Thursday, December 02, 2004

Care Plan Review

Wednesday was a CARE PLAN REVIEW meeting at Patti’s facility.


Assisted Dinning Room was the lead topic. It was a change since our last meeting, though in my opinion that is the proper placement for Patti. No “ifs ands and buts” Patti absolutely must be monitored and assisted when eating. It’s taken 8 months but we all seem to be on the same page. <grin> That’s not surprising to me, even among family and friends I’ve fought an uphill battle over Patti and dinning.


They label it ‘restorative eating’ and don’t just feed Patti but work on therapy for living with Dysphagia. I must say I have noticed recent improvement in Patti’s dinning behavior when out or at home. She is much more conscious of the consequences of either choking or vomiting that can and will occur when she eats beyond her abilities.


Patti’s early bed time was another round table topic because it has a ripple effect across many departments. Bottom line is that Patti’s insistence upon going to bed at 7 PM or often immediately after dinner short circuits most evening procedures. Often whomever is available simply assists Patti into bed ‘as is’, raises sides on bed and appropriate staff come around in turn to change and dress her later. Behavior problems related to bedtime through safety concerns over risk of Patti falling trying to climb into bed herself have necessitated this process.


(MS progression has created significant challenges for Patti in Cerebral functions. Emotional Lability, for example, can stun new or temporary staff with the spontaneity and intensity of a mood change if Patti encounters stress when she wants to go to bed. She cannot always regulate the appropriate emotional level or even assign the correct one. She cannot always process or reason through a verbal command. Telling her “not to get into bed”, will not stop her from trying and falling even though she “knows” her legs do not work.)


Related, Patti had raised to me that she thought she was not getting her sleep medication. A check of her records confirmed this was basically true. I learned that what was happening is that Patti’s sleep medication is “upon request of patient” and at 8 PM medication rounds, Patti was sound asleep. It is not their policy to wake a sleeping resident to ask them if they want their sleeping aid. Makes sense to me.


Related personal hygiene questions about bedtime care, brushing teeth, etc also fell into this category. Patti refuses to get back up out of bed later to use the sink when dressing attendants come by to change and dress her for overnight. They do the best they can at this point as if she was a bed ridden patient.


Even her bed time snack of PBJ sandwich and chocolate milk a long time favorite has gone unclaimed from the snack cart for much of the last two months, as she is already asleep by the time the snack cart comes around.


That tunnel vision about getting to bed is a function of the MS fatigue factor. Yet like 'all things MS' it is unpredictable because other nights Patti willingly participates in evening activities.


Physical Therapy had begun following last care review to improve Patti’s ability to assist with transfers. She had been tucking her legs up and they are noticeably straighter now when she pulls herself up. Rather than an ongoing physical therapy, it will be used as needed to address problems in her ability to assist in transfers. This I agree 1000% with.


Previously they were engaged in a program with a goal to get Patti to walk. Patti's inability to walk is not just related to MS physical progression but mental progression. Failure of the walking program had led to abandonment of physical therapy.


Addressing Patti's ability to adapt to each level of progression is the best that physical therapy can provide. In Patti's case it cannot reverse anything. Enabling her to assist staff in her transfers is the best goal at this point.


Toileting Experiment had just begun. This also enabled because of improvement in ability to assist in her own transfer following physical therapy. Too early to evaluate. In concept, monitored time is devoted daily to using a commode with assisted transfers. Extraordinarily labor intensive program; however the theory is to reduce sheer volume of daily bladder and bowel incontinence and as a result potential for associated rashes and infections. – The time and personnel hours involved could only happen in a care facility however if successful in reducing cost of associated medical risks and treatments necessary it would be more than positive.


Though brief these reviews are excellent opportunities to talk 'across' and with their shifts and departments. I’ve learned that in homecare symptom management and issue management are the same. In a 24/7 care facility they are not. The management of teamwork is a different world than ‘hands on’ homecare. At these reviews the minds can come together and share.

1 comment:

  1. Thanks for all the input Patrick, it is really appreciated. I understand fully what the staff is trying to do to help Patti and as time goes by I think more of the problems will be solved. My sister, Betty told me today that it is getting more and more difficult for them to get Patti into Rob's car so I told her to start substituting a strawberry milkshake for that cigarette Patti THINKS she needs. (grin).


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