issues and some guidelines for discussions with their physicians, families, and loved ones. This fact sheet is also designed to help patients understand the medical, legal, and personal choice they may face in the future.

1. What rights do patient have regarding their medical treatment?

         Patients are entitled to have complete information about their illness and how it may affect their lives, and they have the right to share or withhold that information from others. People with cancer should also be informed about any procedures and treatments that are planned, the benefits and risks, and any alternative that may be available. Patients may be asked to sign an “informed consent” form, which includes this information. Before signing such a form, patients should read it carefully and ask the physician any questions they might have.

         Patents have the right to make decisions about their own treatment. These decisions may change over time. In the face of worsening disease, some patients may want to try every available drug or treatment in the hope that something will be effective. Other patients may choose to forgo aggressive medical treatment. Many patients turn to family member, friends, or caregivers for advice. But, it is the patient’s decision how much for how little treatment to have. Sometimes a patient is unable to make this decision, due to severe illness or change in mental condition. That is why it is important for people with cancer to make their wishes known in advance.

2. What is end-of-life care? What are advance directives?

         End-of-life care is a general term that refers to the medical and psychosocial care given in the advanced or terminal stages of illness. Advance Directives are the legal documents such as the living will, durable power of attorney, and healthcare proxy that allow people to convey their decision about end-of-life care ahead of time. Advance directives provide a way for patients to communicate their wishes to family, friends, and health care professionals and to avoid confusion later on, should they become unable to do so.

         Ideally, the process of discussing and writing advance directive should be ongoing, rather than a single event. Advance directive can be modified as a patient’s situation changes. Even after advance directive have been signed, patients can change their minds at any time.

3. Why are advance directive important?

         Complex choices about end-of-life care are difficult even when people are well. If a person is seriously ill, these decisions can seem overwhelming. But, patients should keep in mind that avoiding these decisions when they are well will only place a heavier burden on them and their loved ones later on. Communicating wishes about end-of-life care will ensure that people with terminal illnesses face the end of their lives with dignity and with the same values by which they have lived. 

4. Why is it important to write a will?

         A will is important so that patients can give instruction about distribution of their money and property when they die. Patient can name a trusted family member, friend, or professional to handle their personal affairs (also known as an executor). It is advisable to seek the expert advice of a lawyer in drawing up a will so that the decision made about taxes, beneficiaries, and asset distribution will be legally binding. This process can relieve a patient’s family and friends of an enormous burden in case of dispute or question about allocation of the patient’s assets.

5. What is a living will?

         A living will is a set of instruction documenting a person’s wishes about medical are intended to sustain life. It is used if a patient becomes terminally ill, incapacitated, or unable to communicate or make decisions. Everyone has the right to accept or refuse medical care. A living will protects the patient’s right and removes the burden for making decision from family, friends, and physicians.

There are many types of life-sustaining care that should be taken into consideration when drafting a living will. These include:

·     The use of life-sustaining equipment (dialysis machines, ventilators, and respirators)

·     “do not resuscitate” orders; that is, instruction not to use CPR if breathing or heartbeat stops

·     artificial hydration and nutrition (feeding tube)

·     withholding of food and fluids

·     palliative/comfort care

·     organ and tissue donation

It is also important to understand that a decision not to receive “aggressive medical treatment” is not the same as withholding all medical care. A patient can still receive antibiotics, nutrition, pain medication, radiation therapy, and other intervention when the goal of treatment becomes comfort rather than cure. This is called palliative care; its primary focus is helping the patient remain as comfortable as possible. Patients can change their mind and ask to resume more aggressive treatment. If the type of treatment a patient would like to receive changes, however, it is important to be aware that such a decision may raise insurance issue that will need to be explored with the patient’s health care plan. Any change in the type of treatment a patient wants to receive should be reflected in the patient’s living will.

After a living will has been drawn up, patients may want to talk about their decision with the people who matter most to them, explaining the values underlying their decisions. Most states require the document be witnessed. Then, it is advisable to make copies of the document, place the original in a safe, accessible place, and give copies to the patient’s physician, hospital, and next of kin. Patients may also want to consider keeping a card in their wallet declaring that they have a living will and where it can be found. 

6. What is a health care proxy and durable power of attorney for health care?

         A health care proxy is an agent (a person) appointed to make a patient’s medical decision if the patient is unable to do so. Generally, people assign someone they know well and trust to represent their preferences when they can no longer do so. Patients should be sure to ask this person for agreement to act as their agent. An agent may have to exercise judgment in the event of a medial decision for which the patient’s wishes are not known.

         The durable power of attorney for health care is the legal document. After it is written, it should be signed, dated, witnessed, notarized, copied, distributed, and incorporated into the patient’s medical record.

         Patients may also want to appoint someone to manage their financial affairs if they cannot. This is called a durable power of attorney for finances, and is a separate legal document from the durable power of attorney for health care. Patient may choose the same person or someone different from their health care proxy to act as their agent in financial matters.

