Home Care Assistant Guide by civilityhc

The Home Care Assistant Guide A Handbook for Helping and Understanding Older Adults Copyright © 2005 by P. Brian Pavich Second Edition First Printing, 2009 Updated - 2012 Updated - 2018 P. Brian Pavich – BriLor Publishing Website:

https://www.homecaremanuals.com

Email Addresses:

info@homecaremanuals.com bpavich@homecaremanuals.com

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any other information storage and retrieval system, without the written permission of P. Brian Pavich, who can be contacted at any of the above listed email addresses. .

Home Care Assistant Guide

INTRODUCTION

The Home Care Assistant Guide for Helping & Understanding Older Adults is designed to assist caregivers and home care service providers to deliver quality care to Older Adults by understanding their needs and challenges and by recognizing and reacting to their various tribulations and personalities. While the guide focuses on Older Adults, its concepts can be applied to any demographic. The guide is divided into sections: 1. The Older Adult Client 2. Health Problems 3. Confusion & Dementia 4. Communication 5. Disabilities 6. Terminal Illness 7. Challenging Behavior

8. Personal Care 9. Nutrition 10. Health and Safety 11. Basics of Emergency Care 12. Infection Control 13. Observing, Documenting & Reporting 14. Ethical & Legal Issues

The guide is a “tool kit” filled with knowledge, skills, procedures, tips and techniques to provide effective home care service. Home Care Assistants, who are new to the profession, will find it educational and helpful. Experienced Home Care Assistants will also find it useful as a refresher course. Additionally, it can be invaluable to Home Care Businesses owners, whether they are self-employed or have staff since it can be used:  as a reference manual for staff;  for staff in-services, training, and development; and,  for developing policies and procedures. This document will improve the efficiency of Home Care Assistants, as it will, in part, help them to recognize what is happening, understand what is happening and how to handle situations. HCAs enhanced efficiency will reflect positively not only on their own credibility and reputation but also on that of the Home Care Agency, which employs them.

Home Care Assistant Guide Table of Contents

DISCLAIMER

The Home Care Assistant Guide is not a certification tool for Home Care Assistants. Readers are advised to undergo the training requirements established for their local area and to follow employer, local, state, and federal requirements for healthcare practices. The contents of this manual provide information, guidelines and techniques on how to care and work with Older Adults. With time, industry standards and regulations may change as a result of new or up-dated information. It is the user’s responsibility to keep abreast of changes and ensure they are applied in their home care business and care practices. The author/publisher cannot accept any responsibility for errors, omissions or for any consequences from application of the information in this manual. The author/publisher makes no warranty, express or implied, with respect to the contents of the manual. All necessary steps have been taken to make these electronic products virus-free. BriLor Publishing will not accept liability for losses or damages because of viruses, worms and the like, which may be transmitted through downloading, transmission, copying and/or other means.

Home Care Assistant Guide Table of Contents

TABLE OF CONTENTS

SECTION 1: THE OLDER ADULT .................................................................................................. 1 Impacts of Aging..................................................................................................................................... 1 Dimensions of Aging............................................................................................................................... 1 Chronological Aging ............................................................................................................................................ 2 Biological Aging .................................................................................................................................................. 2 Social Aging......................................................................................................................................................... 2 Psychological Aging ............................................................................................................................................ 2

Outward Signs of Aging ......................................................................................................................... 2 Aging Effects on Body Systems .......................................................................................................................... 3

Sensory Changes Associated with Aging .............................................................................................. 4 Cognitive Changes Associated with Aging ........................................................................................... 5 Personality Changes Associated with Aging ........................................................................................ 6 Basic Needs of Older Adults .................................................................................................................. 6 Physiological ........................................................................................................................................................ 6 Safety ................................................................................................................................................................... 6 Love, Affection and Belonging ............................................................................................................................ 6 Esteem .................................................................................................................................................................. 7 Self-Actualization ................................................................................................................................................ 7

Factors Affecting Older Adults’ Mental Health .................................................................................. 7 Insufficient or Inadequate Socialization ............................................................................................................... 7 How HCAs Can Assist a Socially Isolated Older Adult.................................................................................. 8 Reduction in Ability to Function.......................................................................................................................... 8 How HCAs Can Assist Older Adults with Functional Decline ....................................................................... 8 Substance Abuse .................................................................................................................................................. 9 Actions HCAs Can Take If Substance Abuse Is Suspected .......................................................................... 10 Changes in Circumstances ................................................................................................................................. 10 How HCAs Can Assist Older Adults with Changes in Life Situations ......................................................... 10 Financial Concerns............................................................................................................................................. 11 How HCAs Can Support Older Adults with Financial Concerns .................................................................. 11 Depression.......................................................................................................................................................... 11 How HCAs Can Support Older Adults with Depression............................................................................... 12

Osteoporosis .......................................................................................................................................... 15 How HCAs Can Help Older Adults with Osteoporosis................................................................................. 16

Stroke .................................................................................................................................................... 17 How HCAs Can Assist Older Adults Who Have Had a Stroke..................................................................... 18

Parkinson’s Disease .............................................................................................................................. 18 How HCAs Can Help Older Adults with Parkinson’s Disease ..................................................................... 19

Home Care Assistant Guide Table of Contents Diabetes ................................................................................................................................................. 19 What Home Care Assistants Need to Know About Diabetic Emergencies ................................................... 20

Cardiovascular Disease ........................................................................................................................ 20 How HCAs Can Help Older Adults with Cardiovascular Disease ................................................................ 21

Heart Attack ......................................................................................................................................... 21 How HCAs Can Assist Older Adults with Heart Attack Symptoms ............................................................. 22

Anemia .................................................................................................................................................. 22 How HCAs Can Help Older Adults, with Anemia ........................................................................................ 22

Chronic Obstructive Lung Disease ..................................................................................................... 23 Chronic Bronchitis ............................................................................................................................................. 23 Emphysema ........................................................................................................................................................ 24

Asthma .................................................................................................................................................. 24 Pneumonia............................................................................................................................................. 24 How HCAs Can Help Older Adults Avoid Pneumonia................................................................................. 25

Working Near Oxygen ......................................................................................................................... 25 Paralysis ................................................................................................................................................ 26 How HCAs Can Help Older Adults with Paralysis ....................................................................................... 27

Cancer ................................................................................................................................................... 27 How HCAs Can Interact with Older Adults with Cancer .............................................................................. 28

Eye & Vision Conditions...................................................................................................................... 28 How HCAs Can Help Older Adults with Vision Problems ........................................................................... 29

Ear & Hearing Conditions .................................................................................................................. 29 Hearing Loss ...................................................................................................................................................... 30 Meniere’s Disease .............................................................................................................................................. 30 How HCAs Can Help Older Adults with Hearing Problems ........................................................................ 30

Common Health Care Mistakes Made by Older Adults ................................................................... 31 How HCAs Can Help Older Adults Deal with Health-Care Mistakes .......................................................... 31

Alzheimer’s Disease.............................................................................................................................. 36 Stages of Alzheimer’s Disease ........................................................................................................................... 37 Stage 1 ........................................................................................................................................................... 37 Stage 2 ........................................................................................................................................................... 37 Stage 3 ........................................................................................................................................................... 37 Behavioral Patterns in Persons with Alzheimer’s Disease ................................................................................. 38 How HCAs Can Assist Older Adults with Alzheimer’s Disease & Other Dementias .................................. 39

Home Care Assistant Guide Table of Contents Effective Communication .................................................................................................................... 42 How HCAs Can Apply Communication Skills ............................................................................................. 43 How HCAs Can Listen Effectively to Older Adults ..................................................................................... 43

Barriers to Effective Communication................................................................................................. 44 How HCAs Can Recognize Communication Barriers................................................................................... 44

Channels for Communicating with Older Adults.............................................................................. 44 Example: Applying Effective Communication Techniques ......................................................................... 46

Communicating with Older Adults with an Impairment ................................................................. 47 Communicating with Older Adults Who are Visually Impaired ........................................................................ 48 How HCAs Can Communicate with Older Adults with Visual Impairment ................................................. 48 Communicating with Older Adults with a Hearing Impaired ............................................................................ 49 How HCAs Can Communicate with Older Adults with Hearing Impairment .............................................. 49 Communicating with Older Adults with Aphasia .............................................................................................. 49 How HCAs Can Communicate with Older Adults with Aphasia .................................................................. 49 Communicating with Older Adults with Dementia ............................................................................................ 50 How HCAs Can Communicate with Older Adults with Dementia ............................................................... 50

Care Team............................................................................................................................................. 51 HCA Responsibilities to Care Team ............................................................................................................. 51 Communicating with the Care Team ................................................................................................................. 51

Summary ............................................................................................................................................... 51 SECTION 5: DISABILITIES............................................................................................................... 2 Meaning of Disability ............................................................................................................................. 2 Disability Categories .............................................................................................................................. 2 Physical Disability .................................................................................................................................. 3 Psychiatric Disability/Mental Illness .................................................................................................... 4 Anxiety Disorders ................................................................................................................................................ 4 Depressive Disorders ........................................................................................................................................... 4 Schizophrenia ....................................................................................................................................................... 4 Bipolar Disorder................................................................................................................................................... 5

Intellectual/Learning Disability ............................................................................................................ 5 Neurological Disability ........................................................................................................................... 5 Sensory Disability ................................................................................................................................... 6 Acquired & Developmental Disability .................................................................................................. 6 Acquired Disability .............................................................................................................................................. 6 Developmental Disability .................................................................................................................................... 7

Functional Limitations of Disability ..................................................................................................... 7 Etiquette Courtesies ............................................................................................................................... 7 How HCAs Can Use Proper Etiquette with Older Adults with Disabilities ................................................... 7 How HCAs Can Practice Proper Etiquette with Older Adults Using Wheelchairs ......................................... 8 How HCAs Can Practice Proper Etiquette with Older Adults with Psychiatric Disabilities........................... 8 How HCAs Can Practice Proper Etiquette with Older Adults with Learning Disabilities .............................. 9

Appropriate and Inappropriate Word Usage ...................................................................................... 9 Word Choices.......................................................................................................................................... 9 How HCAs Can Apply Disability Rights Movement Rules for Word Usage ................................................ 10

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Home Care Assistant Guide Table of Contents The Process of Dying ............................................................................................................................ 13 Rights of the Dying Person .................................................................................................................. 14 Care & Legal Considerations .............................................................................................................. 14 Living Wills ....................................................................................................................................................... 15 Durable Power of Attorney ................................................................................................................................ 15 How a Durable POA Differs from a POA ..................................................................................................... 15 Do Not Resuscitate (DNR) Orders ..................................................................................................................... 15

Hospice and Palliative Care................................................................................................................. 16 Palliative Care .................................................................................................................................................... 16 Hospice Care ...................................................................................................................................................... 16 Difference Between Palliative Care and Hospice Care ...................................................................................... 16

Funeral and Disposal of Remains ....................................................................................................... 17 Basic Needs of Older Adults with a Terminal Illness ........................................................................ 17 How HCAs Can Help Older Adults with Terminal Illness ........................................................................... 17

Care Needs of the Older Adult with a Terminal Illness.................................................................... 18 Physical Needs ................................................................................................................................................... 18 How HCAs Can Help Terminal Older Adults with Physical Care Needs ..................................................... 18 Psychological Needs .......................................................................................................................................... 20 How HCAs Can Help Terminal Older Adults with Psychological Needs ..................................................... 20 Social Needs....................................................................................................................................................... 20 How HCAs Can Help Terminal Older Adults with Social Needs ................................................................. 20 Spiritual Needs ................................................................................................................................................... 21 How HCAs Can Help with Spiritual Care Needs of Terminal Older Adults ................................................ 21

Challenges that Older Adults with a Terminal Illness Face ............................................................. 21 Grief Issues Older Adults with a Terminal Illness Face..................................................................................... 22 How HCAs Can Help Terminal Older Adults with Grief ............................................................................. 23 Loneliness Issues Older Adults with a Terminal Illness Face ............................................................................ 23 How HCAs Can Help Terminal Older Adults with Loneliness..................................................................... 23 Anxieties that Older Adults with Terminal Illness Face .................................................................................... 23 How HCAs Can Help Terminal Older Adults with Anxiety ......................................................................... 24 Depression Issues that People with a Terminal Illness Face .............................................................................. 24 How HCAs Can Help Terminal Older Adults with Depression .................................................................... 25 Anger Issues that Older Adults with Terminal Illness Face ............................................................................... 25 How HCAs Can Help with Anger Issues of Terminal Older Adults ............................................................. 25

Interacting with Family of Terminally Ill Older Adults ................................................................... 25 How HCAs Can Help the Families of Terminal Older Adults ...................................................................... 26

Signs that Death is Near....................................................................................................................... 26 Summary ............................................................................................................................................... 27 SECTION 7: CHALLENGING BEHAVIOR .................................................................................. 72 Older Adults with Challenging Behaviors. ........................................................................................ 72 Behavioral Patterns of Challenging Older Adults ............................................................................. 73 Identifying and Dealing with Challenging Personality Types .......................................................... 73 How HCAs Can Interact with Older Adults with Challenging Behaviors .................................................... 74

Complaints ............................................................................................................................................ 75 Handling Complaints ......................................................................................................................................... 75 How HCAs Can Handle Older Adults with Complaints ............................................................................... 75 Example: Dealing with a Complaint........................................................................................................ 76

Anger ..................................................................................................................................................... 77 How HCAs Can Interact with Older Adults Who Are Angry ....................................................................... 77

Conflict .................................................................................................................................................. 78 Constructive and Destructive Aspects of Conflict ............................................................................................. 79 How HCAs Can Help Resolve Conflict with Older Adults .......................................................................... 79

Home Care Assistant Guide Table of Contents Aggression .......................................................................................................................................... 79 How HCAs Can Interact with Older Adults Who Are Aggressive ............................................................... 80

Violence ............................................................................................................................................... 80 How HCAs Might Defuse Violence in Older Adults .................................................................................... 81

Negativity .............................................................................................................................................. 81 How HCAs Can Deal with Negative Attitudes in Older Adults ................................................................... 82

Negotiating ............................................................................................................................................ 82 How HCAs Can Negotiate with Older Adults............................................................................................... 82

Summary ............................................................................................................................................... 83 SECTION 8: PERSONAL CARE...................................................................................................... 84 Need for Personal Care ........................................................................................................................ 84 Personal Care Skills ............................................................................................................................. 84 Activities of Daily Living ..................................................................................................................... 85 Grooming .............................................................................................................................................. 85 Hair Care .............................................................................................................................................. 86 Brushing & Combing ......................................................................................................................................... 86 How HCAs Can Assist Older Adults with Brushing & Combing Hair ......................................................... 86 Shampooing ....................................................................................................................................................... 86 Basic Shampooing Procedures ...................................................................................................................... 87 How HCAs Can Assist Older Adults with Shampooing ............................................................................... 87 Hair Conditions .................................................................................................................................................. 88 How HCAs Can Help Older Adults with Shaving ........................................................................................ 90

Oral Hygiene ......................................................................................................................................... 91 Brushing Teeth ..................................................................................................................................... 91 Basics of Brushing Teeth ................................................................................................................................... 91 How HCAs Can Assist Older Adults with Brushing Teeth ........................................................................... 92

Flossing .................................................................................................................................................. 92 Basics of Flossing .............................................................................................................................................. 92 How HCAs Can Assist Older Adults with Flossing ...................................................................................... 93

Denture Care ........................................................................................................................................ 93 Basics of Denture Care ...................................................................................................................................... 94 How HCAs Can Assist Older Adults with Denture Care .............................................................................. 94

Bathing .................................................................................................................................................. 95 Bathing Methods: ............................................................................................................................................... 95 Basics of Bathing ............................................................................................................................................... 96 How HCAs Can Assist Older Adults with a Bed Bath .................................................................................. 97

Urinary System Care ........................................................................................................................... 98 Urinary Incontinence.......................................................................................................................................... 98 Types of Urinary Incontinence ...................................................................................................................... 98 Causes of Urinary Incontinence .................................................................................................................... 99 Treatment of Urinary Incontinence ............................................................................................................... 99

Bowel Care .......................................................................................................................................... 100 Common Bowel Problems ............................................................................................................................... 100 Causes of Bowel Problems............................................................................................................................... 100 Treatments for Common Bowel Problems ....................................................................................................... 101

Assistive Items for Elimination and Incontinence ........................................................................... 101 How HCAs Can Assist Older Adults with Urine and/or Fecal Incontinence .............................................. 102

Skin Care............................................................................................................................................. 103 Skin Tears ........................................................................................................................................................ 103 How HCAs Can Help Prevent Skin Tears in Older Adults ......................................................................... 103 Pressure Sores .................................................................................................................................................. 103 How HCAs Can Help Prevent Pressure Sores in Older Adults ................................................................... 104

Home Care Assistant Guide Table of Contents Nail & Foot Care ................................................................................................................................ 104 How HCAs Can Assist Older Adults with Nail Care .................................................................................. 105

Dressing and Undressing ................................................................................................................... 106 How HCAs Can Assist Older Adults with Dressing ................................................................................... 106

Turning and Repositioning ................................................................................................................ 107 Lying Positions ................................................................................................................................................ 107 How HCAs Can Assist Older Adults with Repositioning ........................................................................... 110

Transferring........................................................................................................................................ 112 Basics of Transferring ...................................................................................................................................... 112 Pivot Transfers ................................................................................................................................................. 112 How HCAs Can Assist Older Adults with Pivot Transfers ......................................................................... 113 How HCAs Can Assist Older Adults with “One-Person” Transfers ........................................................... 113 Assistive Transferring Devices ........................................................................................................................ 113 Transfer Belts ................................................................................................................................................... 114 How HCAs Can Use Transfer Belts to Assist Older Adults ....................................................................... 115 Transfer Boards ................................................................................................................................................ 115 How HCAs Can Use Transfer Boards to Assist Older Adults .................................................................... 115 Mechanical Lifts .............................................................................................................................................. 116 Types of Mechanical Lifts ........................................................................................................................... 116 Basics of Mechanical Lifts ............................................................................................................................... 116 How HCAs Can Transfer Older Adults Using Mechanical Lifts ................................................................ 116

Body Mechanics .................................................................................................................................. 117 Basics of Good Body Mechanics ..................................................................................................................... 117 How HCAs Can Apply Good Body Mechanics to Move Objects ............................................................... 118

Range of Motion Exercises ................................................................................................................ 118 Basics of ROM Exercises ................................................................................................................................ 119 How HCAs Can Assist Older Adults with ROM Exercises ........................................................................ 119

Mobility ............................................................................................................................................... 120 Assistive Devices for Mobility......................................................................................................................... 121 How HCAs Can Assist Older Adults with Walking .................................................................................... 122

Falls 122 Causes of Falls ................................................................................................................................................. 122 How HCAs Can Assist Older Adults During a Fall .................................................................................... 123

Meal Assistance .................................................................................................................................. 123 Objectives of Good Eating Programs ............................................................................................................... 123 Impacts on Food Consumption ........................................................................................................................ 123 How HCAs Can Assist Older Adults with Meals ........................................................................................ 124

Self-Care.............................................................................................................................................. 125 How HCAs Can Promote Self Care to Older Adults................................................................................... 125

Vital Signs ........................................................................................................................................... 126 Temperature ..................................................................................................................................................... 126 Pulse ................................................................................................................................................................. 126 Respirations...................................................................................................................................................... 126 Blood Pressure ................................................................................................................................................. 127

Medication Management ................................................................................................................... 127 HCAs Certified in Medication Administration ................................................................................................ 127 How Specially Trained HCAs Can Administer Medications to Older Adults ............................................ 127 HCAs Not Certified in Medication Administration ......................................................................................... 128 How HCAs Can Provide Medication Assistance to Older Adults ............................................................... 128 How HCAs Can Monitor Older Adults Who Manage Their Medications .................................................. 129

