Posted August 24, 2018
“Meet my patient, his name is MM and he is 90years old and was walking 3 months ago. I know he looks like an inactive Elderly man lying on this stretcher but such a rapid decline in a short period of time is not normal, we need to help him, we need to find the cause of all of this.”
My name is Deedee and I am a Homecare nurse. My company was hired to look after MM in his home after his 3rd discharge from hospital. No significant medical history, MM did not have the main Geriatric Syndromes. When I met MM he was weak, not moving and fully dependent on others for care, bed bound most of the time.I knew something was not right about being in and out of hospital three times over the past 2 months.
“Aspiration Pneumonia” was the diagnosis in hospital. Swallowing difficulties during mealtime led to chest infection as food particles entered the lung field. During the first hospitalization the doctors inserted a G Tube (feeding tube into his stomach). Eating orally was no longer an option as per the swallowing assessment. The prolonged hospitalization (3 weeks) weakened his leg muscles beyond use. Sent home with a G Tube. “Aspiration Pneumonia” repeated twice more. IV antibiotics and sent home.
Getting to know the patient. On my first day, I was determined to “get to know the patient”. What was his previous work, what was his day to day program, what foods did he eat, what his sleeping pattern, was he a night sleeper or a day sleeper. Was he a talkative man or was he reserved. I gathered the information from his private carer, domestic staff, as well as daughters and son. Each member of the family provided valuable information that others did not know, and when pieced together it gave a more complete understanding and appreciation of my patient.
I learnt that three months ago, MM was walking around the house with the support of his private carer. MM was a successful business man, and spoke many languages, was very active. After probing deeper to his eating habits it was revealed that he had a history of indigestion, stomach was sensitive, acid reflux and burping was common.
When stomach contents enter into the lung field (aspirate) the chances of chest infection is high. Stomach contents are liquid, acidic, and for those individuals that are bed bound or have a history of reflux GERD, indigestion, and low gastric emptying, chronic constipation are higher risk for aspiration. As we age, the sensors for acid reflux diminish, leaving the airway exposed.
The inner coating of his mouth had signs of repeated acidic exposure. The back of the tongue (hidden and not easily accessible) was coated with a brown film even though he was not eating by mouth. Positioning in the bed was managed well, the feeding volume was controlled through residual volume checks, the medications to control acid and aid in emptying was administered as ordered.
The patient began to cough, and small amount of aspirate came out of his mouth. Another episode of regurgitation had caused MM heart rate to elevate, a fever broke, and his oxygen levels dropped. The family was informed, we need to move to the hospital.
We arrived at the Emergency Department via ambulance in stable condition with applied oxygen. MM cannot speak. I needed to tell his story. His family present alongside the patient, I became the patients voice. I need to get to the facts immediately. I need to summarize the facts in front of the family so that they could add information. As I looked at my patient, I saw a tired Elderly man lying on the stretcher wrapped in blue blankets with a beeping heart rate and completely different to the picture I had painted in my mind.
“Meet Mr MM, he is 90 years old and was walking 3 months ago. He has been in and out of hospital over the last 3 months. He is continuously regurgitating his feeds despite the proper positioning, and volume control. His vital signs have been stable throughout, he does not have any previous medical history, he is receiving all the prescribed medications, not constipated, no signs of infections to his G tube, skin condition is perfect. His family reports that he has a history of indigestion and you may wish to check your records if this was disclosed the first time around. Its worth noting that there were 3 different types of feeds trialed. I am his nurse, and I am speaking for my patient, I know he looks elderly to you, but he was an active man 3 months ago and such a rapid decline in a short period of time is concerning. We need to rule out the cause so that this does not repeat itself.”
LEADERS IN HOME NURSING, Enayati Home Nursing are committed to delivering safe patient care. Enayati nurses are ranked as one of the top nursing teams in the country through the adoption of Canadian Best Practice Guidelines. The RNAO Best Practice Guidelines and caregiving strategies for elders with Dementia, Delirium, and Depression.
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