7. Where can people get assistance with their advance directives?

         If patients need help making the decisions discussed in this fact sheet, they should not hesitate to call on family, friends, and other loved ones.

         Although a lawyer is not needed to complete advance directive, it is important to be aware that each state has its own laws for creating advance directive. Because these laws can vary in important details, special care should be taken to adhere to the laws of the state a patient lives in or is treated in. It is possible that a living will or durable power of attorney signed in one state may not be recognized in another. Appropriate forms can be obtained from health care provider, legal offices, offices on aging, and state health departments.  

The patient with end-stage illness will most probably have various symptomatic problems that will affect ability to eat. A few of these are mentioned below with some suggestion to offer the patient.

Bloating or early satiety

·     Eat small, frequent meals

·     Eat slowly

·     Sit upright when eating

·     Eat easily digestible foods avoiding fatty foods & gas forming vegetables

·     Drink fluids between rather than with meals

Chewing problems

·     Modify food consistency, going from soft to ground to pureed based on severity of problem

·     Moisten foods

·     Emphasize soups, stews, cooked & cold cereals, eggs, custards, puddings, & liquids

·     Chop, mash, or strain cooked fruits & vegetables

·     Try baby foods, they can be used along (spice to taste) or added to soups & broths

Colostomies

·     Chew foods thoroughly & avoid swallowing air

·     Avoid foods that can cause irritation: nuts, popcorn, skins & seeds from fruits & vegetables or coconut

·     Avoid gas forming foods: cabbage, brussels sprouts, green peppers, cucumbers, onions, beans, peas, corn, broccoli, & cauliflower

·     Avoid foods that may produce odors; onions, fish, & eggs

Constipation

·     Drink plenty of fluids

·     Drink a glass of prune juice or hot liquid in the morning or evening to stimulate bowel function

·     Increase fiber or bulk in diet if able

Diarrhea

·     Decrease fiber in diet

·     Avoid foods that may cause cramps; fatty foods, caffeine, spicy foods, carbonated beverages, & gum

·     Keep liquids warm or at room temperature because extremes in temperature may stimulate the bowel & aggravate diarrhea

·     Avoid lactose-containing foods if a lactase deficiency is suspected

·     Take liquids between rather than with meals

·     Potassium can be depleted with large fluid losses. If a patient has large volume, frequent diarrhea, encourage increased fluid & potassium intakes (unless contraindicated). Some high potassium foods: bananas, oranges, orange juice, watermelon, tomato sauce & juice, potatoes, meat, kidney beans, peanut butter, wheat germ, milk, yogurt, molasses, raisins, & apricots.

Dry mouth

·     Encourage frequent mouth rinsing with salt/soda water (1tsp salt & baking soda per quart of warm water). Avoid commercial mouth washers due to alcohol which causes dryness.

·     Increase fluid intake

·     Use a humidifier

·     Use moistened mouth swabs                                                            

Pain

·     Pain must be adequately controlled before any thought can be given to nutritional therapy

Swallow dysfunction (dysphagia)

·     Modify food consistencies (refer to chewing problems)

·     Thick liquids are sometimes better tolerated than thin (they cause less gagging). Add ice cream or mashed banana to milk or milk shakes to make them thicker.

·     Recommend high-calorie, commercial supplements

·     Recommend liquid multivitamins

·     Have the patient try tilting their head back or forward to facilitate swallowing.

Taste alterations (ageusia)

·     Experiment with new flavors & foods

·     Use condiments on chicken, meat, & fish

·     Drink or rinse mouth with carbonated water, ginger ale, or tea after meals to help get rid of bad tastes.

Viscous saliva

·     Milk & milk products may cause increased phlegm production. Patients can try low fat or soybean milk products, or use ginger ale or club soda to “cut” milk & shakes.

·     Clear liquids, broths, hot tea with lemon, popsicles, lemonade, carbonated beverages, sherbets, & ices may be better tolerated than thick liquids (commercial clear liquid high-calorie protein supplements are available)

Activities of Daily Living

Activities of daily living (ADLs) are those things we all need to do on a regular basis to ensure our health and well-being. ADLs are those need-to-do things that take up so much of our day and that we all take for granted – until we cannot do them anymore. Activities involving health and hygiene are called basic activities of daily living. By contrast instrumental activities of daily living are those abilities that allow a person to live independently.

Basic Activities of Daily Living

• Eating

• Bathing

• Dressing

• Toileting

• Continence

• Ability to get out of bed or a chair

• Walking (can be with the aid of a cane or walker)

Instrumental Activities of Daily Living

• Food Preparation

• Housekeeping and Laundry

• Managing Financial Matters

• Shopping

• Use Telephone

• Take Medication

• Responsible for Transportation (public transit, auto, etc.)