HCA Working Tools .......................................................................................................................... 130 Summary ............................................................................................................................................. 130

Home Care Assistant Guide Table of Contents SECTION 9: NUTRITION ............................................................................................................. 132 Nutrition .............................................................................................................................................. 132 Dietary Guidelines .............................................................................................................................. 133 Food Guide Pyramid .......................................................................................................................... 133 USDA Food Guide Structure ........................................................................................................................... 134

Food Servings...................................................................................................................................... 135 Types of Diets...................................................................................................................................... 136 Omnivorous Diet .............................................................................................................................................. 136 Carnivorous Diet .............................................................................................................................................. 136 Vegetarian Diet ................................................................................................................................................ 137 Lacto-Ovo-Vegetarian Diet.............................................................................................................................. 137 Vegan Diet ....................................................................................................................................................... 137 Raw Food Diet ................................................................................................................................................. 138 Special Diets .................................................................................................................................................... 139

Influences on Nutritional Practices................................................................................................... 142 Personal Choice ............................................................................................................................................... 142 Appetite ............................................................................................................................................................ 142 Finances ........................................................................................................................................................... 142 Culture ............................................................................................................................................................. 143 Religion ............................................................................................................................................................ 143

Nutritional Needs of Older Adults .................................................................................................... 144 Causes of Malnutrition in Older Adults ........................................................................................... 145 Signs & Symptoms of Malnutrition in Older Adults ...................................................................... 146 Consequences of Malnutrition in Older Adults ............................................................................... 146 Hydration ............................................................................................................................................ 147 Dehydration...................................................................................................................................................... 147 How HCAs Can Encourage Older Adults to Consume Adequate Food & Fluids ....................................... 149

Dysphagia ............................................................................................................................................ 150 Signs and Symptoms of Dysphagia .................................................................................................................. 150 Food Preparation for Dysphagia ...................................................................................................................... 150

Summary ............................................................................................................................................. 151 SECTION 10: HEALTH & SAFETY ............................................................................................. 152 SAFETY .............................................................................................................................................. 152 Safety Hazards in the Home Environment ...................................................................................... 152 How HCAs Can Help Minimize Risks in the Home Environment ............................................................. 155

Falls ..................................................................................................................................................... 155 Causes and Preventions of Falls ....................................................................................................................... 155

HCA Safety ......................................................................................................................................... 156 How HCAs Can Help Protect Their Personal Safety .................................................................................. 157 HCA Risk of Injury .......................................................................................................................................... 158 How HCAs Can Help Protect Themselves from Injury .............................................................................. 158 HCA Risk of Being Abused ............................................................................................................................. 158 What HCAs Can Do if Verbally Abused .................................................................................................... 158 What HCAs Can Do if Threatened with Physical Attack............................................................................ 159 What HCAs Can Do if Under Physical Attack ............................................................................................ 159

HCA Wellness ..................................................................................................................................... 160 How HCAs Can Help Reduce their Own Stress Levels .............................................................................. 161

Food Safety.......................................................................................................................................... 161 USDA Basics for Handling Food Safely.......................................................................................................... 161

Emergency Preparedness................................................................................................................... 163 Smaller-Scale Disasters ...................................................................................................................... 164

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Home Care Assistant Guide Table of Contents House Fire ........................................................................................................................................................ 164 What HCAs Can Do in The Event of a House Fire ..................................................................................... 164 Power Outages ................................................................................................................................................. 165 Electrocution .................................................................................................................................................... 166

Larger-Scale Natural Disasters ......................................................................................................... 168 Wildfire ............................................................................................................................................................ 168 Guidelines for Wildfire Protection .............................................................................................................. 168 Before Wildfire Erupts ........................................................................................................................... 168 During a Wildfire ................................................................................................................................... 169 After a Wildfire ...................................................................................................................................... 170 Flood ................................................................................................................................................................ 170 What HCAs Should Do When a Flood Warning is Issued .......................................................................... 170 What HCAs Can Do During a Flood ........................................................................................................... 171 What HCAs Should Not to Do During a Flood ........................................................................................... 171 Earthquake ....................................................................................................................................................... 171 What HCAs Can Do During an Earthquake ................................................................................................ 172 What HCAs Can Do After an Earthquake ................................................................................................... 172 Hurricane.......................................................................................................................................................... 173 What HCAs Can Do If a Hurricane Warning is Issued ............................................................................... 173 What HCAs Can Do During a Hurricane .................................................................................................... 173 Tornado ............................................................................................................................................................ 174 What HCAs Can Do During a Tornado ...................................................................................................... 174

Disaster & Emergency Assistance..................................................................................................... 175 Summary ............................................................................................................................................. 175 SECTION 11: BASICS OF EMERGENCY CARE ....................................................................... 177 Objectives of Emergency Care .......................................................................................................... 177 General Rules of Emergency Care.................................................................................................... 178 ABCs of Assessing Person’s Condition ............................................................................................. 179 Recovery Position ............................................................................................................................... 179 Artificial Respiration ......................................................................................................................... 180 Breathing Emergencies ...................................................................................................................... 181 Asthma ............................................................................................................................................................. 182 Signs & Symptoms of Asthma Attack......................................................................................................... 182 Emergency Care for Severe Asthma Attack ................................................................................................ 182 Hyperventilation .............................................................................................................................................. 182 Causes of Hyperventilation ......................................................................................................................... 182 Signs & Symptoms of Hyperventilation ...................................................................................................... 183 Emergency Care for Hyperventilation ......................................................................................................... 183 Allergic Reactions ............................................................................................................................................ 183 Causes of Allergic Reactions ...................................................................................................................... 183 Signs & Symptoms of Allergic Reaction .................................................................................................... 184 Emergency Care for Allergic Reaction ....................................................................................................... 184 Anaphylaxis ..................................................................................................................................................... 184 Signs & Symptoms Anaphylaxis ................................................................................................................. 184 Emergency Care for Anaphylaxis ............................................................................................................... 185

Hemorrhage ........................................................................................................................................ 185 Signs & Symptoms of Hemorrhage ................................................................................................................. 186

Choking ............................................................................................................................................... 187 Sign & Symptoms of Choking ......................................................................................................................... 187

Heart Attack ....................................................................................................................................... 189 Signs & Symptoms of Heart Attack ................................................................................................................. 189 Emergency Care for Heart Attacks .................................................................................................................. 190

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Home Care Assistant Guide Table of Contents Cardiac Arrest .................................................................................................................................... 190 Causes of Cardiac Arrest.................................................................................................................................. 190 Signs & Symptoms of Cardiac Arrest .............................................................................................................. 190 Emergency Care for Cardiac Arrest ................................................................................................................. 191

Stroke .................................................................................................................................................. 192 Causes of Strokes ............................................................................................................................................. 192 Signs and Symptoms of Stroke ........................................................................................................................ 192 F-A-S-T Assessment ................................................................................................................................... 193 Emergency Care for Strokes ............................................................................................................................ 193

Burns ................................................................................................................................................... 194 Signs & Symptoms of Burns ............................................................................................................................ 194 Emergency Care for Burns ............................................................................................................................... 194 What Not to Do When Providing Care for Burns ....................................................................................... 195

Electrocution ....................................................................................................................................... 195 Causes of Electrocution ................................................................................................................................... 195 Signs & Symptoms of Electrocution ................................................................................................................ 195 Emergency Care for Electrocution ................................................................................................................... 196

Fainting ............................................................................................................................................... 196 Causes of Fainting ............................................................................................................................................ 196 Emergency Care for Fainting ........................................................................................................................... 196

Shock ................................................................................................................................................... 197 Causes of Shock ............................................................................................................................................... 197 Signs and Symptoms of Shock ......................................................................................................................... 197 Emergency Care for Shock .............................................................................................................................. 198

Diabetic Emergencies ......................................................................................................................... 198 Signs & Symptoms of Diabetic Emergencies .................................................................................................. 198 Emergency Care for Diabetic Conditions ........................................................................................................ 199

Seizures................................................................................................................................................ 200 Causes of Seizures ........................................................................................................................................... 200 Major Seizures ................................................................................................................................................. 200 Signs and Symptoms of Major Seizures ...................................................................................................... 200 Emergency Care for Major Seizures ........................................................................................................... 201 Minor Seizures ................................................................................................................................................. 201

Heat Exposure .................................................................................................................................... 202 Heat Cramps..................................................................................................................................................... 202 Medical Care for Heat Cramps .................................................................................................................... 202 Heat Exhaustion ............................................................................................................................................... 202 Signs and Symptoms of Heat Exhaustion ............................................................................................ 202 Emergency Care for Heat Exhaustion ......................................................................................................... 203 Heat Stroke....................................................................................................................................................... 203 Signs and Symptoms of Heat Stroke ........................................................................................................... 203 Emergency Care for Heat Stroke ................................................................................................................. 203

Cold Exposure .................................................................................................................................... 204 Signs & Symptoms of Hypothermia ................................................................................................................ 204 Emergency Care for Cold Exposure ................................................................................................................ 205

Psychological Emergencies ................................................................................................................ 205 Signs & Symptoms of Psychological Emergency ............................................................................................ 206 Emergency Care for Psychological Conditions................................................................................................ 206

Legalities of Emergency Care ........................................................................................................... 206 Good Samaritan Laws ...................................................................................................................................... 207 Implied Consent ............................................................................................................................................... 207 Refusal of Emergency Care ............................................................................................................................. 207

Summary ............................................................................................................................................. 208

Home Care Assistant Guide Table of Contents SECTION 12: INFECTION CONTROL ........................................................................................ 209 Infection............................................................................................................................................... 209 Types of Infection ............................................................................................................................... 209 Signs and Symptoms of Infection ...................................................................................................... 210 Transmission of Infection .................................................................................................................. 210 Infectious Diseases .............................................................................................................................. 211 Bloodborne Diseases ........................................................................................................................... 212 The Role of HCAs in Infection Control ............................................................................................ 212 Cleansing Methods for Infection Control ........................................................................................ 213 Universal Precautions for Infection Control.................................................................................... 214 Hand-washing .................................................................................................................................................. 214 Washing Hands with Water ......................................................................................................................... 214 Demonstration: Hand-Washing ............................................................................................................. 214 Washing Hands Without Water ................................................................................................................... 216

Personal Protective Equipment......................................................................................................... 216 Disposable Gloves............................................................................................................................................ 216 Demonstration: Removing Used Gloves ............................................................................................... 217 Gowns & Aprons ............................................................................................................................................. 218 Putting on Gown ......................................................................................................................................... 218 Removing Gown ......................................................................................................................................... 218 Masks ............................................................................................................................................................... 219 Putting on Mask .......................................................................................................................................... 219 Removing Mask .......................................................................................................................................... 219 Protective Goggles ........................................................................................................................................... 219 Putting on Protective Goggles ..................................................................................................................... 219 Removing Protective Goggles ..................................................................................................................... 219

Sharp Objects ..................................................................................................................................... 220 Handling Sharp Objects ................................................................................................................................... 220

Specimens ............................................................................................................................................ 221 How HCAs Should Handle Specimens ....................................................................................................... 221

Blood Sugar Tests ............................................................................................................................... 221 Blood & Body Fluid Spills ................................................................................................................. 221 How HCAs Can Handle Blood & Body Fluid Spills .................................................................................. 222

Household Wastes .............................................................................................................................. 222 Medical Waste ................................................................................................................................................. 222 Infectious Waste............................................................................................................................................... 223 How HCAs Can Handle Household Wastes ............................................................................................... 223

Laundry ............................................................................................................................................... 223 How HCAs CanHandle Laundry ................................................................................................................. 223

Personal Care Items ........................................................................................................................... 224 Personal Care Items ......................................................................................................................................... 224 Special Equipment ........................................................................................................................................... 225 How HCAs Can Handle Personal Care Items & Special Equipment .......................................................... 225

Catheters & Drainage Bags ............................................................................................................... 225 How HCAs Can Clean a Catheter ............................................................................................................... 226 How HCSs Should Empty a Drainage Bag ................................................................................................. 226 How HCAs Can Clean an Emptied Drainage Bag ...................................................................................... 227

Summary ............................................................................................................................................. 227 SECTION 13: OBSERVING, REPORTING & DOCUMENTING .............................................. 228 Observing ............................................................................................................................................ 228 Methods of Observing ...................................................................................................................................... 228

Home Care Assistant Guide Table of Contents Vital Signs ................................................................................................................................................... 228 Objective Observing .................................................................................................................................... 229 Subjective Observing .................................................................................................................................. 229 Guidelines for Observing ................................................................................................................................. 229 Signs & Symptoms of Illness ...................................................................................................................... 230 Physical Health:...................................................................................................................................... 230 Signs & Symptoms of Injury ....................................................................................................................... 230 Signs Evident to Observer ...................................................................................................................... 230 Symptoms Reported by Injured Person .................................................................................................. 231 Signs & Symptoms of Mental or Emotional Changes ................................................................................. 231 Signs & Symptoms of Changes in Home Environment .............................................................................. 231

Reporting............................................................................................................................................. 231 Reporting Channels .......................................................................................................................................... 231 Guidelines for Reporting .................................................................................................................................. 232

Documenting ....................................................................................................................................... 232 Benefits of Documenting ................................................................................................................................. 232 Information to be Documented ........................................................................................................................ 233 Guidelines for Documenting ............................................................................................................................ 233

Standard Medical Abbreviations & Acronyms ............................................................................... 234 Purpose of Abbreviations & Acronyms ........................................................................................................... 235 List of Common Abbreviations & Acronyms .................................................................................................. 235

The 24-Hour Clock ............................................................................................................................. 237 Comparison of the 24-Hour Clock & the 12-Hour Clock ................................................................................ 238

Client Care Records ........................................................................................................................... 238 Purpose of Client Care Records ....................................................................................................................... 238 HCA Responsibilities for Client Care Records ................................................................................................ 239 Details HCAs Should Record ...................................................................................................................... 239 Recordkeeping Benefits for HCAs .............................................................................................................. 240 Case Management Records .............................................................................................................................. 240 Needs Assessments ..................................................................................................................................... 241 Instrumental Activities of Daily Living .................................................................................................. 241 Activities of Daily Living ....................................................................................................................... 241 Nursing Assessments................................................................................................................................... 241 Home Safety Assessments........................................................................................................................... 242 Care Plan ..................................................................................................................................................... 242 Monitoring & Follow-up Evaluations ......................................................................................................... 243 Progress Reports.......................................................................................................................................... 243 Status Notes ................................................................................................................................................. 243 Medication Records..................................................................................................................................... 244 Flow Charts ................................................................................................................................................. 244

Summary ............................................................................................................................................. 244 SECTION 14: ETHICAL & LEGAL ISSUES ............................................................................... 246 Difference Between Ethics and Laws................................................................................................ 246 Ethics ................................................................................................................................................... 246 Ethical Principles ............................................................................................................................................. 246 Work Ethics ..................................................................................................................................................... 247 How HCAs Can Practice Good Work Ethics .............................................................................................. 247

Laws ..................................................................................................................................................... 248 Legal Terms ..................................................................................................................................................... 248 Parameters of HCA Duties ............................................................................................................................... 250 How HCAs Can Avoid Legal Action ............................................................................................................... 250

Home Care Assistant Guide Table of Contents Client Rights ....................................................................................................................................... 251 HCA Rights ......................................................................................................................................... 252 Health Insurance Portability and Accountability Act .................................................................... 253 Privacy Rule ..................................................................................................................................................... 253 Security Rule .................................................................................................................................................... 253 Breach Notification Rule ................................................................................................................................. 254 HIPAA Rights .................................................................................................................................................. 254 How HCAs Can Safeguard Older Adults’ PHI ........................................................................................... 254

Older Adult Abuse ............................................................................................................................. 255 Forms of Older Adult Abuse ............................................................................................................................ 255 Signs & Symptoms of Older Adult Abuse ....................................................................................................... 256 How HCAs Can Report Suspicions of Older Adult Abuse ......................................................................... 257 Abusive Professional Caregivers ..................................................................................................................... 257 Consequences for Caregivers Who Abuse Older Adults ............................................................................. 257 Coping Mechanisms for Abusive Caregivers ................................................................................................... 258

Child Abuse......................................................................................................................................... 258 Forms of Child Abuse ...................................................................................................................................... 258 Signs & Symptoms of Child Abuse ................................................................................................................. 259 Physical ....................................................................................................................................................... 259 Sexual .......................................................................................................................................................... 259

Child Neglect....................................................................................................................................... 260 Child’s Basic Life Necessities ......................................................................................................................... 260 Reporting Suspected Child Abuse/Neglect ...................................................................................................... 260 Report Details.............................................................................................................................................. 261

Mandated Reporters .......................................................................................................................... 261 Confidentiality & Immunity Rights of Abuse Reporters ................................................................................. 262 Consequences of Not Reporting Child Abuse/Neglect .................................................................................... 262 Types of Advance Directives ........................................................................................................................... 262 Living Will .................................................................................................................................................. 263 Durable Power of Attorney for Health Care ................................................................................................ 263 Surrogate Decision Maker ........................................................................................................................... 263 Do-Not-Resuscitate Order ........................................................................................................................... 263

Summary ............................................................................................................................................. 263

xii

Section 1 The Older Adult

SECTION 1:

THE OLDER ADULT

Impacts of Aging Aging is a normal part of living that affects everyone physically, socially and psychologically. As a person matures, there are structural and functional changes to the human body, which are both normal and anticipated. The physical changes in the body are a result of changes in cell structure, chemical activity and hormone production. Psychological changes impact behavior, thinking, functioning and personality. After retirement, these changes impact social interactions, roles and status. They also have a bearing on leisure time and recreational activities. Tagged to the physical and psychological facets are sociological, heath and economic aspects, which can all influence how and how well a person travels along the aging highway. While growing older is inevitable, the rate at which people age varies greatly from person to person, as does their ability to cope. Some factors that influence how a person copes with aging include:     

social support systems; status of health; financial resources; education; and, life experiences.

Since it is important that the Home Care Assistant understands what conditions to expect with the aging process, this section will examine some of the issues facing Older Adults. This background will provide the Home Care Assistant with the tools needed to better understand where an Older Adult is coming from. Being aware of normal changes will also assist in planning home and lifestyle adaptations, which will enable Older Adults to attain and maintain their optimum functioning levels.

Dimensions of Aging There are four basic dimensions of aging:    

Chronological Aging Biological Aging Social Aging Psychological Aging 1

Section 1 The Older Adult

Chronological Aging A person’s Chronological Age is determined by the number of years since their birth. It is not the same as biological or psychological aging, as some individuals may act older than their chronological age while others may act younger than their chronological age.

Biological Aging Biological Aging revolves around the physiological changes that occur throughout the various systems in the body, which tend to slow individuals down. It is theorized that biological aging results from:     

wear and tear on the body; chemical changes in the body; inability to fight disease; changes in the structure of skin and collagen; and, changes in cells and tissues.

Social Aging Social Aging refers to age-related changes in a person’s roles and relationships within their associations with friends and relatives, as well as their associations within formal groups such as clubs and places of worship. Such relationships usually have certain expectations of predetermined behavior. Problems such as multiple losses, retirement and age discrimination can all impact the rate and degree of social aging.

Psychological Aging Psychological Aging refers to changes in behavior and mental processes, which can impact a person’s ability to adapt, adjust and cope with changes. Other conditions that can have an impact are learning abilities, depression and dementias.

Outward Signs of Aging  Skin wrinkling and loss of elasticity due to: • loss of underlying fat layers and oil; • inadequate nutrition; • sun exposure; • heredity; and, • hormone changes.  reduced ability to perspire due to sweat glands wasting away; 2

Section 1 The Older Adult

 development of “age spots” due to deposits of melanin pigment;  hair turns gray due to loss of pigment; and,  nails become thicker due to reduced blood flow.

Aging Effects on Body Systems Body System

Cardiovascular System

Changes  reduced blood flow to the body

Respiratory System

 decreased oxygen intake

Musculature System

 loss of muscle tone and strength

Nervous System Integumentary System

Skeletal System

Gastrointestinal System

Endocrine System

 reduced efficiency of nerve transmission  shrinking of brain  thinning of skin  reduced sebaceous glands to lubricate skin  decrease in sweat glands  decrease in subcutaneous fat  increase in age spots  reduced bone density due to calcium loss

 reduction in production of hydrochloric acid, digestive enzymes & saliva  reduction in taste buds  decrease in metabolic rate

Consequences  reduced stamina  more susceptible to drug toxicity  slower healing rate  reduced response to stress  hypertension  increased chance of stroke, heart attack & congestive heart failure  decreased stamina  shortness-of-breath  anxiety  reduced ability to breathe deeply  constipation,  bladder incontinence  reduced response and coordination time  changes in sleeping patterns  possible negative self esteem  inability to regulate body temperature  drying of skin  greater susceptibility to sunburn  reduction in weight bearing capacity  increased risk of spontaneous fracture  reduction in height  changes in posture and rigidity  degenerative inflammation of the joints  impaired breakdown and absorption of food  gastrointestinal distress  impaired swallowing  delayed emptying of stomach  food is not absorbed as well  reduced stamina  greater susceptibility to drug toxicity

Section 1 The Older Adult

Body System Urinary System

Sexuality

Changes  kidney decreases in size & efficiency  bladder size decreases & loses elasticity  bladder holds less urine & fails to empty completely  changes in thirst sensation  atrophy of ovarian, vaginal & uterine tissues & decreased vaginal fluids  enlargement of prostate

Consequences  affect elimination & filtration of medications  increased need to urinate  residual urine predisposes individual to bladder infections  need to urinate is immediate & urgent  reduce fluid intake leads to dehydration & constipation problems  decreased frequency of sexual activity

Sensory Changes Associated with Aging Sense

Vision

Hearing

Taste & Smell

Skin Sensitivity

Changes  pupils decrease in size & response time to light  thickening & yellowing of eye lens

 decreased sensitivity to high frequency  tones  decreased discrimination of similar pitches  reduction in total number of taste buds  decline in sense of smell (often due to a non-normal condition)  skin becomes less sensitive to sensation, including heat, cold & injury  reduced sense of touch

Consequences  need for light enhanced 3 times  takes longer to focus  increased sensitivity to glare  decreased depth perception  more difficulty distinguishing pastel colors.  some hearing loss  socially disabling  may result in untrue assumptions such as a person is senile, dumb or uncooperative  decreased interest in food  desire for saltier or highly seasoned food  reduced awareness of body odor, & environmental hazards such as smoke, spoiled food & hazardous fumes  increased chance of unknowingly causing self-injury  reduction of touch benefits; i.e. being able to perform functions which will form a sense of self, relieve stress, give comfort, maintain intimacy & convey acceptance/condolences 4

Section 1 The Older Adult

Sense Balance & Gait

Changes  decline in equilibrium, which makes it more difficult to maintain balance  manner of walking changes; i.e. speed, length of stride, height of step

Consequences  a slip or trip can result in a fall, which is the leading cause of injury.

Cognitive Changes Associated with Aging “Cognitive” refers to the mental process of thought, including perception, reasoning, intuition and memory.

Factor

Changes

Intelligence

 reduced efficiency of nerve transmission in the brain affect sensory input

Learning & Memory

 increase in memory problems  cognitive processing & memory may take a bit longer

Consequences  slower information processing & greater loss of information during transmission  inaccurate perceptions  reduced capacity to process additional information quickly.  reduced ability to recall recent events  reduced ability to accumulate additional information  reduced ability to retrieve existing information from memory bank

Note: Cognitive changes are not always due to aging. Since cognitive processes are very responsive to a person’s physical & psychological state, physical illnesses & medications can not only affect neuronal function but can also reduce the energy available for thinking. Additionally, depression & other emotional problems can curb one’s desire to learn & remember additional information.

Section 1 The Older Adult

Personality Changes Associated with Aging Factor Personal Suitability Personality Change

Changes

Consequences

 personality traits change very little with age

 a person is considered “ageless” in terms of personal suitability

 shifts in personality, as the individual becomes preoccupied with his/her inner life

 tendency to be less impulsive & more cautious  men & women become more similar in respect to their values & personality styles  people tend to be “more themselves”, as their interaction styles become more individualized

Basic Needs of Older Adults Older Adults have the same basic needs as their younger counterparts have; i.e. physiological, safety, affection, esteem and self-actualization). Their behavior and thoughts revolve around their quest to meet these needs. If they are not met, their physical, mental and/or emotional health can be affected. The basic needs of all humans, as described by Abraham Maslow, are:

Physiological Physiological needs, which are the strongest of all the needs, consist of the need for oxygen, food, water, and a relatively constant body temperature.

Safety Safety needs are designed to attain and protect security. Unlike children, who will show signs of insecurity, adults have little awareness of their safety needs unless that safety is threatened by emergency or disorganization.

Love, Affection and Belonging Third on the “need tier” are needs associated with love, affection and a sense of belonging. By nature, most people try to avoid loneliness and alienation by giving and receiving love, affection and the sense of belonging.

Section 1 The Older Adult

Esteem Once a person satisfies the needs in the first three groups, he/she tends to seek self-esteem, which includes both self-esteem and the esteem obtained from others. Humans not only desire respect from themselves but also from others. Respect gives a person confidence and value as a person. Lack of esteem will lead to frustration, and feelings of inferiority, weakness, helplessness and worthlessness.

Self-Actualization It is only after all the other needs are met that one seeks self-actualization, which basically means doing what he/she was “born to do”. When such needs are not met, the individual becomes restless, feels on edge, is tense and feels as if he/she is lacking something. It is not always obvious what a person wants when there is a need for self-actualization.

Factors Affecting Older Adults’ Mental Health There are various mental health issues that Older Adults face. The Home Care Assistant should be familiar with the more common ones to recognize signs of mental health deterioration and to provide care which promotes good mental health.

Insufficient or Inadequate Socialization Social interaction provides a sense of purpose and interactive opportunities with others. As a person ages their social interactions become more restrictive for many reasons:  They are less mobile.  They develop a serious or chronic illness.  They lose a spouse or loved one. Lack of socialization can lead to:  a decline in nutrition;  increased anxiety/depression; and,  substance abuse. Social isolation may develop because of:  fewer social contacts;  aging;  death of spouse or loved one; 7

Section 1 The Older Adult

          

financial problems; living alone; transportation problems; no friends or relatives nearby; change in residences; health issues; physical problems; deteriorating cognitive power; increased usage of medication; life satisfaction; and, gender.

How HCAs Can Assist a Socially Isolated Older Adult  Discuss situations and viable solutions with appropriate people; i.e. Care team, family friend.  Encourage more social activities.  Attempt to make the client feel needed and valued.  Encourage the client to participate in community activities and events.  Try to find access to transportation.  Tell the client about supports and services for Older Adults in the community.  Arrange for client to be accompanied on first outing.

Reduction in Ability to Function As people age, they experience some function loss, which can result in a loss of independence and a loss of control over their lives. Causes of functional loss include:        

decreased vision; decreased hearing; decreased mobility; illness such as heart attack, stroke, cancer; falls; injuries; high blood pressure; and, osteoporosis.

How HCAs Can Assist Older Adults with Functional Decline  Promote physical activity to: • increase independence; • improve mental health; 8

Section 1 The Older Adult

• improve quality of life; • provide more energy; • reduce the number of aches and pains; • reduce stress; • improve self-esteem; • control weight; • improve social life; • improve sleep; • have fun; and, • fight disease.  Encourage the client to do some form of physical activity every day such as walking, lifting weights and/or stretching exercises.  Note: Client should discuss exercise plans with his/her Physician before starting an exercise regime.  Encourage client to talk to friends and family about participating in activities.  Encourage client/friends/family to become involved in community activities.  Prevent falls, which play a huge role in the physical and mental health of Older Adults.

Substance Abuse Substance abuse is the excessive use of alcohol or drugs, which can:    

reduce brain activity, influence alertness, affect coordination and reaction times; and, increase the risk of injuries/falls.

The aging process causes people to absorb and dispose of alcohol and medication differently, which can be very serious or even fatal. Substance abuse can occur simply by not taking medications as prescribed or it can be a deliberate and planned misuse of substances. An Older Adult may develop a problem with substance abuse because of:      

loneliness; death of friends/family member; failing health; retirement; changing residences; and, reduced income.

Section 1 The Older Adult

An Older Adult may suggest he/she has an alcohol problem if he/she:     

has medical, social or financial problems because of drinking; feels irritable, resentful or unreasonable when not drinking; loses interest in food; lies to mask drinking habits; and, drinks to calm nerves or reduce depression.

Actions HCAs Can Take If Substance Abuse Is Suspected  Watch for signs of substance abuse when interacting with the client, the family and/or the caregiver.  Watch for signs of substance abuse by the caregiver.  Be aware that problems can develop when prescription medications are combined with alcohol.  Ensure that the person on the care-giving team, who is responsible for taking action for substance abuse, is apprised of the situation.

Changes in Circumstances Change is constant throughout life. As people age, they continue to be faced with ongoing changes in their life situation, which can be due to:     

serious events; death of a loved one; emergence of health conditions; need to change residences; and, need to move into a nursing home or retirement home.

These factors can affect mental health which, in turn, impact physical health. How HCAs Can Assist Older Adults with Changes in Life Situations  Spend time with clients and listen to them talk about their past. Allow them to share their experiences with you if they choose to share them.  Aid in connecting with specific organizations that may be able to help; e.g. Hospice can provide support to the dying individual and his/her family.  Be alert for any negative impacts on the client’s physical or mental health, which change may have. This can become evident when talking to the client or to the caregiver/family.  If you sense there is a need for professional attention; e.g. counselors, therapists, contact the individual on the care-giving team, who is responsible for taking action on life situation changes. 10

Section 1 The Older Adult

Financial Concerns There is nothing like financial security to promote independence and have control over one’s life. A major cause of stress for Older Adults is the worry that their resources might not be enough to obtain the services and support they need. This stress can lead to anxiety, especially if they do not qualify for publicly-funded assistance. Additional issues which contribute to financial insecurity are:       

insufficient income to meet existing needs; not enough savings to assist with present and impending needs; expenses are greater than income; unable to budget appropriately, due to lack of knowledge or ability; permanent health-related expenses; e.g. medications, supplies; susceptibility to scams by con artists; and, financial abuse.

Some indicators of financial insecurity are:  Items of value disappear.  The Older Adult may become depressed.  Comments are made by the Older Adult and/or family, which state or hint at an inability to pay for health care and the basics of daily living. How HCAs Can Support Older Adults with Financial Concerns  Discuss the situation with the client, if the client is receptive. Interact in a nonintimidating or non-meddling manner.  Enlighten clients about the existence of scam artists and encourage them to contact a family member or service provider before agreeing to give money to anyone they aren’t familiar with and/or are suspicious of.  Contact the person on the care-giving team who is responsible for taking action for financial insecurity.

Depression Depression is a mental state, which is characterized by a pessimistic sense of inadequacy and a despondent lack of activity. There are various signs of depression:    

suicidal thoughts; feeling sad; having a non-positive attitude about the past, present and future; losing interest in activities once enjoyed; 11

Section 1 The Older Adult

    

feeling listless and without energy; having difficulty in making decisions; experiencing a disruption in sleep patterns; having a decreased appetite and subsequent weight loss; and, having depressing dreams.

How HCAs Can Support Older Adults with Depression  Become familiar with the client’s situation.  Find out if support systems exist within the family or the community.  Watch for the “red alert” indicators of depression; e.g. sadness, withdrawn, lethargic, neglected hygiene and personal appearance.  Take all comments about death or suicide seriously.  Support the client in finding help.  Avoid giving “pep talks”, as they are not beneficial.  Listen to the client with a non-judgmental and non-critical ear.  Be supportive and understanding.  Don’t assume any guilt over the client’s condition.  Contact the person on the care-giving team who is responsible for taking action for depression.

Summary Aging is a normal part of living and affects everyone physically, socially and psychologically. Many changes occur not only in outward appearances but also within the body systems. There are also changes in cognitive reasoning, personality, and senses. Basic needs remain the same but the challenge to fulfill them increases, as the aging person faces changes in function, social interactions, life situations and financial security. These factors can make the Older Adult susceptible to depression. People’s reactions and coping abilities vary considerably from individual to individual. By understanding the aging process and the challenges it presents, Home Care Assistants can help their Older Adult clients come to terms with the inevitable and help them attain and maintain their optimum functioning levels.

Section 2 Health Problems

SECTION 2: HEALTH PROBLEMS

As people age, they can experience various health problems including chronic diseases. A chronic disease has one or more of the following characteristics:    

It is permanent and leaves a disability. It is not reversible. It requires special rehabilitative training. It may require a lengthy period of supervision, observation or care.

Examples of chronic diseases are arthritis, stroke, Parkinson’s disease and diabetes. Generally, they are treated with medication, exercise and diet. These diseases can limit the mobility of Older Adults. Older Adults can also fall victim to other health problems such as cancer, pulmonary disease and heart disease. It is helpful if Home Care Assistants are familiar with some of the health conditions that plague Older Adults to improve the quality of care they provide. This section will take a cursory look at the more common health problems and outline how they may affect the lives of those they strike.

Arthritis Arthritis is an inflammation of the joints of the body due to cartilage wearing down. (Cartilage is the substance that pads the ends of the bones and reduces friction during movement.) The joints that are affected most often in women are the hands, knees, ankles and feet. In men, they are the hips, spine, and wrist. The severity of the condition can range from mild to severe. The following table outlines some of the traits, which are common to diverse types of arthritis: Causes/Risk Factors  age  extra weight  insufficient exercise  hereditary factors  injuries  certain exercises, occupations & sports

Symptoms  stiffness in joint  difficulty moving joint  pain in joint  pain around joint  swelling of joint  fatigue

Consequences  pain  disability  loss of joint function  loss of movement  restricted activities

Treatment  medications  joint replacements  rest  exercise  diet  heat & cold therapies  water therapy  surgery

Section 2 Health Problems

There are two main types of arthritis:  Osteoarthritis  Rheumatoid Arthritis

Osteoarthritis Osteoarthritis is a degenerative joint disease. In osteoarthritis, cartilage breaks down and the bones rub together. The joint then loses shape and alignment. As they thicken, bony growths (spurs) form on the bone ends and pieces of cartilage and bone float in the joint space. Osteoarthritis can affect any joint and may only involve a couple of joints. Joints most often affected are knees, hips, back, fingers and feet. Its severity can range from mild to severe.

Causes/Risk Factors  age  obesity  joint injuries resulting from sports or workrelated accidents  cartilage breaks down & causes bones to rub against each other due to aging  irritation of the joints  wear & tear of the joints  overuse in professional sports  hereditary factors

    

Symptoms

Consequences

inflammation redness swelling heat pain

 pain  disability  loss of joint function  loss of movement

Treatment       

no cure relieving pain relieving stiffness application of heat application of cold weight loss assistive device to carry out activities of daily living  surgical joint replacement

Rheumatoid Arthritis Rheumatoid Arthritis is a chronic disease wherein the immune system attacks the lining of the joint. This causes an inflammation, which can result in deformity. The disease can be severe and can involve not only the joints but also the whole body including the heart, lungs, kidneys, skin and eyes. Causes/Risk Factors  actual cause is unknown

Symptoms  inflammation  redness  swelling

Consequences  painful & swollen joints  disability

Treatment  control pain  maintain joint motion 14

Section 2 Health Problems

Causes/Risk Factors 

inflicted person’s own immune cells attack the body (autoimmune disease)  possibly playing a role are: • infections • genes • hormones

Symptoms  heat  pain  joint stiffness  limited joint motion  weight loss  aching muscles  anemia

Consequences     

loss of joint function loss of movement cartilage destruction bone erosion tendon inflammation

Treatment  prevent deformities  range of motion exercises  medications  surgical joint replacement

How HCAs Can Help Older Adults with Arthritis  Offer encouragement and remind them to: • Focus on their abilities instead of disabilities. • Focus on their strengths instead of their weaknesses. • Find new ways to carry on and enjoy their favorite activities. • Be flexible and open to treatment choices. • Accept encouragement and praise. • Maintain a positive attitude. • Break down activities into small tasks that can be managed more easily • Develop a daily routine that schedules both rest and activity. • Develop a support system of family, friends, and health caregivers. • Rest when their body needs to rest, as too much activity or over exercising can cause more pain.  Discuss their treatment options with their Physician; e.g.: • Are medications available, which may stop or reduce pain, so they can function better? • How to protect their joints and take pressure off them? • Should they lose weight to reduce stress on joints and slow down further injury? • Should they join a self-help and education program? • Will assistive devices (canes, grab bars, larger handles) help? • Should heat be used to relieve joint pain? • Should cold compresses be used to reduce swelling? • What exercises can help sore and swollen joints?

Osteoporosis Osteoporosis is a disease wherein there is an accelerated loss of bone mass and a reduction in bone quality. If not prevented or if left untreated, it can progress painlessly until a bone breaks, usually in the hip, spine and/or wrist. 15

Section 2 Health Problems

Fractures to the hip and spine are of greatest concern, although any bone can be affected, A hip fracture usually requires hospitalization and major surgery. It can affect a person's ability to walk unassisted and may cause prolonged or permanent disability or even death. When fractures occur in the spine, they can have profound consequences, including loss of height, severe back pain and deformity. Causes/Risk Factors  Specific causes are unknown but there are risk factors: • older age • female gender • Caucasian or Asian • race • small, slender bones • low calcium diet  post menopause  low physical activity  ovaries removed  cigarette smoking  too much alcohol & caffeine  family history  excessive use of medications such as cortisone & prednisone  previous fracture  certain diseases such as rheumatoid arthritis & lupus

Symptoms  often there are no symptoms  fractures

Consequences  bones become fragile and are susceptible to fracture  loss of height  severe back pain  deformity

Treatment  eat a calcium rich diet  take sufficient Vitamin D  estrogen replacement therapy (to be determined by client’s Physician)  do weight bearing exercises  wear a back brace or corset (determined by Physician)  use walking aids  medications  surgery

How HCAs Can Help Older Adults with Osteoporosis    

Do some physical activity every day. Avoid cigarettes and other forms of smoking. Establish an exercise program with the help of a physical therapist. Avoid falling: • walk carefully – be alert for uneven ground; • wear good shoes; • don’t hurry when conducting activities; 16

Section 2 Health Problems

• reduce risk of accidents by making the home safe; • eat a diet with sufficient calcium and Vitamin D; and, • discuss hormone therapy with their Physician.  Manage pain: • apply ice and heat compresses; • take medications (consult with Physician); • positive thinking; • relaxation; • meditation; • acupuncture; • visualization; and, • surgery.

Stroke A stroke occurs when the supply of blood and oxygen to the brain is interrupted. It can be caused by a blood vessel breaking, with blood bleeding into the brain or it can be caused by a blood clot blocking the blood supply to the brain. Whichever type of stroke it is, the death of brain cells may occur. When this happens, the parts of the body, which the dead cells once controlled, do not function.