Nutrition Components

3 major groups :

• Proteins

• Carbohydrates

• Fats

Other important components:

• Vitamins

• Minerals

• Water

Principles of Good Nutrition

1. Balance

2. Variety, Variety, Variety

3. Moderation

Balance

We need a good balance of the 3 main groups of nutrition, ie carbohydrates, proteins and fats to stay healthy. Vitamins, minerals and water should also be taken in the right amounts.

The general guideline for our caloric intakes is:

• 15% to 20% from proteins

• 15% to 30% from fats

• 50% to 85% from carbohydrates

Variety

• Every food or food group has its own unique nutritional values

• Only a good mix of the various food groups will give you the complete essential nutritional needs

• A wide variety of food groups helps to complement each other in nutrition’s

Moderation

• Too much of any particular food can result in unbalanced nutritional intakes, causing excess weight and too much of certain nutrients

• On the other hand, too little of any particular food can lead to certain nutritional deficiencies

• Taking food in moderate amounts helps to prevent any imbalance

Complications of Poor Nutrition

• Heart disease

• Cancer

• Stroke

• Diabetes

• Osteoporosis

• Many others...

Dehydration

How do you know if you are properly hydrated? Generally speaking, the clearer the urine, the better hydrated you are. If it is a clear-pale lemonade color, you are hydrated. If it is a darker lemonade to apple juice color, you are dehydrated. And if it is dark and cloudy, you are severely dehydrated.

Why is it so important to stay hydrated?

The body depends on water for survival. Did you know that water makes up more than half of your body weight? Every cell, tissue and organ in your body needs water to function correctly. For example, the body uses water to maintain its temperature, remove waste and lubricate joints. Water is essential for good health.

How does a body lose water?

When you go to the bathroom, sweat, and even when you breathe. Water is lost even faster when the weather is really hot, during exercise, or with a fever. Vomiting and diarrhea can also lead to rapid fluid loss. If you do not replace the water you lose, you can become dehydrated.

Symptoms of dehydration include:

• Little or no urine, or urine that is darker than usual

• Dry mouth

• Sleepiness or fatigue

• Extreme thirst

• Headache

• Confusion

• Feeling dizzy or lightheaded

• No tears when crying

Special Diets

There are many types of diets for all different reasons, such as weight loss, religious beliefs, vegetarian, but the diets most associated to our patient are medical based. Here are a few of those types of diets.

People's dietary choices are sometimes affected by intolerance or allergy to certain types of food. There are also dietary patterns that might be recommended, prescribed or administered by medical professionals for people with specific medical needs.

• Best Bet Diet: A diet designed to help prevent or mitigate multiple sclerosis, by avoiding foods with certain types of protein.

• Colon Cancer Diet: Calcium, milk and garlic are thought to help prevent colon cancer. Red meat and processed meat may increase risk.

• Diabetic diet: An umbrella term for diets recommended to people with diabetes. There is considerable disagreement in the scientific community as to what sort of diet is best for sufferers.

• DASH Diet (Dietary Approaches to Stop Hypertension): A recommendation that those with high blood pressure consume large quantities of fruits, vegetables, whole-grains and low fat dairy foods as part of their diet, and avoid sugar sweetened foods, red meat and fats. Promoted by the US Department of Health and Human Services, a United States government organization.

• Elemental diet: A medical, liquid-only diet, in which liquid nutrients are consumed for ease of ingestion.

• Elimination diet: A method of identifying foods which cause a person adverse effects, by process of elimination.

• Gluten-free diet: A diet which avoids the protein gluten, which is found in barley, rye and wheat. It is a medical treatment for coeliac disease.

• Gluten-free, casein-free diet: A gluten-free diet which also avoids casein, a protein commonly found in milk and cheese.

• Ketogenic diet: A high-fat, low-carb diet, in which dietary and body fat is converted into energy. Used as a medical treatment for refractory epilepsy.

• Liquid diet: A diet in which only liquids are consumed. May be administered by clinicians for medical reasons, such as after a gastric bypass or to prevent death through starvation from a hunger strike.

• Specific Carbohydrate Diet: A diet that aims to restrict the intake of complex carbohydrates such as found in grains and complex sugars. It is promoted as a way of reducing the symptoms of irritable bowel syndrome (IBS), Crohn's disease, ulcerative colitis, coeliac disease and autism.

Meal Preparation

1. Get the patients input on what meal items they want prepared. Consider if the requested item fits in the patients diet. (Regardless it is the patient’s choice but encourage the patient to consider their diet, if the patient is not willing to change their request, prepare the request meal.

2. Clean.

This allows for clear counters for food prep and it is easier to find your equipment. An empty dishwasher and sink gives you somewhere to put your dirty stuff and a head start on cleaning. Remember to clean as you go. This is a key tip for meal preparation.

3. Check the refrigerator for items that may go with the meal.

A little left over roasted sweet potatoes will add a nice richness and color to the mashed potatoes.