Causes/Risk Factors  smoking  high blood pressure  hardening of the arteries  heart disease  diabetes

Symptoms  sudden weakness, numbness &/or tingling of the face, arm or leg  sudden, temporary loss of speech or trouble understanding speech  sudden loss of vision, particularly in one eye, or double vision  unsteadiness or sudden falls  sudden, severe headache for no apparent reason

Consequences  paralysis or weakness on one side of the body  vision problems  trouble using or understanding language  inability to recognize or use familiar objects  tiredness  depression  expression of emotional responses that are exaggerated or inappropriate  difficulty learning & remembering additional information

Treatment/Prevention Treatments  medications  surgery  rehabilitation  prevention  control high blood pressure  eat a high fiber, low salt and low-fat diet  do regular, moderate physical activity  avoid alcohol & tobacco

Section 2 Health Problems

Causes/Risk Factors

Symptoms

Consequences

Treatment/Prevention

 changes in personality  slow or slurred speech  behavioral changes  mobility problems  functional limitations

How HCAs Can Assist Older Adults Who Have Had a Stroke        

Learn as much as possible about the stroke. Learn what affects the stroke has had on the Older Adult. Help the Older Adult cope with his/her situation. Use humor appropriately. Be patient and kind. Be optimistic but realistic. Maintain the Older Adult’s dignity and privacy. Avoid being condescending or juvenile when interacting.

Parkinson’s Disease Parkinson’s Disease is a progressive neurological condition. The cells in the part of the brain, which control movement, are damaged. The rate of progression and the symptoms of the disease vary considerably from individual to individual.

Causes/Risk Factors  Underlying cause is unknown, but it has several potential causes: • brain tumor • head injury • degeneration of the nerve tissue • poisoning • stroke • medication

Symptoms  tremors  rigidity causing muscle pain & stiffness  slowness of movement  difficulty with posture or poor balance  mask-like appearance

Consequences  shuffling walk  hesitant speech  abnormal posture  slow movement  slowed mental function (in some people)

Treatment    

medication surgical techniques physical therapy exercise

Section 2 Health Problems

Causes/Risk Factors

Symptoms  drooling

Consequences

Treatment

 impaired memory (in some people)

How HCAs Can Help Older Adults with Parkinson’s Disease  Accept the disease as part of their lives.  Take advantage of supportive measures, which will help them remain in control of the disease.  Consult with a physiotherapist to develop a physical therapy program that is tailored to their needs.  Exercise consistently and regularly. Consult with Physician before starting an exercise regime.  Eat a balanced and healthy diet.  Promote normal bowel elimination.  Practice safety measures to prevent injury.  Maximize their well-being. Note: The Home Care Assistant should always treat clients as adults and give them dignity and respect.

Diabetes The pancreas produces a hormone (insulin), which is responsible for regulating the level of sugar in the blood. When the level of sugar becomes abnormally high, the resulting condition is known as diabetes. There are two main types of diabetes which affect Older Adults:  Type 1 Diabetes: use to be called “insulin-dependent” or “juvenile diabetes”. Is caused by the lack of insulin production by the pancreas.  Type 2 Diabetes: use to be called “non-insulin dependent” diabetes. Is also known as “adult onset”. It is believed to be related to life style habits.

Causes/Risk Factors Type 1 Cause is unknown, but possibilities include:  interaction between genes & environmental factors

Symptoms  excessive thirst  frequent urination  weight loss  lack of energy

Consequences  blindness  kidney failure  electrolyte imbalance

Treatment Type 1 - insulin therapy Type 2 – depends on what part of the body has defects;

Section 2 Health Problems

Causes/Risk Factors

Symptoms

 viral infections

Consequences  insulin shock  diabetic coma  heart disease  stroke

Type 2 Cause believed to be related to life styles. Susceptible people are:  those with a family history  people between 40 & 75  people of Asian or African/Caribbean origin  people who are overweight  women who have given birth to large babies.

Treatment e.g. pancreas, liver, muscle  medications  monitoring blood sugar levels

Note: Not all people who develop diabetes display symptoms; hence, it may go undetected for years.

What Home Care Assistants Need to Know About Diabetic Emergencies People with Type 1 diabetes and some people with Type 2 diabetes are at risk for developing insulin shock or going into a diabetic coma. Therefore, a Home Care Assistant should be alert for signs of either condition. Note: Refer to Section 11 - Diabetic Emergencies

Cardiovascular Disease Cardiovascular disease is a disease of the heart and blood vessels often caused by a narrowing of the blood vessels. This is often due to accumulation of plaque in the lining of the blood vessels.

Causes/Risk Factors  high blood pressure  high blood cholesterol  previous heart attacks  coronary artery disease  heart arrhythmias  heart valve disease

Symptoms  shortness-ofbreath  fatigue  persistent cough  fluid buildup in veins  swelling of feet legs and ankles  frequent urination at night

Consequences  congestive heart failure  heart attack  decreased circulation to extremities

Treatment  diuretics to remove excess fluid  medications  surgical procedures  adopting a healthy diet

Section 2 Health Problems

Causes/Risk Factors  congenital heart defects  inflammation of the heart muscle  alcohol & drug abuse  lack of exercise  obesity  diabetes  stress

Symptoms

Consequences

Treatment

 weight gain due to fluid buildup  chest pain  loss of appetite  indigestion  swollen neck veins  cold, sweaty skin  restlessness, confusion & decreased attention span & memory

How HCAs Can Help Older Adults with Cardiovascular Disease Encourage them to:      

Participate in a medically supervised aerobic exercise program. Quit smoking. Control high blood pressure, cholesterol and diabetes. Limit consumption of alcohol and fluids. Eat a heart-healthy diet which is low-fat and low salt. Weigh daily to monitor fluid retention.

Heart Attack The main symptoms and warning signs of a heart attack are:  Chest pain: • fullness or burning • heaviness, pressure or squeezing • tightness, discomfort or crushing  Pain spreading from center of the chest: • down one or both arms • up to the neck, jaw, shoulders or back  Additional Signs • nausea, vomiting and/or indigestion • anxiety or fear • denial, refusing to admit that anything is wrong • paleness, sweating or weakness or shortness-of-breath 21

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How HCAs Can Assist Older Adults with Heart Attack Symptoms Home Care Assistants must be familiar with the signs and symptoms of a heart attack. 9-1-1 must be called immediately if a person displays or experiences heart attack signs and symptoms. See Section 11: Emergency Care for Heart Attacks and Emergency Care for Cardiac Arrest

Anemia Anemia is a condition in which there aren't enough healthy red blood cells to carry adequate oxygen to the tissues of the body. It is not a disease but is a symptom of an underlying health problem. Anemia can be temporary or long-term and can range from mild to severe.

Causes/Risk Factors  blood loss from accident, surgery, bleeding ulcer & hemorrhoids  increased destruction of red blood cells  toxins or diseases  inherited disorders  acquired condition  chronic illness  vitamin deficiency

Symptoms  tiredness or easily fatigued  weak or unable to exercise  prone to breathlessness, even with little exertion  lightheadedness  pale in appearance

Consequences  congestive heart failure  decreased cognitive function  functional impairment  falling

Treatment  treatment varies depending on cause & include: • iron vitamin supplements • blood transfusions • bone marrow transplant

Note: Older Adults may not display the common symptoms of anemia. Instead anemia may present itself in the form of confusion, fainting spells, falls, chest pain or congestive heart failure.

How HCAs Can Help Older Adults, with Anemia Encourage them to:  Take treatments and medications as prescribed.  Eat a balanced diet consisting of several small meals, even when tired, as several small meals will provide more energy.  Eat foods that contain iron (eggs, red meat, liver and spinach).  Get more rest; i.e. sleep more hours overnight and take naps during the day.

Section 2 Health Problems

 Don’t try to do too many things in the one day – save some for the next day and/or get help.  Lie down flat when feeling dizzy and when time to get up, rise very slowly.  Consult with Physician, nurse or Dietician about taking vitamin supplements.

Chronic Obstructive Lung Disease The Respiratory System brings oxygen into the lungs and expels carbon dioxide. When this function is interfered with, a person is said to have a chronic obstructive lung disease (COPD). Causes/Risk Factors    

smoking genetic abnormalities low level infection environmental pollutants  allergies

Symptoms  progressive shortness-ofbreath  phlegm producing cough  rapid labored breathing  blue tinge to skin  breathing difficulties when lying flat

Consequences  early death  temporary flare ups  respiratory failure, which leads to heart rhythm irregularities

Treatment     

quit smoking medications inhalers oxygen therapy surgery

The two main types of Chronic Obstructive Lung Disease are:  Chronic Bronchitis  Emphysema

Chronic Bronchitis Chronic Bronchitis is an inflammation of the lining of the bronchial tubes, which connect the windpipe with the sacs of the lungs. The inflamed bronchial tubes produce a lot of thickened mucus, which can be discolored. This leads to coughing and difficulty breathing. Cigarette smoking is the most common cause but breathing in air pollution, fumes, or dust over an extended period may also cause it. Chronic Bronchitis differs from Acute Bronchitis, in that it is irreversible and is characterized by frequent reoccurrences. Acute Bronchitis usually begins 3 to 4 days after an upper respiratory infection, with symptoms disappearing after 2 to 3 weeks.

Section 2 Health Problems

Emphysema Emphysema is a disease wherein there is destruction of the lungs’ air sacs (alveoli), which impairs or destroys lung tissue. As a result, airflow, on expiration, is slowed or stopped because over-expanded air sacs do not exchange gases when a person breathes. Thus, air is trapped in the lungs, which affects airflow and blood flow. This not only impacts the ability of the lungs to empty its air sacs but also the ability of blood to flow through the lungs to receive oxygen. The most common symptoms of emphysema are cough and shortness-ofbreath. It is frequently preceded by chronic bronchitis.

Asthma Asthma is an inflammation of the lower airways, which obstructs air flow and makes breathing difficult. Air passages become inflamed, which results in a temporary narrowing of the airways that carry oxygen to the lungs. Symptoms include:  coughing,  wheezing,  shortness-of-breath, and,  chest tightness. If it is severe, asthma can result in decreased activity and inability to talk. Some people with asthma may go for extended periods without having any symptoms but, on occasion, experience worsening of their symptoms (asthma attacks). Others may experience asthma symptoms every day. In addition, some people may only have asthma during exercise, or with viral infections like colds.

Pneumonia Pneumonia is an infection of the lungs with a range of causes and can be a serious and lifethreatening disease. It is normally caused by a variety of microorganisms including bacteria, virus and fungus. The lungs become inflamed, and the tiny air sacs, inside the lungs fill up with fluid. Like the flu, pneumonia can cause serious problems for the Older Adult. Causes/Risk Factors  bacteria  viruses  gender (men are more susceptible)  smoking & secondhand smoke

Symptoms

Consequences

fever chills cough rapid or labored breathing  vomiting

 fluid around the lungs  pus in the plural cavity  low blood sodium

   

Treatment     

antibiotics bed rest plenty of fluids therapeutic coughing breathing exercises

Section 2 Health Problems

Causes/Risk Factors        

heart problems lung problems diabetes, dementia prednisone (medication) alcohol & drug abuse medical conditions age environmental factors

Symptoms  chest pain  sore throat

Consequences  abscess in lung

Treatment  pain relieving medication  fever-reducing medication

How HCAs Can Help Older Adults Avoid Pneumonia HCAs can help Older Adults reduce their chances of coming down with pneumonia by advising them of prevention techniques, which include:      

Don’t smoke or quit smoking. Ask Physician about relevancy of a flu shot every fall. Ask Physician of relevance of pneumonia vaccine. Eat proper diet. Get enough exercise. Obtain enough sleep.

Working Near Oxygen Home Care Assistants are not responsible for administering oxygen. However, there are some things that they should be aware of when working with a client who is on oxygen therapy:  Never smoke or allow others to smoke when oxygen is in use.  Signs should be posted on doors of home to indicate that oxygen is in use.  Keep flammable objects such as cleaning fluids, aerosols and alcohol containing sprays away from oxygen.  Avoid using anything greasy around oxygen equipment.  Do not use any electrical appliance, which has a motor, around oxygen; e.g., electric razor.  If a fire starts, turn the oxygen off immediately.  Keep a fire extinguisher within easy reach.  Keep the oxygen container away from open flames; e.g. fireplaces, candles.  Be alert for oxygen leaking from its container (hissing sound) – open windows to clear out excess oxygen.  Don’t leave oxygen cords lying around in places where somebody can trip over them.  Store oxygen containers in an upright position – don’t let them fall horizontally. 25

Section 2 Health Problems

 Don’t adapt a 2-hole electrical outlet to accommodate a 3-prong plug.  Do not use an extension cord to plug in oxygen.  If area around client’s nose becomes dry and irritated, apply padding or a water-based product; e.g. K Y Jelly. Do not use oil-based products; e.g. petroleum jelly.

Paralysis Paralysis is a complete loss of strength in an affected limb or muscle group. While it can affect a single body part, it usually affects an entire body region. The types of paralysis are classified by the region affected:     

Monoplegia: affects only one limb; Diplegia affects the same body region on both sides (e.g. both arms); Hemiplegia: affects one side of the body; Paraplegia: affects both legs and the trunk; and, Quadriplegia: affects all four limbs and the trunk.

Causes/Risk Factors

       

stroke tumor trauma Multiple Sclerosis Cerebral Palsy metabolic disorder herniated disc Rheumatoid Arthritis

Symptoms/Consequences

 loss of movement in affected parts.  pain  numbness & tingling  speech difficulties  balance problems  vision changes  breathing difficulties  loss of bowel & bladder function  loss of sexual function

Treatment

 treatment of underlying cause  physical therapy to strengthen muscles that still work  use of assistive devices such as canes, braces, wheelchairs  Occupational Therapy to develop tools & techniques to facilitate self-care  depending on the impairment, assistance may be needed; e.g.: • Respiratory Therapist

• Counselor, • Social Worker • Speech Pathologist

Section 2 Health Problems

How HCAs Can Help Older Adults with Paralysis  Provide emotional and psychological support.  Encourage the Older Adult to undergo therapies recommended; e.g. Physical Therapy, Occupational Therapy and Speech Therapy.  Assist with exercises or perform range of motion exercises to maintain muscle function.  Follow bladder and bowel training programs.  Use devices such as pillows and footboards to maintain good body alignment always.  Give good skin care to prevent bed sores.  Turn and position the Older Adult at least every two hours.  Prevent burns by ensuring temperatures are within safe limits.  Prevent falls.

Cancer Cancer is any malignant growth or tumor, which is caused by abnormal and uncontrolled cell division. It may spread to other parts of the body through the lymphatic system or via the blood stream. Many types of cancer are curable, if caught early. Treatment varies depending on the type and classification of cancer a person has. People diagnosed with the disease make the choice whether to undergo treatment. Some choose to let the disease run its course, without medical intervention to prolong life. Other individuals choose all types of treatment available. It is a personal decision and the ill person needs to be supported, regardless of the option he/she chooses. Home Care Assistants need to respect their client’s wishes and not pass judgment on his/her decision. Causes/Risk Factors General risk factors:  food/diet  genetics  hormones  radiation  tobacco  physical activity  weight  workplace exposures  environment

Symptoms/Consequences General Symptoms:  a lump or thickening in the breast or testicles  a change in a wart or mole  a skin sore or a persistent sore throat that doesn't heal  a change in bowel or bladder habits  a persistent cough or coughing blood  constant indigestion  difficulty swallowing  change in bowel or bladder habits  unusual bleeding or vaginal discharge

Treatment  chemotherapy  hormonal therapy  radiation  surgery  pain management  combination of above

Section 2 Health Problems

Causes/Risk Factors

Symptoms/Consequences

Treatment

 chronic fatigue Consequences:  some cancers are fatal  some cancers are curable  some cancers can be put into remission  some cancers are painful

How HCAs Can Interact with Older Adults with Cancer              

Be yourself and don’t worry about whether things are being done right or wrong. Be a good listener; i.e. hear what they are saying. Let the client take the lead in conversations. It is not necessary that interactions always involve conversation. Silence is okay as it allows clients to collect their thoughts. Try to maintain eye contact with the client. Be careful what emotions and body language you project to avoid upsetting the client. Clients are not seeking advice, so don’t offer any. Don’t say you know how the client feels when you really haven’t experienced what he/she is going through. Don’t visit with the client if you lack control over your own emotions. Bring some levity to the conversation; i.e. talk about humorous things and other topics. Don’t dwell on the cancer, unless this is what the client wants to talk about. Try to involve clients in as many activities as they would like to become involved in. Don’t be a human shield for the client. Be empathetic and show concern. They are the best “gifts” you can give to him/her.

Eye & Vision Conditions Vision can be affected at any age. Sight problems may develop suddenly, or they can evolve over a period of years. Two of the more common eye disorders that affect Older Adults are:  Glaucoma: a disease of the eye, which is marked by increased pressure within the eyeball. If it is left untreated, glaucoma can damage the optic nerve and cause loss of vision.  Cataracts: clouding of the lens of the eye(s). Many cataracts are age-related and take years to develop. If left untreated, cataracts will eventually cause blindness.

Section 2 Health Problems

Disorder

Glaucoma

Cataract

Symptoms

Treatment

        

difficulty adjusting to dark rooms difficulty focusing double vision tearing of eyes sensitivity to light or glare sudden loss of vision blurred vision seeing white or black spots seeing a halo around light

 Can be controlled but not cured with:  surgery  medication  eye drops  laser treatments

   

blurry vision double vision sensitivity to light & glare colors appear “dimmer”

 surgical removal of clouded lens followed by implantation of an artificial lens

How HCAs Can Help Older Adults with Vision Problems    

Encourage them to consult with their Physician regarding treatment options. Protect their eyes from ultraviolet light. Avoid smoky environments, as smoke increases the rate of cataract formation. Determine to what degree their vision is impaired by asking them to describe how much they can see.  Help them to learn Braille, if that is their wish.  Become familiar with the techniques for helping the blind. Note: Refer to Section 4 - Communicating with Older Adults

Ear & Hearing Conditions The two primary functions of the ear are hearing and balance. Many people experience some hearing loss, as they age, which ranges from mild to total deafness. Common ear problems that can be found in Older Adults are:  Hearing Loss  Meniere’s Disease

Section 2 Health Problems

Hearing Loss Causes  damage to the nerve fibers in the inner ear  obstruction or infection in the ear canal  perforation of ear drum

Symptoms

Treatment

 difficulty hearing sounds  hearing the wrong words  problems hearing in a group setting  trouble hearing higher-pitched voices  responding inappropriately to questions  turning up volume on tv, radio or stereo  perception that others mumble a lot

 hearing aids are helpful when hearing loss is a result of nerve damage  medical treatment is used for most other types of hearing loss; e.g. surgery, medication

Meniere’s Disease Meniere's disease is a disorder of the inner ear, which affects balance and hearing. It is characterized by dizziness, loss of hearing in one or both ears and ringing in the ear. Causes  Exact cause is unknown, but possibilities include: • middle ear infection • head injury • syphilis • genetic disposition • certain medications

Symptoms  intermittent dizziness  intermittent hearing loss in one ear  intermittent ringing in the ears  intermittent feelings of a “plugged” ear  nausea  vomiting  sweating  uncontrollable eye movements

Treatment  No known cure but treatment is focused on treating the symptoms and lowering the pressure in the middle ear; e.g. medications, surgery, hearing aid

How HCAs Can Help Older Adults with Hearing Problems  Be aware that hearing loss is a debilitating condition and can affect Older Adults’ relationships, social involvement, emotional stability and communication.  Encourage Older Adults to seek medical attention quickly if an ear infection is suspected.  Be aware of Older Adult’s tendency to lose balance and be ready to provide immediate assistance.  Check to ensure the Older Adult has his/her hearing aid turned on. 30

Section 2 Health Problems

 Learn the techniques for communicating with the hearing impaired. Note: Refer to Section 4 - Communicating with Older Adults

Common Health Care Mistakes Made by Older Adults Following are the most common health-care mistakes Older Adults make:          

Don’t ask family and friends for help. Don’t participate in prevention programs. Don’t seek medical help when warning signs occur. Don’t have one primary Physician who oversees the medical treatment plan. Don’t take measures to guard against falls. Don’t understand information provided by their Physician. Don’t have a plan for managing medications. Don’t discuss intimate health problems with their Physician or Health Care Provider. Don’t accept assistive devices, which will help them cope with the aging process. Don’t give up driving when safety becomes an issue.