4. Put all the food on the counter that you need and determine the order to start each item.

5. Prepare the items per recipe or carton instructions.

6. Serve and remind patient if items are hot!

7. Clean up any mess!

Body Mechanics

A. Purpose

1. To maximize strength

2. To avoid injury to the aide and the patient

B. General Guidelines and Precautions for Lifting and Moving

1. Wear loose clothing and low heeled, comfortable, non-skid shoes to allow good body mechanics.

2. Always get help from co-workers when needed before lifting heavy objects or patients who are unable to

stand.

a. Plan the lift ahead of time.

b. Lift on signal such as "on the count of three."

3. Elevate the bed to comfortable working height when working at the bedside. Remember to return the bed to the lowest horizontal position when finished for patient safety.

4. Maintain good posture and good body alignment while lifting.

a. Keep your back straight.

b. Keep your knees bent.

c. Keep your weight evenly distributed on both feet.

d. Keep your feet at shoulder width (about 12 inches apart) to provide a broad base of support.

5. Use the strongest and largest muscles to do the job. Leg and arm muscles are the strongest. Back and

abdominal muscles are the weakest.

6. Bend from the hip and knees--not waist--when lifting objects.

7. Always squat down to lift heavy objects from the floor.

8. Keep objects close to your body when lifting and carrying.

9. Use both hands when lifting or moving heavy objects.

10. Slide, push or pull heavy objects rather than lifting them, when possible.

11. Use the weight of your body to help push or pull objects.

12. Work with smooth, even movements--not quick, jerky motions.

13. Face your work and avoid twisting your body.

14. To change the direction of your work, take short steps and turn your whole body without twisting your back and neck.

15. Avoid unnecessary bending and reaching.

16. Do not lift objects higher than your shoulders.

Assistive Technology

Assistive technology devices are mechanical aids which substitute for or enhance the function of some physical or mental ability that is impaired. Assistive technology can be anything homemade, purchased off the shelf, modified, or commercially available which is used to help an individual perform some task of daily living. The term assistive technology encompasses a broad range of devices from “low tech” (e.g., pencil grips, splints, paper stabilizers) to “high tech” (e.g., computers, voice synthesizers, braille readers). These devices include the entire range of supportive tools and equipment from adapted spoons to wheelchairs and computer systems for environmental control. The Individuals with Disabilities Education Act (IDEA), the federal special education law, provides the following legal definition of an assistive technology device: “any item, piece of equipment, or product system... that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.” Under IDEA, assistive technology devices can be used in the educational setting to provide a variety of accommodations or adaptations for people with disabilities.

Perineal Care

Perineal care is performed after a patient uses the bedpan, becomes incontinent, and as a part of daily bathing.  As the nurse’s aide performs perineal care, she is able to observe the skin on the perineal area for signs of infection such as lesions or swelling, which can be early signs of more serious conditions.  Care performed regularly and properly will reduce the risk of urinary tract infection which can lead to bladder and kidney infection.  Before you begin, wash your hands thoroughly and put on a pair of gloves.  Then, follow these steps:

1. Ask the patient to open his or her legs if they are able.  If not, you will need to gently separate the legs.

2. Using a washcloth and warm water, gently clean the skin of the perineal area moving from front to back.  Do not move from back to front due to the risk of introducing germs from the anal area into the urethra, a primary source of urinary tract infection.

3. When you are finished washing, dry the area thoroughly to prevent skin from becoming chapped.

4. Never reuse linens used to clean the perineal area to clean any other part of the body.  Use a clean washcloth for this area only to minimize the spread of germs.

5. If bed linens are soiled or become wet during the cleaning process, you will need to replace them as quickly as possible.

6. Place used linens in the appropriate receptacle.  Help the patient move to a comfortable position.  Dispose of gloves and wash hands.

As you work, remember it is important to look for signs that may indicate infection.  This can include pain or tenderness in an area, rashes, sores, or boils.  If you notice any of these signs, report them to your supervisor immediately.  Proper care can help your patient remain comfortable as they recover.

Bedpan

Find out how to assist with use of a bed pan in this important PCA skill. For patients who are unable to walk or stand, the use of a bedpan may be necessary.  Assisting your patient in the use of the bedpan can minimize embarrassment and prevent unpleasant messes.  Before you begin, wash your hands to prevent the spread of germs.  Greet your patient, and explain that you will be helping him/her to use the bedpan.  Ensure the patient has adequate privacy, and put on a pair of gloves.  Assist the patient into a supine position (laying on the back, face up), and then help him/her turn onto their side.  Follow these steps to make the process safe and efficient:

• Place the bedpan against the patient buttocks, and then roll the patient back onto his/her back.  Ask the patient to spread their legs to ensure the bedpan has been properly placed.  Raise the head of the bed to make the patient comfortable, and then step away to allow the patient privacy.  Remove gloves and dispose of them properly.  Wash your hands thoroughly.