How HCAs Can Help Older Adults Deal with Health-Care Mistakes Home Care Assistants can encourage Older Adults to change their “Don’t” attitude to “Do” actions. HCAs primary goals are to:  Improve communications between Older Adults and their Physicians.  Help Older Adults gain a better understanding of how the health care system works.  Educate Older Adults what they can do themselves to stay healthy.

Summary Aging brings with it a series of chronic conditions such as arthritis, diabetes, cardiovascular disease, respiratory disease and nervous system disorders. The development of these conditions is a normal process and can inflict many Older Adults. While chronic problems are not usually life-threatening, they do affect lifestyle, functionality and sense of purpose. They bring with them physical, mental and emotional challenges, the likes of which many Older Adults have never faced before. Learning to accept these unwanted realities takes time, patience and understanding.

Section 2 Health Problems

Along with chronic conditions, Older Adults are also susceptible to more serious and lifethreatening diseases, such as cancer, which can be devastating to them and their families. By being supportive and knowledgeable about the causes, symptoms and treatment of these conditions/diseases, Home Care Assistants can help their clients cope and ease into their golden years with as little stress as possible.

Section 3 Confusion & Dementia

SECTION 3: CONFUSION & DEMENTIA Cognitive Powers As people age, changes in the brain cause some decline in short-term memory and a slowing down in learning ability. This section deals with changes in the older person’s brain, which affect their cognitive powers including:     

memory; thinking; reasoning; judgment; and, behavior.

By being knowledgeable about typical cognitive functioning and common neurological conditions that inflict Older Adults, Home Care Assistants can better understand the reasons behind their clients’ thoughts and actions. Knowledge will also give HCAs a better understanding of confusion and dementia and will assist them to recognize the impact these conditions have on Older Adults. It will also help them understand that delirium, dementia and severe memory loss are not part of the normal aging process but are, instead, indicative of degenerative brain disorders, such as Alzheimer’s Disease. Home Care Assistants will also learn that confusion can be attributed to other causes such as infections and fluctuations in glucose levels. This is important, as often people are too easily (and wrongly) categorized as being “senile”.

Nervous System Changes Due to Aging The aging process causes several changes in the nervous system:         

confusion; memory shortfalls; forgetfulness; dizziness; slower reflexes; loss of brain cells; decreased hearing and vision; decreased blood supply to brain; decreased sense of taste and smell; 33

Section 3 Confusion & Dementia

 slower nerve conduction;  slower response and reaction times; and,  reduced sensitivity to pain.

Confusion Confusion is a state of unstable awareness, which results in disrupted thoughts and affects decision making. Often orientation is affected in terms of person, place and time. Confusion is not a diagnosis but rather it is a symptom, which is the reason that assistance or intervention is sought in the first, place. Confusion can be divided into two categories:  Acute Confusion (Delirium)  Chronic Confusion (Dementia)

Acute Confusion (Delirium) Delirium is characterized by:  being temporary;  having a fast onset; and,  displaying a combination of inappropriate behaviors.

Causes  hospitalization  emotional & social disruptions  loss of hearing  loss of sight  diseases  infections  medication reactions  physical conditions such as: • nutrition • cardiovascular conditions • changes in urinary functions • changes in body temperature

Symptoms

Treatment

 disoriented regarding person, place or time  inaccurate perceptions  delusions  poor judgment  forgetfulness  difficulty communicating  angry  withdrawn  uncooperative  restless  hyperactive or lethargic

 control or reverse the cause of the symptoms  make environment pleasant, comfortable & safe  stopping or changing medications  treat physical ailments which are contributing to confusion  provide glasses &/or hearing aids, as required  advise of realities frequently

Section 3 Confusion & Dementia

Chronic Confusion (Dementia) Chronic Confusion (Dementia) is characterized as being:  long-term;  progressive; and,  possibly degenerative. Dementia is a slow, progressive decline in mental function in which memory, thinking, judgment, and the ability to learn are impaired. Dementia is a much more serious decline in mental ability than confusion is. With time, it becomes worse. Older Adults who are aging normally may become forgetful or misplace objects, but those with dementia, may forget entire events. Individuals with dementia have problems conducting regular tasks such as driving, cooking, and handling finances. Dementia progresses at different rates, depending on the cause. Generally, it takes from two to ten years before death occurs, which is often attributed to an infection, such as pneumonia.

Causes            

Alzheimer’s Disease Strokes Parkinson’s Disease Infections such as Aids Drug or Alcohol Abuse Head Injuries Cardiac Arrest Huntington’s Disease Multiple Sclerosis Brain Tumors Syphilis Conditions that worsen dementia are: • diabetes • emphysema • heart failure

Symptoms

Treatment

 forgetfulness  No treatment can restore mental functions.  inability to recognize people places & objects  Sometimes, treating a disorder that is worsening the dementia  difficulty finding & using the right word will slow the progression down.  difficulty working with numbers  fast and severe range in emotions  changes in personality  worriers become more worried  failure to perform routine tasks  withdrawn  less control over behavior  unable to follow conversations  inability to speak  becoming bed-ridden  difficulty swallowing food

How HCAs Can Help Older Adults Who Are Confused    

Do one thing at a time; i.e. have them complete one task before starting another. Keep instructions simple and try to ensure they understand what is required. Explain everything that will happen before it happens, regardless of their state of alertness. Avoid startling them. 35

Section 3 Confusion & Dementia

                 

Pay attention to complaints of hunger, thirst or pain. If they seem agitated, distract him/her by asking a question. If they resist care, don’t continue trying to provide that care. Protect them from injury and other problems. Communicate effectively with them. Be relaxed in your interactions. Support their family. Ensure they have privacy. Remind them of special occasions and events. Tell them what the day and date is. Encourage them to wear glasses and hearing aids, if needed. Discuss current events with them. Maintain a calm, safe and peaceful environment. Keep their routine consistent. Encourage them to help in self-care. Mark reminders on a calendar. Provide stimuli such as newspapers, TV and radio. Read to them.

Alzheimer’s Disease Alzheimer’s Disease is the commonest form of dementia. It is a progressive and relentless loss of mental function revolving around memory, language and thought. Causes The cause is not known but theories are:  chemical deficiencies  genetic factors  body attacks its own immunity system  virus  defective blood vessels in the brain

Symptoms  problems remembering conversations  forgetting where objects have been placed  routine tasks, which require thought, become more difficult  difficulty responding to simple problems  becoming lost in familiar surroundings  difficulty finding the appropriate words  problems paying attention  less responsive

Treatment There is no cure, but it can be managed by:  medications to: • delay the onset • slow the rate of progression • improve memory, language, attention span & orientation  healthy diet  regular exercise  intellectual stimulation  social interactions  stimulating environment  support groups

Section 3 Confusion & Dementia

Stages of Alzheimer’s Disease Alzheimer’s Disease has three stages. Signs and symptoms become more severe with each stage and eventually death occurs. Stage 1 Individuals in Stage 1 can generally manage their daily activities themselves, but they may require some assistance with organization. Traits common to Stage 1 include:          

loss of memory; problems finding the right words; problems exercising good judgment; problems making good decisions; becoming lost in familiar places; problems carrying out multi-task activities; feeling sad, depressed, & anxious; avoiding social interactions; problems remembering appointments, names or recent events; and. misplacing items.

Stage 2 Individuals in Stage 2 may have more problems taking care of themselves, but they can still be involved in their daily care and follow a routine. Traits common to Stage 2 include:         

some assistance is needed with activities of daily-living; becoming restless, especially during the evening hours; loss of memory increases – they may not know family or friends; failure to recognize dangers and differentiate between hot and cold; becoming angry or easily upset; need to be reminded to eat; having trouble expressing self and understanding others; some bowel and bladder incontinence; and, loss of impulse control; e.g. uses foul language, poor table manners, sexually aggressive.

Stage 3 Individuals in Stage 3 usually require complete assistance with daily care. Traits common to Stage 3 include:  unable to communicate – may grunt or scream;

Section 3 Confusion & Dementia

        

does not recognize self or family members; touching or patting things continuously; sleeping more often; disoriented to person, place and time; cannot sit or walk – becomes confined to bed; total bowel and urinary incontinence; unable to swallow; may have seizures; coma; and,  death.

Behavioral Patterns in Persons with Alzheimer’s Disease Behavior Recurring Behaviors Abnormal Sexual Behavior Screaming Aggression

Agitation

Disastrous Responses

Delusions

Hallucinations

Description Recurring behavior is doing the same act over and over; e.g. folding a towel. Sexual behavior may involve the wrong person, at the wrong time, in the wrong place. Or, it may involve an inappropriate action; e.g. exposing themselves or masturbating in front of others. Screaming occurs to communicate. It can involve screaming a name, a word or simply making yelling sounds. Aggression & combativeness often occur because of restlessness or agitation; e.g. hitting, punching, biting. An agitated individual may walk back & forth, hit or yell. Disastrous responses are extreme responses, with the individual reacting as if a major disaster has occurred. Delusions area false beliefs, even when facts say differently; e.g. a person may think he/she is going to be murdered.

A hallucination is hearing, seeing smelling or feeling things that are not there; e.g. individuals may think snakes are in bed with them.

How to Handle the Behavior  Allow the individual to continue the repetitive behavior.  Take individual for walk.  Encourage affection with individual’s sexual partner.  When masturbating, lead individual to a secluded area.  Provide a calm & quiet environment.  Determine if there are vision or hearing problems.  Do not argue with the individual.  Remain calm & collected.  Protect yourself.  Determine why the individual is agitate; (e.g. Hungry? In pain? Insufficient sleep?  Maintain a calm & quiet environment.  Avoid having too many stimuli present at one time. (e.g. Asking questions when the tv is on.)  Maintain a calm & quiet environment  Reassure individuals that you will protect them & they are safe.  Use touch to cam them.  Distract the individual with some type of activity.  Reassure individuals that you will protect them from harm.  Don’t argue with them, as they do not understand what you are saying.

Section 3 Confusion & Dementia

Behavior

Sun downing

Wandering

Description Sun downing is the appearance of confusion, agitation, and other severely disruptive behavior coupled with inability to remain asleep. It occurs in the late afternoon & evening hours.

Since Alzheimer’s Disease causes the individual to be disoriented in respect to person, place or time, they may become lost or use poor judgment, which compromises their safety.

How to Handle the Behavior  Make sure their basic needs are looked after; e.g. hunger, toileting, warmth.  Provide a clam setting at the end of the day.  Keep a light on, as many individuals with Alzheimer’s Disease may be afraid of the dark.  Ensure individuals are not able to wander away by securing safety locks at tops or bottoms of doors & windows.  Keep their environment free from hazards.

How HCAs Can Assist Older Adults with Alzheimer’s Disease & Other Dementias  Create a supportive environment by: • providing extra security measures such as posting notes to serve as reminders; e.g. turn stove off; • keeping the environment familiar; e.g. don’t move furniture around; • establishing and maintaining a regular daily routine; and, • keeping the client oriented; e.g. clock, calendar, radio, night light.  Evaluate home for safety and take corrective actions by: • removing scatter rugs; • storing household cleaners and harmful substances in a safe place; • removing sharp & breakable objects from the environment; and, • using plastic eating and drinking utensils.  Provide structure and routine.  Schedule low stress activities.  Speak slowly and clearly to facilitate their understanding of what is being said.  Provide simple explanations on everything said.  Research community resources, which will benefit the client.  Encourage them to share their memories, if they can recall them.  Plan physical activities, as they will offset disruptive behavior.  Encourage mental activities; e.g. reading, crafts, keeping abreast with current events.  Provide their basic needs.

Section 3 Confusion & Dementia

Summary As people grow older, changes in the brain cause some decline in short-term memory and a slowing down in learning ability. There is a general decrease in cognitive powers, which affect the individual’s memory, thinking, reasoning, judgment and behavior. These changes, which occur throughout the nervous system, often cause a person to become confused. There are two main types of confusion -- acute confusion, also known as “delirium”, and chronic confusion, also known as “dementia”. They each have distinct characteristics which affect cognitive abilities and behavioral patterns. The most common type of dementia is “Alzheimer’s Disease”, for which there is no cure. It is a progressive disease and has three main stages. While it can’t be cured, it can be managed. There are several measures Home Care Assistants can apply to support Older Adults with Alzheimer’s Disease or other dementias, including maintaining a safe and calm environment, making the Older Adult feel secure and providing ongoing and increasing support with their activities of daily living.

Section 4 Communication

SECTION 4: COMMUNICATION Communication Communication is the process of sharing information, thoughts and feelings between people through speaking, writing or body language. To be effective, communication methods should ensure that the message being delivered is received and understood by the recipient. There are two main categories of communications:  verbal communication  nonverbal communication

Verbal Communication Verbal communication is comprised of any form of communication involving words, spoken, written or signed, although it is more commonly known as the “oral” or “spoken” word. Communication is used to advise others of our needs, to impart knowledge, to clarify confusion and to provide missing information. It can also be used as a means of persuasion, an opportunity for debate, a method to stimulate thought and creativity, and a channel to deepen and create new relationships. How HCAs Can Communicate Verbally with Older Adults  Use open ended questions to obtain information; e.g. questions that requires more than a “yes” or “no” answer.  Avoid using professional or complicated language.  Speak at the appropriate level of vocabulary and understanding of the person to whom you are speaking.  Make sure the person being spoken to understands what has been said.  Summarize information they receive to reiterate facts and to ensure the message was received as intended.  If the message was not understood as intended, rephrase it, as opposed to speaking louder or repeating the same word.

Non-Verbal Communication Non-verbal communication includes body language, such as gestures, facial expressions, eye contact, postural stance and vocal inflections. It can be used to strengthen, contradict,

Section 4 Communication

substitute, complement or emphasize verbal communication. Touching (providing it is accepted) communicates feelings, comfort level and personality. How HCAs Can Communicate Non-Verbally with Older Adults  Avoid creating physical barriers when communicating; e.g. sitting on opposite sides of a desk.  Pay attention to the person with whom you are speaking.  Show interest in what is being said.  Maintain eye contact.  Use “touch”, when appropriate.  Remain seated until the conversation is completed.  Avoid fiddling or doodling.  Be alert for non-verbal hints, which may support or be against what is being said.  Show the person how to do something, as opposed to telling him/her.  Use writings or pictures, instead of talking, to promote comprehension and understanding of what is being communicated. Try to get the message through on the “first take” to avoid having to repeat it.

Effective Communication The goals of effective communication include creating a common perception, changing behaviors and acquiring information. It is important that participants know what is expected of them, that the appropriate person receives the correct information and there is coordination amongst the participants. However, effective communication is more than an exchange of information, as it also involves understanding the intentions and emotions behind the information. Effective Communication requires careful listening to ensure the full meaning is grasped and the other party feels heard and understood. Since effective communication is especially important when working with Older Adults, Home Care Assistants require more than just social skills to efficiently perform their duties. Communication is also necessary for clinical judgments and interventions. When effective communication is not utilized, inappropriate care and/or increased levels of anxiety can negatively affect the Older Adult’s health. Therefore, Older Adults need to be allowed and encouraged to exchange information; i.e. they must not become an information receptacle but should also be able to respond and express their own thoughts and feelings.

Section 4 Communication

How HCAs Can Apply Communication Skills The purpose of communication is not simply to convey a message, but it is also a way to determine if the message is understood. Therefore, it is essential that Home Care Assistants have effective communication skills, including:        

Be able to understand gestures, words and behavior. Be able to recognize verbal and non-verbal messages. Be a good listener. Allow enough time for interactions to occur. Let another person interject. Provide suitable replies. Managing stress in the moment. Be assertive in a respectful way.

How HCAs Can Listen Effectively to Older Adults Listening is probably the most important part of communicating and should be utilized extensively by Home Care Assistants. Following are some tips on how HCAs can be effective listeners when interacting with Older Adults:

 Recognize that listening is very effective as a first response when dealing with Older Adults who are angry or upset.  Be alert for defensive feelings, which can present as aggression or anger. They are counterproductive to effective communications.  Reflect what the Older Adult has stated in respect to facts, thoughts, beliefs, feelings, wants, and expectations.  Use your own words when paraphrasing what the Older Adult has said; i.e. as opposed to repeating the same words the Older Adult used.  Look for the intent and feelings of the words, as well as their meanings.  Ensure the Older Adult is looking for a response before prematurely giving one.  Use eye contact and avoid looking at others or items in the area.  Avoid distractions; e.g. telephone.  Avoid crossing your arms or appearing critical.  Show interest by nodding your head and leaning forward.  If you don’t understand what is being said, get clarification.  Be empathetic and non-judgmental.  Be accepting and respectful of the Older Adult without compromising your values.  Recognize when to stop listening and start talking.

Section 4 Communication

Barriers to Effective Communication Lack of proper communication can be one of the biggest obstacles when working with Older Adults, as it can be frustrating for both the Older Adult and the Home Care Assistant. Some of the more common causes of communication difficulties are:      

hearing loss; vision difficulties; neurological or physical condition; medication; inability to express thoughts clearly; and, language barriers.

How HCAs Can Recognize Communication Barriers Home Care Assistants need to recognize the barriers to effective communication; e.g.:  Use of words or language that are not understood by both parties.  Misinterpretations in cross-cultural situations, especially in respect to time, space and privacy.  Assumption that both parties do not see the situation the same way.  Misjudged body language, tone and non-verbal forms of communication.  Exposure to noisy transmissions, which make messages unreliable and inconsistent.  Frequent or sudden changes to the subject at hand.  Statement of opinion, which suggests the other is being judged.  Excessive talking by one party. The other party doesn’t have a chance to “get a word in”.  Failure to hear what is being said.  Responses using standard answers, which suggests to one party that he/she is being ridiculed by the other.  Defensive attitudes, which comes across as anger or aggression and sets up communication blocks.  Stereotypical labeling individuals without supporting facts.  Afflictions, which affect body movement and ability to speak.

Channels for Communicating with Older Adults There are several communication channels available that can help HCAs connect with Older Adults. The key is to find the most effective, convenient and appropriate modes for an individual’s situation and preferences. The following outlines some of the advantages and disadvantages of different communication channels.