• When the patient is finished, again ensure that the patient has adequate privacy.  Wash your hands and put on gloves.

• Return the head of the bed to a flat position, and assist the patient in turning onto his/her side.  As you turn the patient, support the bedpan in order to prevent contents from spilling onto the bed.  If a spill does occur, you will need to immediately change bed linens.

• Remove the bedpan and set it aside.  Ensure that the patients buttocks and genitals are clean to prevent infection.  Return the patient to a comfortable position of his/her choice.  Provide a damp cloth to allow the patient to wash his/her hands, if the patient wishes.

• Measure the output and record appropriately, then dispose of the secretions as directed.  Ensure that the bedpan is either replaced or cleaned.

• Remove your gloves and immediately wash hands for at least one minute.

Careful use of the bedpan will prevent infection and allow the patient to complete necessary bodily or bowel functions with a minimum of discomfort.  Try to remain professional as you assist the patient with this process, and ensure proper hand washing procedures are followed.

Catheter Cleaning

A Foley catheter is a sterile (germ-free) tube that is inserted through your urethra and into your bladder to drain urine. The catheter has a small balloon filled with solution that holds the catheter inside your bladder. A Foley catheter is also called an indwelling urinary catheter.

Gather all of the supplies needed for your catheter care. This would include:

• A basin of clean warm water or use of a clean sink with running warm water.

• Two clean washcloths and a clean towel

• Soap

1. Wash your hands thoroughly with soap and water before and after cleaning and touching the catheter, drainage bag, or urine.

2. Apply soap and water to one washcloth and thoroughly clean the area around the meatus then rinse well to remove all soap.

3. Rinse the washcloth, apply more soap, and clean the rest of the area between your legs and buttocks. For female patients, it is important to wipe from front to back to prevent an infection. For male patients, it is important to begin at the tip of the penis and wash downward toward the body.

4. Rinse and pat dry the area well with the towel.

5. Change the water in the basin and clean the catheter next.

6. Apply soap to the second washcloth.

7. Firmly grasp the catheter to prevent tugging on it and gently wash the tubing. Begin at the meatus and wash the first 2 to 3 inches of the tube, moving away from the body toward the drainage bag. DO NOT wash from the tubing toward the body because this may push bacteria into the meatus.

8. Gently remove any drainage or crusting that may be present on the tube.

9. Gently dry the tubing.

10. Do not use any powders in this area.

11. After cleansing, the catheter should be secured to the inner thigh to prevent irritation around the meatus and to prevent pulling the catheter out.

Drainage Bag

The drainage bag should be emptied, at a minimum, two to three times a day. The bag should not be allowed to become full. This will put pressure on the catheter and cause tugging and irritation at the meatus. It also will be too heavy and bulky to carry around.

1. Wash your hands before and after emptying the bag.

2. The bag should be kept below the level of the hip (bladder) at all times to prevent urine from flowing back into the tubing and into the bladder.

3. Use a clean container to empty urine into if your doctor wants you to measure the amounts in the drainage bag. Otherwise, you can also empty the bag directly into the toilet.

4. Carefully open the spigot (pour spout) at the bottom of the bag to empty. Do not allow the spigot to touch the container or toilet. This causes contamination of the bag with bacteria.

5. Clean the end of the spigot with rubbing alcohol on a gauze pad or cotton ball.

6. Close the spigot securely to prevent leaking.

7. Do not allow the drainage bag to rest on the floor.

8. When completed position drainage bag so that is the tubing is not kinked and the bag does not tug on the patient.

Urinary Tract Infection (UTI)

Symptoms of lower urinary tract infections usually begin suddenly and may include one or more of the following signs:

• The urge to urinate frequently, which may recur immediately after the bladder is emptied.

• A painful burning sensation when urinating. (If this is the only symptom, then the infection is most likely urethritis, an infection limited to the urethra.)

• Discomfort or pressure in the lower abdomen. The abdomen can feel bloated.

• Pain in the pelvic area or back.

• The urine often has a strong smell, looks cloudy, or contains blood. This is a sign of pyuria, or a high white blood cell count in the urine, and is a very reliable indicator of urinary tract infections.

• Occasionally, fever develops.

Colostomy

A surgically created opening in the abdomen and the colon (or large intestine). The surgeon brings the colon through the abdominal opening and sews it down to the skin.

• You will hear this new opening referred to as “stoma”, “ostomy”, or “colostomy”.

Types of Ostomies:

Colostomy: Typically installed as a result of the loss of all or a portion of the patient's colon (large intestine).

Ileostomy: Similar to a colostomy, an ileostomy is connected to the small intestine and can also be temporary or permanent.

Urostomy: A common form of ostomy which is designed to divert urine from the genitals into a pouch for collection.