Section 4 Communication

Communication Channel Personal

Telephone

Meetings/ Gatherings

Radio

Videotape

Forms

Signage

Advantages

Disadvantages

 is beneficial for communicating with Older Adults who have low literacy levels  can be more effective than formal techniques  readily accessible  ideal way to keep in touch with friends & family  generally, is easy to operate

 due to the limited numbers of face-toface communicators, some Older Adults may not receive any information

 enables Older Adults to absorb information at their own rate

 practical way of exchanging information  allows for oral exchange of information  provides a social setting  provides a chance to confirm the information taken in  has a large, viewing audience  can be entertaining  can provide “captioned” messages to assist Older Adults with hearing impairments  is effective for Older Adults with vision impairment

 may be difficult for Older Adults with hearing impairment  may not be able to speak to a real person  automated answering systems can be frustrating & complicated  may pose difficulties for Older Adults who: • have vision impairment • have literacy problems (reading) • are not familiar with the language  cannot always hear well enough in a group setting  may not come forward with thoughts & feelings

 does not enable viewers to set the rate at which information is received  may present problems for people who cannot absorb information quickly or who have limited retention abilities  broadcasts must be carefully tailored to suit Older Adults; e.g.: • suitable pitch of voice tones • appropriate rate of delivery • absence of background sounds  use of graphics & action sequences  does not enable viewers to set the rate enable Older Adults to be shown the at which information is received message instead of being told the  may present problems for people who message cannot absorb information quickly or who have limited retention abilities  enable a lot of specific information  must be designed carefully to capture to be gathered at one time & in one essential information location  Older Adults often require assistance with completing information  can capture attention quickly  Older Adults with low or declining vision may have problems with: • reading the material 45

Section 4 Communication

Communication Channel

Public Address Systems

Advantages

 can reach many people at one time  is convenient & easily setup

 are convenient Automated  are readily accessible Systems; e.g. Bank Machines

Internet

 can reach a large segment of the Older Adult population  encourages Older Adults to take computer courses to be able to “surf the net”

Disadvantages • certain color combinations  Older Adults often have difficulty hearing the message because of: • background noise • interference • speed of message delivery • pitch of announcer’s voice  Older Adults undergo changes in their functioning levels, which may affect their ability to physically & mentally use the systems  Older Adults find automation very impersonal & usually prefer face-to-face interactions  intricate web design & presentation may present challenges (web sites should be made “Older Adult friendly”).

Example: Applying Effective Communication Techniques There are also several techniques Home Care Assistants apply, which will facilitate effective communication. Examples are illustrated here, as conversations between the Home Care Assistant (HCA) and an Older Adult:  Be an effective listener. Communication is a “two-way” street. Participants need to express their thoughts and feeling and to hear what the other is saying. Listening shows caring and respect.   Ask direct questions to solicit specific information. They can either be “yes” or “no” answers or short responses; e.g.: HCA: “Do you have a Physician’s appointment tomorrow?” Older Adult: “Yes” HCA: “Where is your Physician’s office?” Older Adult: “It’s in the Mall on Main Street” Ask open-ended questions. They require more than a “yes” or “no” answer and are often used to solicit thoughts, feelings or ideas; e.g.: HCA: “Tell me about your deceased spouse.” 46

Section 4 Communication

Older Adult:

(To answer this question, the Older Adult needs to provide details.)

 Clarify the information to make sure you understand what is being communicated. Often it is accomplished by asking them to repeat what they stated; e.g.: HCA: “I’m not sure what you mean. Could you repeat that please?” Or, HCA: “Are you saying that you have chest pain?”  Paraphrase to repeat in your own words what you have heard for purposes of encouraging further communication; e.g.: Older Adult: “My son said he is coming to see me today. I wonder what is wrong.” HCA: “You don’t know why he is coming to see you?”  Focusing can be helpful to keep attention on a certain subject. It is useful when an Older Adult’s thoughts roam elsewhere; e.g.: HCA needs to know why the Older Adult didn’t sleep last night but the Older Adult just talks about other times in his life when he didn’t sleep. The HCA attempts to direct the Older Adult back to last night by saying: “Tell me why you had trouble sleeping last night.”  Silence can be a potent means of communicating with an Older Adult as it: • gives the Older Adult time to organize his/her thoughts; • gives the Older Adult time to gain control over his/her emotions; and, • shows the Older Adult you care; e.g.: Older Adult: Is very quiet and a tear slides down his face. HCA: Leans over and takes Older Adult’s hand, saying nothing verbally.

Communicating with Older Adults with an Impairment Communicating with mentally or physically impaired Older Adults can be exasperating and complex but is a task that most Home Care Assistants will face. When dealing with impaired Older Adults, it is important to:  listen carefully;  speak clearly and slowly; and,  use body language to help deliver the message. Depending on the type of impairment, communications can be designed to suit the existing disability. Various techniques can be used to communicate with individuals who have disabilities such as: 47

Section 4 Communication

   

visual impairment; hearing impairment; speech impairment; aphasia (Aphasia results in the loss of power to partially or completely understand words and is usually the result of brain damage.) And,  dementia.

Communicating with Older Adults Who are Visually Impaired Poor vision and blindness can be caused by eye diseases, congenital abnormalities, accidents and some diseases such as diabetes. Older Adults often have vision problems and depending on the degree of vision loss, it can have a major impact on their daily lives.  How HCAs Can Communicate with Older Adults with Visual Impairment            

Ask the Older Adult how much they can see. Ask the Older Adult how much lighting they want. Utilize whatever vision they do have. Ask the Older Adult how you can be of assistance. When walking: Offer your arm for guidance. Walk slightly ahead. Alert Older Adult when approaching steps or stairways. Give specific directions such as “right” or “left”. Walk at a normal pace. Don’t speak loudly unless the Older Adult has hearing problems. When entering a room with the Older Adult, describe the layout, who else is in the room and explain what is going on.  If leaving an Older Adult alone in a room: • tell them they are alone; and, • don’t leave them in the middle of a room.  Don’t leave doors partially opened or closed.  Don’t change the furniture around.  State the Older Adult’s name before touching him/her.  When speaking to a Third-Party, tell the Older Adult who you are talking to.  Keep environment safe and free from clutter.  Tell them where food and beverages are positioned by equating their location to the times on a clock.

Section 4 Communication

Communicating with Older Adults with a Hearing Impaired Hearing impairments can range from mild loss of hearing to total deafness. Older Adults who are experiencing hearing difficulties often:      

speak loudly; lean forward to hear; turn in the direction of the sound; “cups” his/her ear; answer questions or responds inappropriately; and frequently ask for things to be repeated or frequently says “pardon”.

How HCAs Can Communicate with Older Adults with Hearing Impairment Many Older Adults wear hearing aids to facilitate hearing. For some, that is all the help that is required. For others, additional assistance is required:               

Ensure they are wearing their hearing aids and that the batteries are turned on. Alert them of your presence by raising a hand or touching them. Wait until you are directly in front of them before speaking. Position yourself on the same level as they are when speaking. Keep your hands away from your face while talking. Keep items out of your mouth while talking; e.g. Gum, food. Speak clearly, distinctly and slowly. Use short sentences and simple words. Rephrase words they have difficulty understanding. Speak to the better ear. Reduce background noise. Speak in a normal tone, without shouting. Write notes, as required. Use body language to convey messages, and, Allow sufficient time to converse.

Communicating with Older Adults with Aphasia Aphasia is a complete or partial loss of the ability to understand words. It often results from brain damage or a stroke. How HCAs Can Communicate with Older Adults with Aphasia  Allow lots of time to communicate.  Be patient. 49

Section 4 Communication

    

Be honest – if you can’t understand them, admit it. Ask them what the best way to communicate with them is. Allow them time to get their words out – don’t try to guess what they are trying to say. Suggest they write down what they are trying to say and then try to read it to you. Use body language and gestures to try to interpret what they are saying and to get your point across.  Use pictures to offer suggestions – they merely point to the picture, which indicates what they want.  Use touch generously to: • help them concentrate; • establish another communication channel; and, • offer support and comfort. \

Communicating with Older Adults with Dementia As discussed in Section 3, dementia is “a slow, progressive decline in mental function, wherein memory, thinking, judgment, and the ability to learn are impaired”. The most common type of dementia is Alzheimer’s Disease. How HCAs Can Communicate with Older Adults with Dementia Older Adults, who have dementia, are especially challenging to communicate with, but there are actions that Home Care Assistants can take:             

Create an environment with little stimulation. Meet them head on to avoid surprises. Speak to them face-to-face. Don’t move arms and hands around unnecessarily. Keep eye contact and smile – avoid frowning. Stand/sit one to one-and-a-half feet away from them -- respect their personal space. Walk with those who pace back and forth -- talk to them as you walk. Use distractions when required. Ask only one question at a time. Repeat words they have difficulty understanding. Move your head in agreement only if what they say is understood. Speak to them in a normal tone and volume of voice. Use a low-pitched, slow speaking voice.

Section 4 Communication

Care Team The Care Team is a group of people working together to meet the care needs of an individual. The Care Team is usually comprised of representatives from a variety of disciplines, backgrounds and professions. Collectively, they can provide more effective care than they can working individually. Each member of the Care Team is expected to contribute and cooperate with other team members. HCA Responsibilities to Care Team                

Attempt to identify what is happening when there is a problem. Try to solve problems. Summarize what is happening. Offer opinions and information. Suggest directions or actions that might be taken. Try to get the Care Team working. Listen actively. Give positive feedback to other members of the Care Team. Provide relevant input. Keep focused on the task at hand. Help to relieve tension. Be willing to compromise. Try to observe what is happening in the Care Team. Take responsibility for ensuring tasks are completed. Try to make Team meetings an enjoyable time. Free schedule for meeting times.

Communicating with the Care Team Home Care Assistants are an integral member of the Care Team. One of their primary responsibilities is to communicate accurate, timely and relevant information about the individuals they care for. Sharing information is carried out via verbal reports and written documentation. Note: Refer to Section 13 - Observing, Reporting & Documenting

Summary Communication is the core activity of interactions amongst individuals. Its functions are to ensure that players know what is expected of them, to ensure that the appropriate person receives the correct information and to ensure there is coordination amongst the players. 51

Section 4 Communication

Older Adults make up the largest percentage of clients that Home Care Assistants serve. Due primarily to the aging process, they come with a myriad of impairments that present communication challenges. There are various techniques that HCAs can use to communicate effectively, which will enhance Older Adults’ qualify of life. Effective communications will also create a happier and healthy environment for both Older Adults and Home Care Assistants. Consistent, accurate and timely communication is essential amongst members of the Care Team to provide coordinated and effective support. Reporting involves the usage of oral statements and written documentation, which become part of clients’ records.

Section 5 Disabilities

SECTION 5: DISABILITIES Meaning of Disability The World Health Organization defines a disability as “any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being”. This label made it easy for disabled people to be stereotyped as people who are ill, powerless and dependent on others. To counteract this connotation, Disabled People International redefined the term to mean “the loss or limitation of opportunities that prevents people, who have impairments, from taking part in the mainstream life of the community on any equal level with others due to physical and social barriers”. It is important to people with disabilities that they are viewed as having an “impairment”, instead of being labelled “disabled”. They want emphasis placed on what they can do, as opposed to what they cannot do. Home Care Assistants need to be aware that people with disabilities prefer the Disabled People International’s definition, as it will make care and interactions between them and their clients flow more smoothly. Home Care Assistants also need to be aware that disabled clients want to be acknowledged for who they are as opposed to what condition they have. This section will familiarize the Home Care Assistant with the more common types of disability and will provide guidelines on how to interact with people who have them.

Disability Categories The main categories of disability are:     

Physical Disability Psychiatric Disability/Mental Illness Intellectual/Learning Disability Neurological Disability Sensory Disability

Section 5 Disabilities

Physical Disability Physical disabilities can be caused by birth defects, injuries or illness. They can be temporary conditions or long-term conditions. Usually, they result in a loss of one or more functions and may or may not cause people with disabilities to be dependent on others to meet their basic needs. When help is needed, often it is the Home Care Assistant who provides it. Consequently, Home Care Assistants should be familiar with the more common forms of physical disability:

Physical Disability Amputation Blindness Cerebral Palsy

Communicative Disorder Congenital Disability Cystic Fibrosis Deafness Epilepsy Dystrophy Hemiplegia Paraplegia Quadriplegia Spasticity Polio (Infantile Paralysis)

Description A part of the body is missing because of injury or surgery; e.g. arm, leg, hand There is total loss of vision. This term refers to many conditions which were caused by damage to the nervous system, which frequently occurs because of trauma at birth. Note: Do not assume that because there is physical damage, there will also be mental damage. This term refers to several conditions, which result in speech, hearing and learning disabilities. They impact on a person’s ability to communicate. This refers to a disability that existed at birth. This is an inherited disease, which primarily affects the gastrointestinal and pulmonary systems and resembles Chronic Obstructive Lung Disease. This refers to total loss of hearing. This term refers to any number of disorders that are caused by disturbances in the electrical rhythms of the central nervous system. They result in seizures (involuntary muscle spasms). This disease refers to several diseases, which cause a weakness and degeneration of the muscles that control movement; e.g. Muscular Dystrophy. This is a partial or total paralysis of one side of the body, which is caused by brain damage because of disease, trauma or stroke. This is a partial or total paralysis of the lower part of the body, which causes a loss of the function in both legs. This is a paralysis of the body, which results in total or partial loss of function in both arms and both legs This refers to the sudden and involuntary spasms of the abdominal muscles. Polio is caused by a virus which enters the nerves of the brain & spinal cord causing them to stop working normally. This results in the affected nerves not functioning, which can cause muscles in the arms, legs, chest, diaphragm & throat to become weak or paralyzed.

Section 5 Disabilities

Psychiatric Disability/Mental Illness Psychiatric Disability is a term used when mental illness significantly interferes with the performance of major life activities such as learning, thinking, communicating and sleeping. It can develop at any age. The type, intensity and duration of symptoms vary from person to person and do not always follow a regular pattern. While symptoms can be controlled effectively with medication and/or psychotherapy or may even go into remission, some people still have reoccurrences which require treatment. Consequently, varying degrees of support will be required, depending on the individual. Home Care Assistants may be required to provide some of the support needed. Mental Illness can involve a broad range of mental and emotional conditions. The most common forms of mental illness are:

Anxiety Disorders Anxiety Disorder is a term used to describe a variety of disorders which are characterized by severe fear or anxiety associated with objects and situations; e.g.:  Post-Traumatic Stress Disorder: occurs after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.  Obsessive Compulsive Disorder: is characterized by obsessive thoughts and compulsive actions, such as cleaning, checking, counting or hoarding.

Depressive Disorders Depressive Disorder is a term used to describe a variety of disorders in which there are intense feelings of loss, sadness, hopelessness, failure and rejection; e.g.:  Major Depression (Clinical Depression): is characterized by an inability to concentrate, lack of sleep, loss of appetite, feelings of extreme sadness, guilt, helplessness and hopelessness, inability to experience pleasure and thoughts of death.  Seasonal Affective Disorder: occurs usually during the late fall and winter when there are decreasing amounts of light and colder temperatures.

Schizophrenia Schizophrenia is s a disorder usually characterized by:  withdrawal from reality; 4

Section 5 Disabilities

 illogical patterns of thinking;  delusions; and,  hallucinations. It is accompanied by other emotional, behavioral, or intellectual disturbances.

Bipolar Disorder Bipolar Disorder (formerly called Manic Depression) is a mental disorder marked by:  alternating episodes of intense enthusiasm, interest or desire; and,  episodes of extreme sadness, hopelessness, failure or rejection.

Intellectual/Learning Disability Intellectual (Learning) Disabilities are disabilities characterized by cognitive (thinking), emotional, or physical impairments, which result in a reduced capacity to learn tasks or process information. They usually appear in infancy or childhood and result in a failure or delay to progress through the normal developmental stages of childhood. These disabilities may be caused by:  physical damage;  lead poisoning; or,  medical conditions such as: • brain inflammation; • metabolic disorders; • brain tumors; or, • difficulties experienced during pregnancy; e.g. German Measles.

Neurological Disability Neurological disorders are diseases of the brain, spine and the nerves that connect them. They can cause loss of some physical and/or mental function, which may affect a person’s ability to move, to manipulate things, to express their feelings or to manage their behavior. Examples of Neurological Disability include:  Brain Tumors  Epilepsy  Parkinson's Disease 5

Section 5 Disabilities

 Stroke  Dementia (certain types) Disabilities, resulting from brain injuries, are the most widely known of the neurological disabilities. They are caused by injuries to the head or to the brain; e.g. car accidents. Affects to the body depend on what part of the brain was damaged. Therefore, individual responses vary considerably. Note: It is seldom true that people with brain injuries also have intellectual disability.

Sensory Disability A Sensory Disability is a disability of the senses; e.g. sight, hearing, smell, touch, taste. As 95% of the information about the world comes from our sight and hearing, a sensory disability can affect how a person gathers information from the world around them. Examples include:  Low Vision/ Blindness  Hearing Loss  Sensory Processing Disorder

Acquired & Developmental Disability Acquired Disability An Acquired Disability is a physical, mental or emotional disability that a person develops at some point after birth. It is often caused by an accident, incident or illness, including:        

Paralysis Chronic Pain Mental Illness Alzheimer’s Disease & other dementias Loss of limb Loss of sight Mobility difficulty caused by an illness such as Parkinson's Disease and Arthritis. Permanent Neurological Condition resulting from a severe reaction to a medicine, illness or accident.

Section 5 Disabilities

Developmental Disability Developmental Disabilities are physical or mental disabilities that a person is either born with or becomes evident before the age of 22 and are often chronic conditions. These disabilities can be inherited, be the result of trauma or be caused by illness. Examples include:      

Autism Spectrum Disorder Cerebral Palsy Intellectual Disability/Mental Retardation Vision Impairment Hearing loss Epilepsy

Functional Limitations of Disability Acquired and Development Disability can cause functional limitations in one or more of the following:       

self-care; receiving and conveying language; learning; mobility; self-direction; independent living; and, handling financial affairs.

Etiquette Courtesies Etiquette refers to the rules of social behavior and good manners. While most people are familiar with the guidelines for general etiquette practices, many do not know what etiquettes and courtesies are recommended for interacting with individuals who have disabilities. It is important that Home Care Assistants not only know what these common courtesies are but, more importantly, know how to apply them. How HCAs Can Use Proper Etiquette with Older Adults with Disabilities  Don’t assume that an impairment doesn’t exist just because it is not visible.  Treat them in the same manner you would treat any other individual.

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 Don’t reference them as a third person. Speak to them directly instead of asking someone else a question that should be directed to them; e.g. does he want his sweater on?  Don’t use behavior patterns that you would use for a child; e.g. don’t pat them on the head, as if to say: “good boy”.  Don’t make assumptions that they can or can’t do something. Find out from them what they can do. (You may be surprised.)  Ask them if they need help instead of jumping right in to provide it.  When assisting them, let them tell you how they would like you to help. (They usually know best.)  When speaking to them, face them directly and make eye contact.  Shake their hand, even if it is an artificial limb. (Let the person with the disability decide on the type and strength of handshake.)  When speech impediments exist, let them know if you don’t understand what is being said or offer them paper to write on. How HCAs Can Practice Proper Etiquette with Older Adults Using Wheelchairs  Either get a chair to sit on or crouch down. (Having to look straight up at you, may cause discomfort in their neck.)  Don’t lean on the wheelchair. (It is part of their body space.)  When arranging a get together away from their home, be sure the chosen location is wheelchair accessible; e.g.: • Suitable restrooms are available. • Convenient parking is available. • There is a ramp for safe access. • Doorways and halls are wide enough to accommodate a wheelchair. • Be aware of structural barriers in restaurants, theatres and open spaces. How HCAs Can Practice Proper Etiquette with Older Adults with Psychiatric Disabilities  Don’t tell anyone that the person has a psychiatric disability unless permission has been given to do so.  When a person mentions their disability, don’t ask them questions about it. Any questions should pertain to how their needs can be accommodated.  Be patient when talking to them, as some become agitated and cannot remain focused.  When they have a companion with them, avoid speaking through the companion; i.e. speak directly to the person with the disability.

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How HCAs Can Practice Proper Etiquette with Older Adults with Learning Disabilities  Use simple language and uncomplicated sentences.  Have them repeat back what has just been said.  If they are having problems assimilating oral or written information, use pictures or other types of physical demonstration.  Be aware that some are very sensitive about the negative attitudes of others.

Appropriate and Inappropriate Word Usage People with disabilities are sensitive to certain words that are often innocently used. The following outlines some words to avoid and provides some suggestions on appropriate substitutions. Inappropriate Words victim

cripple

invalid

Appropriate Words

 person who has (whatever)  person who experienced (whatever)  person with a disability

 patient

 person (most people who have disabilities are not sick)

 sympathy

 person who has a disability caused by (whatever)  no need to label

 confined to wheelchair

 no substitutions (most people with disabilities would prefer to be accepted for their abilities)  uses a wheelchair

normal

afflicted with

Inappropriate Words

 person who has (whatever)

 unfortunate, pitiful, poor, deaf & dumb, mute, deformed, blind as a bat  homebound employment

 No substitutions (words are judgmental & stereotyping)  works at home  telecommunicates

Word Choices The Disability Rights Movement is a global movement to secure equal opportunities and equal rights for all people with disabilities. It is made up of disability activists who champion:

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 accessibility and safety in: • architecture; • transportation and, • physical environment.  equal opportunity for: • independent living; • employment; • education; and, • housing.  freedom from: • discrimination; • abuse neglect; and, • other rights. The Disability Rights Movement advocates that certain words are appropriate and certain words are not appropriate to use when talking or writing about people with disabilities. How HCAs Can Apply Disability Rights Movement Rules for Word Usage  When referring to the disability, put the person first, not their disability. Emphasize people not labels.  Do not refer to the disability unless it is relevant.  Do not focus on the disability.  Use “disability” instead of “handicap”.  Do not portray successful people with disabilities as superhuman, special or heroes.  Do not patronize (act superior towards) or give excessive praise or attention.  Do not sensationalize a disability.  Do not label people as part of a disability group. Do not use generic labels for disability groups such as “the retarded”.  Understand that although a disease may have caused a disability, the disability itself is not a disease and is not contagious.  Do not use “normal” to describe people who do not have disabilities.  Emphasize people’s abilities, not limitations.  Recognize and show people with disabilities as active participants of society. Note: Be sure to put people before the disability; e.g. don’t say “disabled people”. Instead, say: “people with disabilities”.

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Summary There are several types of disabilities with various causes, symptoms and treatments. While they have similar challenges and problems to face, each type of disability also has its own specific implications. Being disabled does not necessarily mean being ill, as many individuals who have disabilities are healthy. It is important to people with disabilities that the emphasis is placed on them, as opposed to on the disability. They want to be acknowledged for their abilities and talents and are sensitive to attitudes and inappropriate word choices that can seem condescending to them. There are established etiquette practices in place for interacting with people who have disabilities, which have been reinforced through human rights movements. It is essential that Home Care Assistants be familiar with the distinct types of disabilities, the challenges faced and the acceptable ways to interact with people who have disabilities. This will enable them to provide the best support they can, thus enhancing the lives of their clients and their own personal satisfaction levels.

Section 6 Terminal Illness

SECTION 6: TERMINAL ILLNESS Terminal Illness Many illnesses can be cured or controlled while others are incurable and considered to be “terminal”. The timeframe from diagnosis to death can be from a few days to a few years. It is hard to predict a more precise time because individuals react differently. Those who have hope and the will to live will usually outlive those who have minimal or no hope at all. Attitude has a definite influence on a terminal person’s longevity. Things that might influence a person’s attitude towards death are experience, culture, religion and age. Generally, the Older Adult doesn’t have as much fear of death as their younger counterparts do. They are more resigned to the fact that death will occur largely by having had more exposure to death and dying. Many have lost family members and friends. Some welcome death as freedom from pain, suffering, and disability. What they often fear, however, is dying alone. This section will help the Home Care Assistant understand the complexities of the dying process and the role Home Care Assistants play when working with the terminally ill.

The Positive Side of Terminal Illness The adage “every cloud has a silver lining” can also be applied to terminal illness because, in addition to the problems, there can be opportunities to take advantage of; e.g.:

Reconciliation with Self As individuals look back on and evaluate their lives, they face their pain and mistakes which, in turn, helps them to understand the totality of life. This reconciliation helps them to realize and accept that this was life.

Reconciliation with Others Relationships long characterized by contention may be restored. While factors may not be agreed upon by those involved, the important thing is that there is forgiveness on both sides. It does not necessarily mean that a perfect relationship will develop but there will be some peace acquired. 12

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The Process of Dying There are five stages in the dying process:     

Denial Anger Bargaining Depression Acceptance

 Denial is the first stage in which dying individuals refuse to believe they are dying. Even when a Physician informs them that nothing can be done, they still feel a mistake has been made. This information can give them time to: • • • •

prepare; take care of business; close doors; and, make amends.

Note: The shock begins to ebb as they face reality.  Anger is the second stage in which individuals feel anger and rage. Suddenly they are not in control of their lives or death. There are no options – they are going to die. Feelings of helplessness develop, then guilt surfaces. They also experience envy towards those who are healthy. The anger is directed at everyone and no one in particular.  Bargaining is the third stage in which dying individuals are now willing to compromise. They are willing to do or not do specific things in exchange for more time, which can be based on an upcoming event or on the belief that their families are dependent on them. Bargaining is usually done privately and on a spiritual level.  Depression is the fourth stage in which dying individuals realize that death is inevitable. They are aware, angry and filled with sorrow. There is mourning over things that were lost and things that will be lost without a future. This is a normal part of the process of preparing to die.  Acceptance is the fifth stage in which dying individuals have worked though the numerous conflicts and feelings that death brings. They succumb to the inevitable, as they grow more tired and weak. They become less emotional and are calm and at peace. They realize the battle is almost over and it's really alright to die. Reaching the acceptance stage does not mean that death is near. 13

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Individuals, who are dying, do not always go through all five stages. Some may never go beyond a certain stage; others may bounce back and forth from stage to stage. Some stay in one stage until death.

Rights of the Dying Person Dying people have the right to:               

keep their individuality; be treated as live human beings; convey their feelings about death and pain; be involved in all decisions about their care; be optimistic; be cared for by optimistic people; be cared for by compassionate, sensitive and well-informed people; expect continuing medical care, regardless of the prognosis; have all questions answered truthfully and completely; seek spirituality; be free from physical pain; understand the stages and process of dying; die in peace and with dignity; not die alone; and, expect that the sanctity of the body will be respected after death.

Care & Legal Considerations Terminally ill people have the right to make choices and decisions about the types and extent of medical care they want to accept or refuse. Therefore, it is wise for them to discuss certain issues with their families while they are still able to do so. That way there is no doubt about their preferences and wishes. Some of the issues that should be addressed are:     

living will; durable power of attorney; “do not resuscitate” orders; hospice care; and, funeral and disposal of remains.

While these issues are primarily between the dying person and the family, Home Care Assistants need to be informed of any current “Do Not Resuscitate” (DNR) orders. If such a DNR order is in place, Home Care Assistants would not provide emergency care such as Cardio Pulmonary 14

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Resuscitation (CPR). A copy of the DNR should be available and given to Emergency Response Personnel.

Living Wills Some people, whether they are terminally ill or not, choose not to be resuscitated in the event of death. Individuals have every right to refuse treatment. To ensure that their wishes are respected, written instructions, known as a living will, are drawn up. A living will states that an individual does not want life prolonged by extraordinary means, if there is no reasonable expectation of recovery. Most states allow living wills, but their laws may vary; e.g. some require the person to be at least 18 years of age and require that new living wills be made up every 5 to 7 years. In addition to having a living will prepared, Physicians and families should know the individual’s wishes.

Durable Power of Attorney With a Durable Power of Attorney (POA), the “power” to make decisions on health care is given to another person (usually a family member, friend or lawyer). When the individual is not able to make decisions about his/her own health care, then the person with the Durable Power of Attorney has the legal right to make the decisions on their behalf. How a Durable POA Differs from a POA If a Power of Attorney (POA) is durable, it remains valid and in effect when an individual becomes incapacitated and unable to make decisions for himself/herself. However, if a Power of Attorney does not explicitly state that the power is durable, it ends when that person becomes incapacitated.

Do Not Resuscitate (DNR) Orders When death is sudden and unexpected, every effort is made to save the individual’s life by giving cardiopulmonary resuscitation (CPR). Some people with a terminal illness do not want to be resuscitated and therefore direct their Physician write a DNR order. Doing so, allows the individual to die in peace and with dignity. If the individual is not mentally capable of making that decision, his/her family can make it on his/her behalf.

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Hospice and Palliative Care Palliative Care Palliative Care is provided to individuals to help individuals with serious illnesses feel the best they can. It prevents or treats symptoms and side effects of disease and treatment. It also treats emotional, social, practical and spiritual issues that are precipitated by serious illness to help improve their quality of life. Palliative Care can be commenced:    

at the time of diagnosis; throughout treatment; during follow-up and, at the end of life.

Palliative care is designed to serve patients throughout their illness particularly, although not exclusively, in acute care hospitals and in ambulatory outpatient settings. Note: An ambulatory outpatient is someone, who is not admitted to hospital but goes to the hospital for treatments.

Hospice Care Hospice Care has been referred to as the "gold standard" of palliative care. It is an organized program for providing medical services, emotional support and spiritual resources for people who are in final states of a serious illness; e.g. cancer or heart failure. It also helps family members manage the practical details and emotional challenges of caring for a dying loved on. The goal of hospice is to keep dying individuals comfortable and improve their quality of life. Hospice services also include support groups and follow-up care for family and friends. Hospice Service are available in:  The terminally ill person’s home;  Hospice Center, and, in some cases: • Nursing Homes • Long-Term Care Facilities • Hospitals

Difference Between Palliative Care and Hospice Care Palliative Care and Hospice Care both provide comfort. However, Palliative Care can begin at the time of diagnosis, and during treatment. On the other hand, Hospice Care begins after treatment of the disease is stopped, when it is obvious an individual is not going to survive the illness.

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Funeral and Disposal of Remains When people are diagnosed with a terminal illness, they should think about what they want done after death in terms of funeral arrangements and disposal of their remains. While some people are organized and have already given the topic some thought, others have refused to look at the fact that one day they will die. It makes it much easier on the families, if dying individuals have made their wishes known. Some people do not want a service, some are against cremation, some do not want their ashes buried – there are several variables. It can be very stressful for all concerned if the dying person has not relayed his/her preferences.

Basic Needs of Older Adults with a Terminal Illness Older Adults, who are dying, have the same physical, emotional, and spiritual needs as everyone else. In addition, they have concerns about pain and distress, losing control over their bodies and being deserted. What they need most of all is to be cared about, not just cared for. Caring for terminally ill Older Adults can be very challenging, as they have a lot to deal with including the physical effects of the disease, medication, psychological and social challenges. They need to be involved as much as possible in making decisions and developing plans. How HCAs Can Help Older Adults with Terminal Illness  Help them to accept that they have a terminal illness; i.e. If they pretend they don’t have the illness, ensure they are not doing anything harmful as a result, such as refusing to take their medication.  Create an environment that encourages and supports sharing feelings; i.e. discuss topics in a calm location, which is favorable for conversations to take place. Let them know you are available and leave the timing of conversations up to them.)  Understand that men and women communicate in different ways and allow for those differences; i.e. women express their feelings more readily than men do.  Be realistic and flexible about what you hope to agree on or communicate about; i.e. let them talk about whatever they want and with whomever they want. If they don’t want to tell the whole story, that is alright. If they are uncomfortable talking with the HCA, encourage them to speak to someone else.  Help them to deal with anxiety and depression. There will be times when Home Care Assistants and terminally ill people disagree. The following suggestions may be helpful in these situations:  Explain your needs openly.  Choose your battles carefully. 17

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 Allow them to make as many decisions as possible.  Support their spiritual concerns.  Help to resolve their unfinished business.

Care Needs of the Older Adult with a Terminal Illness There are four primary areas of care for Older Adults who are dying:    

Physical Psychological Social Spiritual

Physical Needs The process of dying may take only a few minutes, or it may take several weeks. Generally, there is a gradual slowing down of body functions, the body becomes weaker and the level of consciousness decreases. The person is given as much independence as possible. As the person weakens, Home Care Assistants can help to meet basic needs, which will promote physical and psychological comfort. While dying people may totally depend on others for their basic needs and for activities of daily living, it is important to give them as much as independence as possible and enable them to die in peace and dignity. How HCAs Can Help Terminal Older Adults with Physical Care Needs Function

Physical Environment

Body Reaction  maintain pleasant environment to promote calmness & peace

Body Comfort

 body may become uncomfortable for a variety of reasons

Body Positioning

 person may become uncomfortable if not repositioned regularly

Care Required  adequate ventilation  even, comfortable temperature  well lit  pleasant  unnecessary equipment removed  oral hygiene  good skin care  back massages  personal hygiene  ensure good body alignment  turn regularly  use pillows & other support measures

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Function

Speech

Mouth

Nose

Vision

Hearing

Skin

Elimination

Body Reaction

Care Required

 becomes difficult  may be hard to understand  sometimes the person is not able to speak

 don’t ask questions that require long answers  ask questions which can be answered by “yes” or “no”  continue to talk to the person, even if he/she is unable to speak  good oral hygiene is usually sufficient if the person can eat  when not able to good oral hygiene should be given frequently  cleaning of the tubing  lubricant on nose irritation

 mucous can collect in the mouth  person may have trouble swallowing  crusting & irritation of the nostrils usually caused by secretions, oxygen or nasal tubing  vision blurs & gradually fails  may be afraid of the dark  eyes may be half opened  secretions may collect in the corners of the eyes  person turns toward the light

 hearing is one of the last functions to go, often at the time of death  even if unconscious, the person may hear

 explain what is being done  keep the room lit, but avoid bright lights & glare  wipe eyes from inside to outside. If eyes don’t close, it may be necessary to apply an ointment & moistened pads. (Note: HCA to check with Supervisor before applying eye ointments.)  always assume that the dying person can hear, even if unconscious  speak in a normal voice  provide reassurance about the care  offer comforting words  avoid topics that could be upsetting

 body temperature rises  circulation slows down  perspiration increases  skin feels cool & is pale

 give god skin care  ensure regular bathing  prevent pressure sores  change linen and clothing frequently  use light covers as blankets increase warmth & increase restlessness

 person is often incontinent of urine & feces

 Physicians may order enemas & indwelling (left in continuously) catheters. If so, enemas may need to be given and catheter care provided. (Note: HCAs do not insert or remove catheters, they only clean them & ensure there are no kinks in the tubing to block flow of urine.)

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Psychological Needs Older Adults who are dying have negative feelings such as anger, sadness, anxiety and fear. It is important that Home Care Assistants take these emotions seriously, that they not ignore them and that they be aware of them. Such feelings need to be identified, recognized, and communicated. How HCAs Can Help Terminal Older Adults with Psychological Needs     

Be physically present. Be honest. Listen actively. Touch the dying person gently, hold their hand or give hugs. Practice effective communications by: • allowing the dying person to express feelings, worries and concerns; • not being concerned about saying the wrong thing; • not being concerned about finding the right words; • not feeling obligated to talk -- silence is okay and effective.

Social Needs Older Adults who are dying still have a need to remain connected to certain people in their lives such as family and friends. They have concerns about their positions in the family unit and in the community. Common worries they share are who will care for and support their survivors and what will happen to their belongings. Dying people are very individualistic in their preferences regarding socialization. Some may want friends and family around, others prefer to be left alone. Some may want to spare their families unnecessary strife and, therefore, will only express their thoughts and feelings to a “Third-Party” such as Home Care Assistants. It is quite understandable that some HCAs find these situations to be uncomfortable, primarily because they do not know what to do or what to say. There is no “one size fits all”, which can apply to these situations. How HCAs Can Help Terminal Older Adults with Social Needs      

Be available and listen to their needs. Allow them to talk about their social needs and concerns. Allow them to think about their social options. Allow them to suggest how their social needs might be met. Give suggestions on social options, when appropriate. Be an advocate, when social requests are made.

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Spiritual Needs Terminal illness can cause some Older Adults to question their faith and religion. In the wake of physical pain and loss of hope they wonder what the point is. In the chains of loneliness and loss of relationships, they wonder if God has deserted them. They think about the errors of their ways and their inadequacies, which cause them to feel helpless but, ultimately, they do face their mortality. Questions terminal Older Adults may ponder over:    

Has my life made a difference? What is the meaning of life? Have I accomplished my goals? What will happen to me after death?

Terminal Older Adults may bring up spiritual issues. (Spirituality is concerned with or affecting the spirit or soul.) They may ask questions out loud but are not really looking for answers. Instead they are expressing what they are thinking about and are trying to determine the answers to their own questions. Some dying people put a lot of emphasis on their spiritual needs. They may wish to see a priest, rabbi, or minister and/or they may want to participate in religious practices. They may wish to have religious objects nearby; e.g. bible, rosary, statues. How HCAs Can Help with Spiritual Care Needs of Terminal Older Adults         

Provide comfort and stability. Acknowledge and empathize circumstances and fears. Be respectful of religion and customs. Focus attention, thoughts and feelings on the task at hand. Be a good listener and allow discussions, when initiated. Reaffirm that their lives have been meaningful and continue to be meaningful to others. Allow privacy during spiritual moments. Offer connection with spiritual leaders. Be courteous to spiritual leaders.

Challenges that Older Adults with a Terminal Illness Face Few people find being ill to be an easy task and this is especially true for the terminally ill. The illness brings new and frightening trials. Problems that were once in the forefront now take a back seat and problems that were in the back seat can come to the forefront.

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Primary issues or problems experienced during terminal illness:      

Grief Loneliness Anxiety Depression Anger Spiritual Distress

Grief Issues Older Adults with a Terminal Illness Face The most common response to terminal illness is grief, which may cause Older Adults to:  be stunned and try to avoid the pain;  be imbalanced during which physical and emotional reactions are apparent; and,  become adjusted. Grief is a normal and expected reaction to the losses that may occur:       

Independence Control Physical Health Security Immortality Fantasy Loved Ones Life Contentment

Classic physical and emotional reactions that Older Adults with a terminal illness experience:  Physical Reactions: • changes in appetite; • changes in sleep patterns; • shortness-of-breath; • changes in digestive system; and, • fatigue.  Emotional Reactions: • shock; • denial; • sadness; • anger; 22

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• • •

guilt; isolation; and, loss of emotions.

How HCAs Can Help Terminal Older Adults with Grief     

Understand that grief is predictable and normal. Recognize & express the losses that are part of terminal illness. Explore the losses and their meanings. Encourage them to resolve disagreements and relationships. Realize that some conflict and relationships cannot be resolved.  Determine what is possible for the future.

Loneliness Issues Older Adults with a Terminal Illness Face Loneliness seems to go hand in hand with terminal illness. Sometimes it can be physical when there are few people around. Other times, it can be emotional, when people present are unwilling to hear or to help dying individuals express their feelings. Since many people fear dying alone, it is beneficial for them to see and hear others around. How HCAs Can Help Terminal Older Adults with Loneliness     

Be there. Listen with hearts, souls and minds. Be receptive to their flaws and deficiencies without being judgmental. Be consistent with their presence and care. Accept that sometime Older Adults will feel lonely, regardless of who is present.  Realize there is more than what can be seen with the naked eye; i.e. or some, the presence of loved ones who have passed over can be more helpful than the presence of any earthly being.

Anxieties that Older Adults with Terminal Illness Face Anxiety is the most common psychological distress in Older Adults who have a terminal illness. It manifests itself through:       

dismay; fright; apprehension; grumpiness; changes in appetite and eating habits; shortness-of-breath; and, craving alcohol or drugs. 23

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Anxiety can be related to:     

stress and/or treatment of the disease; poorly managed symptoms; disease processes; side effects of drugs; and, other outside causes.