Handling an ostomy means dealing with human waste and as a result, you must handle it carefully. Always wear latex gloves when handling the ostomy valve and be sure to clean the tube thoroughly after each evacuation. Pay close attention to the instructions included with the ostomy to ensure that you handle it correctly and that you replace the valve as needed. It is best to empty the bag before it gets too full to prevent leaks and spills.

Procedure:

Changing a 1-Piece Pouch

1. Gather all supplies (Washcloth, Pen, Pouch, Scissors, Stoma Paste, Stoma

Measuring Guide)

2. Gently remove the pouch from skin working from top to bottom.

3. Wash skin around your stoma with a soft cloth and water.

4. As needed, shave the hair around stoma starting close to the stoma and moving outward in order to prevent nicking the stoma.

5. Using the Stoma Measuring Guide, measure and select the smallest size that fits around the stoma without touching it.

6. Trace the correctly-sized pattern on back of pouch.

7. Cut along traced line.

8. Check the fit of the pouch.

9. Remove backing paper from the wafer adhesive.

10. Squeeze out stoma paste or “caulking” around cut opening on the back of wafer.

11. Re-clean skin and dry well.

12. Apply pouch to the skin.

13. Remove remaining strips of backing paper.

14. Close tail.

15. Cover pouch with hand for 5 minutes to trap body heat, which “melts” wafer onto skin.

Changing a 2-Piece Pouch

1. Gather all supplies (Washcloth, Pen, Wafer/Pouch, Scissors, Stoma Paste, Stoma Measuring Guide)

2. Gently remove the pouch from skin working from top to bottom.

3. Wash skin around your stoma with a soft cloth and water.

4. As needed, shave the hair around stoma starting close to the stoma and moving outward in order to prevent nicking the stoma.

5. Using the Stoma Measuring Guide, measure and select the smallest size that fits around the stoma without touching it.

6. Trace the correctly sized pattern on back of wafer.

7. Cut along traced line.

8. Check the fit of the wafer.

9. Snap the wafer and pouch together and check the seal.

10. Remove backing paper from the wafer adhesive.

11. Squeeze out stoma paste or “caulking” around cut opening on the back of wafer.

12. Re-clean skin and dry well.

13. Apply pouch to the skin.

14. Remove remaining strips of backing paper.

15. Close tail.

16. Cover pouch with hand for 5 minutes to trap body heat, which “melts” wafer onto skin.

Constipation and Diarrhea Symptoms

Constipation is a symptom, not a disease. Constipation is when a person passes small amounts of hard, dry stool, usually fewer than three times a week. People who are constipated may find it difficult and painful to have a bowel movement.

Other constipation symptoms include feeling:

• Bloated

• Uncomfortable

• Sluggish.

Diarrhea is not an illness; it is a symptom, similar to the way fever is a symptom. Depending on the cause of diarrhea, other symptoms may or may not accompany it. So when someone asks, "What are diarrhea symptoms?" he or she is most likely interested in the other symptoms that may come along with diarrhea.

While diarrhea is extremely common, many people are not familiar with its formal definition. Diarrhea is defined as loose, watery, unformed stools occurring more than three times in one day. People with diarrhea may pass more than a quart of stool a day. Diarrhea is not the occasional loose stool or the frequent passing of formed stools.

Diarrhea may be accompanied by a number of other symptoms. These symptoms can help your healthcare provider diagnose the cause of diarrhea. Symptoms that may be present with diarrhea include:

• Cramping abdominal pain (or stomach pain)

• Bloating

• Nausea

• An urgent need to use the bathroom

• An inability to control the bowels (fecal incontinence)

• Feeling sick to the stomach

• Fever

• Chills

• Muscle aches or pain

• Headache

• Low heart rate

• Joint pain

• Alternating constipation

• Blood in stool

• Mucus in stool

Skin Care

The skin consists of three layers:  Epidermis, dermis, and subcutaneous tissue.  The outermost layer, the epidermis, is composed mostly of dead skin cells that are constantly being shed and replaced.  The dermis or second layer has sweat glands, oil glands, nerve endings, and small blood vessels called capillaries, which are all woven together by a protein called collagen.  Collagen provides nourishment and support for skin cells.  The nerves ending in this layer transmit sensations of pain, itch, touch and pleasure.  The hair follicles also originate in this layer.  Destruction of either the epidermis or dermis can leave the body open and susceptible to infection.  The subcutaneous adipose tissue is the deepest layer of skin and is a layer of fat and collagen that houses larger blood vessels and nerves. This layer is important in controlling the temperature of the skin itself and the body and protects the body from injury by acting as a shock absorber. The thickness of this layer varies throughout the body and from person to person.  Underneath the subcutaneous tissue lays muscle and bone. 

For the most part, the skin is tough, pliable and resistant to injury.  If the skin becomes injured or broken, it is generally very resilient and has an amazing ability to self-repair and heal.  Despite this resiliency, the skin is susceptible to breakdown, if subjected to prolonged abuses, such as excessive pressure, shear force, friction or moisture.  This is a major concern for persons with transverse myelitis or other neuroimmunologic conditions that cause paralysis and/or decreased sensation. 

For people with paralysis, the skin is at increased risk for breakdown for several reasons.  Paralysis itself affects the skin and underlying tissue.  There is loss of collagen which weakens the skin and makes it less elastic.  The lack of muscle function around boney areas of the body leads to muscle atrophy, resulting in less padding, which in turn, adds to the risk of skin breakdown.  People with paralysis often have difficulty shifting their weight, repositioning themselves, or transferring without assistance. 

Impaired sensation is often present, limiting the ability to sense when to make a weight shift or position adjustment.  People with impaired sensation are also vulnerable to injury from many other hazards, such as, heat, cold, sun and trauma.  Loss of sensation put an individual at risk for burns from very ordinary activities, such as using a lap top computer sitting directly on your lap or sitting too close to a fireplace.  Injury can be caused from things that are too cold such as, ice packs or cold exposure causing frostbite.  Ingrown toenails can become infected, and sunburn can become severe without feeling it. 

When limited mobility is coupled with decreased sensation, a person is more likely to develop a specific type of skin breakdown called a pressure ulcer.   According to the National Pressure Ulcer Advisory Panel, a pressure ulcer is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Pressure ulcers are one of the leading causes of complication across the life span of persons with paralysis.  Up to 95 % of adults with spinal cord injury will develop at least one serious pressure ulcer at some time during their life.

Skin breakdown can range from minor scrapes, cuts, tears, blisters or burns to the most serious pressure ulcers with the destruction of tissue down to and even including the bone.  A pressure ulcer, especially one that requires surgery, such as a muscle flap or skin graft, can cost thousands of dollars to treat, require lengthy hospitalization, and weeks to months away from family, work, school or community activities.  It has been estimated that for persons with spinal cord injury the cost of care for pressure ulcers is about $1.2 to 1.3 billion dollars annually.

With a concerted effort, skin breakdown is, for the most part, preventable.  It can occur, however, even in people who maintain the most diligent care and use the proper equipment.  If skin breakdown is identified early, when still in the minor stages, and if the cause of the breakdown can be identified and eliminated, healing should occur fairly quickly.  If it is not identified in its early stages, skin breakdown can rapidly progress from minor to serious. 

Skin breakdown is caused in several different ways, including friction, shear, moisture and pressure.  These causes can occur individually or in combination.  Friction, moisture and sheer are identified as contributing factors to pressure ulcers. A friction injury occurs when the skin rubs on surfaces, such as a bed sheet, arm rest or brace and has the appearance of a scrape, abrasion or blister.  This type of injury is typically seen on the heels and elbows and may result from repositioning, propping or rubbing due to increased spasticity.

A shearing injury occurs with dragging or sliding of a body part across a surface and has the appearance of a cut or tear.  This type of injury can occur from dragging your bottom during a transfer or sliding down in bed when the head of the bed is elevated.  With the sliding force, bone is moved against the subcutaneous tissue while the epidermis and dermis remains essentially in the same position; against the supporting surface such as a wheelchair or bed.  This action causes occlusion of the blood vessels, decreasing blood flow, oxygen and nourishment to the skin, which eventually leads to breakdown.  Sometimes a shear injury will actually tear the tissue over the tailbone and with unrelieved pressure will become a pressure ulcer. 

Too much moisture over-hydrates the skin, making it weak and more sensitive to friction, shear and breakdown (think about being in the tub or pool for a long time).  Primary sources of excess skin moisture include sweating, bowel and bladder accidents, and drainage from wounds. 

Pressure ulcers occur when skin, soft tissue and blood vessels are compressed or squeezed between a bony prominence (such as your tailbone) and an external surface (such as your wheelchair cushion).  With compression of these vessels, the blood that nourishes the cells and takes away waste is cut off, starving the tissue of oxygen and vital nutrients.  Without food and oxygen, tissue dies and skin breakdown begins.  The body tries to compensate by sending more blood to the area.  This process results in redness and swelling, places even more pressure on the blood vessels, and further endangers the health of the skin and underlying tissue. Ultimately, a pressure ulcer forms.  Increased pressure over short periods of time and slight pressure over long periods of time have been shown to cause equal amounts of damage. 

Many factors have been identified as responsible for the development of skin breakdown and pressure ulcer formation.  In addition to immobility, impaired sensation and the external factors described above, many internal contributing factors have been identified.  These internal factors include poor nutrition and hydration, weight, impaired circulation and oxygenation, impaired cognition or thinking, substance abuse, depression and age.  Nutritional factors important to prevent or heal wounds include a balanced diet with an adequate intake of protein, vitamin C, vitamin A, and zinc, as well as an adequate intake of fluids (8). When a person is overweight, extra pounds place extra pressure on vulnerable skin areas increasing the risk of compression of blood vessels.  Individuals that are underweight often have decreased muscle mass with less fat padding over boney areas leaving them vulnerable to skin breakdown.  Smoking, diabetes, anemia and other vascular conditions all lead to decreased circulation, increasing risk for skin breakdown.  Individuals who are depressed or have impaired thinking and judgment due to substance abuse are less likely to be vigilant with regard to important self-care issues, such as skin health.  Young children generally have more resilient and elastic skin and more baby fat and padding so they often have very little difficulty with skin break down.  As children move into adolescence, their skin loses some of its elasticity.  They generally have more body weight, putting more stress on pressure areas, such as the ischial tuberosities and tailbone with sitting.  Teens often begin to have more difficulty with skin breakdown.  As we continue to age, our skin becomes increasingly less pliable and resilient. We experience the loss of collagen and muscle mass, as well as decreased circulation, making the skin more vulnerable.  The elderly are most prone to skin tears and stripping due to fragile, thin, and vulnerable skin.  In addition, incontinence may become a more frequent issue for bedridden or ill persons, increasing problems with moisture as described above.

Avoid prolonged pressure on any one spot

Encourage patients to reposition frequently.  If the patient is unable the aide must assist with relieving pressure. When seated in a wheelchair, do weight shifts every 15 minutes.  When lying in bed, reposition every 2 - 4 hours.  Use pillows or wedges behind your back and between bony areas, such as knees and ankles.  “Float” your heels and ankles off of the bed by supporting your lower leg with a pillow.  Keep the head of the bed up less than 30 degrees to prevent shearing of skin from sliding down or the need to be pulled back up.  If you use a wheelchair most of the day, avoid lying on your back at night.  Instead, turn side to side to give your backside a break.  Better yet, sleep on your stomach, if this position is comfortable and you are able to breathe safely.  When positioned on your stomach, you have fewer pressure points, and can generally turn less frequently.  Being on your stomach gives your backside a break, and allows you to stretch your hip flexor muscles and hamstring muscles, all for the price of one!

Maintenance of a clean and safe environment

Ensuring that the homes of our home health patients are clean and safe is an essential component in the provision of effective healthcare. It is also of paramount importance for our patients and their families to ensure a germ free environment to maintain optimal health and ward off respiratory problems, insect and rodent infestation and other health and environmental problems. A clean and tidy premise is also fundamental to assist our patients to remain healthy. And finally, a clean, safe and healthy home environment is critical to prevent and/or control the spread of healthcare associated infections.

The goal of healthy housekeeping is to reduce the number of microorganisms in the home to minimize the risk of infection and accidents to both the patient and other family members.

Keep patient area free of clutter and filth.

Special Needs of the Elderly

There are a number of aspects that are involved in taking care of elderly or aged people. Having a good amount of awareness about the various possible needs and requirements of the elderly is extremely important for those people who have the responsibility of taking care of their aged family members, parents or relatives.

Financial Needs
If elderly individuals happen to be living on their own, i.e. without anyone else's support, it is but natural that they will have a certain amount of financial needs. They will need to fend for themselves for everything such as food, groceries, medicines, etc. Pensioners would have the benefit of a steady source of monthly income (whatever be the amount trickling in). However, those senior citizens who do not have any pension facilities or any other sources of income would have to live entirely on the basis of their savings or through special senior citizen government finance schemes.

Health Care Requirements
Senior health is the most important requirement when it comes to elderly needs. With advancing age, the body tends to slow down and becomes less efficient. Elderly people are prone to a few age-related health issues. This is a normal aspect of life and one cannot help it. However, through proper care and nursing facilities, one can definitely help in keeping most of these health issues in check and preventing them from causing any serious harm. Regular medical checkups are necessary. They can help in anticipating potential future health-related issues. At the same time, they may help in identifying serious health problems at an early enough stage during which treatment is possible.

Dietary Requirements
As people age, their digestive system gradually starts weakening. Aged and elderly people especially, face this problem wherein they start finding certain foods indigestible or difficult to digest. What one must realize is that their diet can no longer be the same as it was say, twenty years ago. Their diet should now be modified accordingly such that it remains a nutritious, balanced diet and yet, contains foodstuffs that their system is able to accept, without causing them any discomfort or problems. Often, the diets of elderly people need to be altered depending on their medicinal prescriptions.

Activities of Daily Living (ADLS)
Elderly people whose mobility has become limited due to aging, he or she would require a certain amount of assistance in his or her daily routine They may require assistance in basic activities like walking, eating, bathing, dressing, etc.

Social and Other Needs
Just because they have become older and slower, does not mean that you should ignore them or let them be confined to themselves. Remember, a few years down the line, you yourself will be in their position. Spend time with them, chat with them and make them feel wanted, cared for and loved. Pay special attention to their room. You could consider installing a few senior citizen friendly appliances which they would be comfortable using. Also, you should consider installing certain medical alarms that are specially made keeping in mind elderly citizens.

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