How HCAs Can Help Terminal Older Adults with Anxiety     

Respond to physical symptoms. Increase their/their families control & involvement in decision making & care. Understand the illness, treatment and routines. Explore anxious feelings & underlying issues. Ensure medications are taken as scheduled. (Note: HCAs do not administer medications but can ensure they are taken.)

Depression Issues that People with a Terminal Illness Face Depression is a profound sadness, which may include feelings of helplessness, worthlessness, and suicide. It often is unresponsive to supportive interventions. Terminal illness increases the risk of depression when physical symptoms are not managed effectively. Many Older Adults with terminal illness contemplate suicide. Factors that increase the risk of attempting suicide include:            

advanced illness; pain; disorientation; exhaustion; fatigue; alcoholism; little social support; history of depression; history of other psychological problems; history of attempted suicides; unresolved grief; and, male gender.

When Home Care Assistants suspect that terminally ill Older Adults are considering suicide, ask them directly if they are thinking about committing suicide. This often brings relief to Older Adults, as they usually have mixed feelings about suicide. By being able to talk about their 24

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thoughts, often the problem causing the idea can become manageable. If the suicidal persons admit they are considering suicide, help should be sought; e.g. Physician, suicidal & crisis hotlines). How HCAs Can Help Terminal Older Adults with Depression  Advise or update professionals, such as Physicians and therapists of symptoms.  Ensure they take prescribed medications are taken, as directed. (Note: Home Care Assistants do not administer medications but can ensure they have been taken.)  Manage physical symptoms.  Maintain hygiene, diet and other activities of daily living.  Allow expressions of sadness, guilt, anger and other negative feelings.  Be alert for, and act on, signs of suicidal thoughts.  Ensure goals are reasonable.

Anger Issues that Older Adults with Terminal Illness Face Because anger is a reaction to fear, threat or anxiety, it is quite prominent during terminal illness. It is often directed at family, caregivers and God. It can be displayed through aggressive behavior, fault finding or depression. When anger is consistent, it will drive others away, resulting in isolation problems, which leads to more fear and anxiety. Anger has an important function, as it expresses and alleviates anxiety and fear. An effective way to deal with anger is to address the underlying issues, which could be actions or other emotions. The angry person should be permitted to express feeling of anger and to relay what the root of the anger is. How HCAs Can Help with Anger Issues of Terminal Older Adults  Be aware of the nature and function of anger.  Recognize that some anger is unavoidable in terminal illness.  Determine what the underlying emotions or problems behind anger are; e.g. helplessness, fear & lack of control.  Deal with the underlying emotions & problems.  Be familiar with HCAs’ own responses to anger.

Interacting with Family of Terminally Ill Older Adults The families of terminally ill people have a tough road to walk. Because the reality can be hard and devastating, it may be very difficult to comfort them. In their grief, the family goes through

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stages like the dying person goes through. It is important that Home Care Assistants realize this and do not take anything said or done personally, especially when anger is at the forefront. How HCAs Can Help the Families of Terminal Older Adults  Understand what they are going through.  Treat them with courtesy & respect.  Show genuine feelings to them by being: • compassionate; • available; and, • considerate.  Use touch to show concern.  Respect their right to privacy.  Allow them to participate in the care of their dying family member.  Be supportive.

Signs that Death is Near When working with the terminally ill, Home Care Assistants should be familiar with the signs of approaching death, which can have a rapid onset or develop gradually: As the body dies, the following may be noted:

Sign/Symptom Sensation, Muscle Tone & Movement

Gastrointestinal

Body Temperature

Respiratory System

Occurrence  sensation, muscle tone & movement disappear. It starts in the feet and legs and then spreads to the rest of the body  jaw drops, as the muscles of the mouth relax  mouth may stay open  face has a peaceful expression  peristalsis slows down or quits (Peristalsis is a series of contractions that move food through the digestive tract.)  incontinence occurs  stool may bind-up  nausea  vomiting  temperature increases as circulation slows down  person feels cool or cold  person looks pale  person perspires heavily  pulse is fast, weak & irregular  blood pressure drops  respirations gradually increase in rate and depth and then become shallow and slow

Section 6 Terminal Illness

Pain Signs of Death

 mucous collects in the respiratory tract, which causes the “death rattle” to be heard  pain decreases as the person loses consciousness  some individuals remain conscious until the moment of death  no pulse  no respirations  no blood pressure  pupils of eye are fixed and dilated

Summary Many illnesses can be cured or controlled while others are incurable and are considered “terminal”. The timeframe from diagnosis to death takes from a few days to a few years. It is hard to predict a more precise time because individuals react differently. There are five stages in the dying process but not everyone goes through all the stages or goes through them in any specific order. Dying people are entitled to certain rights, which assure quality care and being treated as human beings. They have defined physical, psychological, social and spiritual needs that must be met. In addition, they have concerns about pain and distress, losing control over their bodies and worries about being abandoned. What they need most is to be cared about, not just to be cared for. Caring for the terminally ill can be very challenging. The job of Home Care Assistants is to involve them as much as possible in making decisions and developing plans, being an effective listener and ensuring their needs are addressed. It is important that Home Care Assistants realize that terminal illness is still life. While it may be short, it is the only life left. Terminal illness also has a positive side in that dying people can seek reconciliation with themselves and with others. It is a normal phase of the life process.

Section 7 Challenging Behavior

SECTION 7: CHALLENGING BEHAVIOR

Not all Older Adults are pleasure to be around. At times, it can be a real challenge to be in the presence of some, even for a minute. Their personalities, actions, behavior and/or dispositions don’t come close to being tolerable, but still we need to interact with them. Tolerance levels can be raised by understanding what they are all about. This section will show the Home Care Assistant how to deal with difficult Older Adults.

Older Adults with Challenging Behaviors. When individuals are labeled “challenging” or “difficult”, it generally means that others have problems interacting with them. Since difficulty is all about unmet needs, the behaviors, which make people hard to get along with, are the result of their needs not being met. Unmet needs can cause some Older Adults to become:  Withdrawn: they retreat and refuse to interact.  Passive: they fail to take any action.  Manipulative: they use devices or dishonest means.  Violent: they conduct a physical act, which is intended to cause damage to themselves, to others or to property.  Intimidating: they bully others to make them do something or not do something.  Critical: they find real or perceived faults in others.  Threatening: they utter intentions of injury or punishment against others.  Angry: they exhibit strong displeasure or antagonism about real or supposed injury on themselves or others.  Uncooperative: they are not willing to work with, or be helpful to, other people.  Passive Aggressive: they get back at people indirectly, as opposed to confronting them head on and can become increasingly more hostile and angry. 72

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 Mistrustful: they become openly suspicious and are unwilling to confide.  Non-empathetic: they are not understanding and sensitive towards the feelings of others in an emotional sense.

Behavioral Patterns of Challenging Older Adults Difficult clients display certain types of behavioral patterns. By being familiar with these patterns, Home Care Assistants can better understand what is up with them, which will help HCAs interact with them more effectively. A difficult client might knowingly or unknowingly:  take the opposite point of view regardless of what the issues or opinions are. Most of these people are not aware that they are doing this or that it affects others.  complain, whine and blame others constantly. These people are playing the victim role, which causes others to react as persecutors.  not let an issue go, even when situations are different. It affects other people by causing them to feel frustrated and drained.  avoid outright disagreements but instead take actions secretly. They have hidden agendas and attempt to sabotage processes and interactions, which affects other people by compromising their trust.  Hold other people hostage through abusive language, threats or emotional outbursts. This affects others because nothing else can go on while this behavior is being displayed.

Identifying and Dealing with Challenging Personality Types Every Older Adult has a personality type. While some are enjoyable, others are not. Certain personality types can make life difficult for people who must interact with them. By learning about the more annoying types of personalities, Home Care Assistants can better understand their clients. One way to deal with challenging personalities is to determine where the individual is coming from and figure out what makes him/her tick. If HCAs take the time to understand their clients’ viewpoints and change their attitudes about them, they will have a more effective and pleasant relationship with them. The following chart identifies some difficult personalities that Home Care Assistants may have to deal with:

Section 7 Challenging Behavior

Personality Type Deceitful

Manipulative

Bully Glory Snatcher

Hot Head

Definition  They use clever and often dishonest methods to deceive others to gain control. They are generally smart, calculating & determined.  They only give half the story & will provide only pieces of information, which will be in their best interest.  They try to threaten others into doing things they would rather not do.  They try to take all the credit when some of it belongs to others.  They have bad tempers and need to  spout off.

How to Deal With them  They are the hardest individuals to get along with. If you can’t avoid them, then protect yourself & fight with politeness, as opposed to playing their games.  Be prepared, so when they start their game, you can counter with the facts.  Challenge them in front of others to defend their suggestions.  Stand up to them and be ready to compromise between what they want and what you are willing to do.  Don’t hesitate to advise of your contributions, either orally or in writing.  Listen to them privately, if possible.  If others are around, don’t confront them; instead, recommend that you talk to them later in private once they have cooled down.

How HCAs Can Interact with Older Adults with Challenging Behaviors Home Care Assistants need to relate effectively with difficult behaviors and personalities to better understand why individuals act as they do and to promote a peaceful environment. There are several approaches HCAs can use:  Don’t make the difficulty a personal issue; i.e. try not to hold their behavior against them but instead try to understand where they are coming from and try to help them.  Avoid making value judgments against them as people; i.e. show them that you respect them, that you value their opinions and that their thoughts deserve contemplation.  Be kind and treat them in the same manner that you would treat your friends; i.e. when behaviors become unpleasant, remain calm and nice, as this will pacify annoying situations.  Show an interest in them; i.e. their self-esteem is at stake here. By showing interest, you are validating them, which should soften them up.  Identify who has the problem; i.e. people who complain that others are difficult, often have difficulties themselves. Ask yourself why you have problems with them and then take steps to address the problems instead of keeping things inside.  Change whatever you can with yourself; i.e. since you cannot change what somebody else is doing, concentrate on modifying how you handle the problem.  Ask them what they want; i.e. this will be a good starting point for developing an understanding and trust between you.

Section 7 Challenging Behavior

Complaints A complaint is an expression of dissatisfaction, grievance or resentment. Some Older Adults complain regularly. While reasons vary, often they complain because they have sore and aching bones and muscles, which they did not have when younger. As a result, their mobility can be affected. In addition, their hearing, eyesight and other senses don’t function as well. Other possible contributors are life changes, emotional conditions and mental conditions. Anyone of these can have an undesirable effect on others. Regardless of the cause, crabbiness can be a means for expressing their discontent.

Handling Complaints It is inevitable that Home Care Assistants will face complaining clients -- some days the complaints will seem endless. For some complainers, complaining forms a part of their individual constitution. If Home Care Assistants know what to do, they needn’t feel stressed or inadequate because knowing and applying a few simple principles can often minimize or eradicate complaints completely:           

Recognize that the dissatisfaction is a complaint. Pay attention by listening carefully and objectively. Be sympathetic and be sincere in your desire to help. Repeat what you have heard to avoid misunderstanding. If there is a problem, admit to it and apologize for any inconvenience. Ask what they want done about the problem. Avoid any defensive reactions. Don’t give excuses or place blame. Don’t make promises that can’t be kept. Provide explanations. Offer solutions.

How HCAs Can Handle Older Adults with Complaints         

Assure them you are there to help and be supportive. Get the details of the complaint; e.g. The “how”, “what”, “when” “where” “why” and “how”. Learn as much about them as possible. Ask them what they want done about the problem. Suggest appropriate options for solving the problem. Obtain their input and come to an agreement on the best solution. Implement corrective actions (with the client’s approval). Follow-up on any actions taken to determine effectiveness. If the solution is unsuccessful, consider an alternative and follow through again.

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Example: Dealing with a Complaint The following example illustrates how a Home Care Assistant might handle a complaint. Scenario: A Home Care Assistant has a new client. Arriving at his home, he/she is greeted by a complaining client who tells the HCA to go away because he doesn’t want any help. He has had it with Home Care Assistants. Steps in Complaint Process

Interactions Between HCA and Client

HCA: “Mr. X, I am sorry to hear that you are not satisfied. I am only here to Assure them you are there to help & would appreciate it if I could talk to you for a few minutes.” help & be supportive. CLIENT: “Alright but make it fast”. HCA: Obtain the details of the complaint.

Learn as much about them as possible

Ask them what they want done about the problem

Suggest appropriate options for solving the problem

“I am sorry that you feel this way. Would you like to share with me why you don’t want me to help?” CLIENT “You are the fourth one I’ve had this month and I am tired of a bunch of strangers coming in.” HCA: “You’ve had three other Home Care Assistants this month?” CLIENT “You got it-- but they didn’t stay. One had an operation, one moved away and one said she had too many people to look after.” HCA: “You must have found that to be very frustrating.” CLIENT: “Frustrating and upsetting -- they shouldn’t treat me this way. What do they think I am anyway -- a piece of chopped liver?” HCA: “You are not a piece of chopped liver. You seem to be a sensitive and caring man.” CLIENT: “I am a nice guy.” HCA: “I believe you. Would you like to tell me a few things about yourself, as I would like to get to know you?” CLIENT: (Proceeds to give HCA an overview his life.) HCA: “What an interesting life you have led. I would enjoy hearing more at another time. HCA: “I am concerned that if you don’t accept help, your needs won’t be looked after. What would you suggest be done so you can get the care you deserve?” CLIENT: “I want the same person every time and they better be someone I can get along with.” HCA: “That is not an unreasonable request. Let’s see, I would like to be that person, if you agree, or I can refer you to somebody else.”

Obtain their input and come to HCA: “What do you think about those suggestions?” an agreement on the best CLIENT: “Are you sure you would stay on with me?” solution HCA: “I would not leave unless something unforeseen happens. What I can also do is bring another HCA in one day and show her the routine. If you like her, she could be my backup just in case I can’t come in some time. How does that sound to you?” CLIENT: “I guess that would be alright”

Section 7 Challenging Behavior

Steps in Complaint Process

Interactions Between HCA and Client

HCA: “Now, how about today? Should we give it a try?” Implement corrective actions CLIENT: “May as well -- you are already here.” Follow-up on actions taken to Over the next several weeks, both client and HCA can assess how things are determine effectiveness. working out. Minor adaptations can be made as indicated. If the solution is unsuccessful, consider alternatives & follow If either party is not satisfied, they can try another option; e.g. HCA can refer the client to someone else with the client’s agreement. through again.

Anger It is the rare person, indeed, who never experiences some degree of anger. Therefore, the likelihood of Home Care Assistants facing angry clients is quite high. By understanding anger, its causes, its impacts, and how to react to it, Home Care Assistants can constructively “maintain their cool” instead of “flying off the handle”, which would only worsen the situation.

Anger is an emotion that can range from mild to furious and is a natural response to threats. It can be caused by people, events, memories and/or personal problems. It is a normal human emotion but if it gets out of control, it can create difficulties. Anger can cause the heart rate, blood pressure and energy hormones to increase. It can seriously affect relationships. The healthiest way for anger to be expressed is to talk about the reason for the anger in an assertive, nonaggressive way. (Note: Assertiveness means being respectful of others and yourself while aggressive means being pushy or demanding.) If anger is not expressed, other problems can be created; e.g. passive aggressive behavior, being critical, making mocking comments. When helping clients to deal with their anger, Home Care Assistants would benefit by knowing the goal of anger management, which is to reduce feelings and physical stimulation caused by anger. They can help clients learn to control their reactions, even though they cannot avoid or change their causes.

How HCAs Can Interact with Older Adults Who Are Angry Dealing with angry clients can be an awkward and uneasy task. There are a few things that Home Care Assistants can do to prevent Older Adults from becoming even more emotional.

   

Allow them to “spout off” and then, gently, start to speak. Get the facts, which allows you to focus on the issue and not on their emotions. Pay attention to their own body language. Maintain an open, friendly and tranquil appearance by: • keeping a passive facial expression; 77

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• moving your head up and down from time to time; and, • showing that you are listening.  Speak in a normal, even tone -- by being calm, you are in control.  Utilize communication skills by: • repeating what the angry client is saying; • emphasizing statements by acknowledging you understand their feelings; and, • temporarily pausing the situation by stating their name.  Ask how you can help them.  Don’t make the situation worse by using statements such as: • What is bugging you anyway?” • “If you will just settle down.” • “If you will just hear me out.” • “You are being unfair.”  Respond instead of reacting by: • applying empathy, which will allow you to see their point of view; • being compassionate, which bring tolerance to the situation; and, • being assertive, which enables you to stand up for your rights without infringing on their rights.  Resist the temptation to fight back by keeping your own emotions under control. This can be accomplished by: • counting to 10 before speaking; • taking deep breaths, which will promote relaxation and help focus to focus on the moment; • thinking more rationally; • not jumping to conclusion; and,  changing your thoughts and attitudes by using humor.

Conflict Conflict occurs when people do not get what they want and are looking after their own selfinterests. Sometimes, they are not aware of their needs and unconsciously start to act out. Other times, they know exactly what they want and actively try to get it. Conflict may occur when:        

Wants or needs are not being met. Values are being tested. Perceptions are questioned. Assumptions are made. Knowledge is minimal. Expectations are too high or too low. Personality, race or gender differences are present. Conflict is with oneself. 78

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Constructive and Destructive Aspects of Conflict Constructive       

Problems & issues are clarified. Solutions are found for the problems. Valid communication results. People are involved in resolving issues. Familiarity may result in people cooperating. Individuals develop understanding & skills. Emotion, anxiety & stress are relieved.

Destructive     

Irresponsible & harmful behavior can result. People become less cooperative. Differences are enhanced. Morale & self-concept are damaged. Attention is removed from other important issues.

Home Care Assistants may become involved in a conflict personally or they may be drawn into one when their clients become involved. If they are armed with a basic knowledge of dealing with conflicts, Home Care Assistants may be able to help defuse the situation and thus reinstate and maintain stability in Older Adults’ lives. How HCAs Can Help Resolve Conflict with Older Adults          

Share information. Hear each other out. Use power to raise an issue instead of to impose a solution. Set a time and place to talk privately. Define expectations for the outcome. State the event, feelings about it, ending with a question. Explore all relevant information concerning the event. Explore solutions that would benefit both sides. Offer fair exchange proposals. Test for commitment.

Note:

It is important to acknowledge that in every conflict, both parties contributed to the problem and they should face the issues as soon as they occur.

Aggression Aggression is a deliberate behavior intended to inflict damage or other unpleasantness upon another individual. The possibility for aggression exists whenever there is a conflict between two or more individuals. Older Adults may become aggressive when:  They are frustrated with: • themselves for not being able to control their emotions; • people they don’t understand; and/or, 79

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• the world they face.  They feel inadequate as they: • perceive that other people are looking down on them; • have a lot going on in their head and aggression releases pent up energy; • were exposed to aggression as children; • were abused as children; and, • may have a biological problem; e.g. reduction of certain chemicals in the brain. Few individuals have never faced an aggressive person and Home Care Assistants are no exception. Regardless of past experiences, HCAs are likely to encounter aggressive clients during their careers. A natural reaction when someone becomes aggressive is to fight back. However, that is not always the smartest way to handle the situation. A wiser alternative is to help these aggressive people to:  feel understood;  calm down; and,  discuss the situation reasonably. How HCAs Can Interact with Older Adults Who Are Aggressive             

Allow them to speak their peace without interruption. Ask for elaboration and clarification. Show concern. Speak with a soft and low-level voice. Summarize what has been said. Don’t argue. Agree with whatever you can. Be empathetic. Offer to share your information. Find out what is needed to improve the situation. Provide suggestions, if none have been suggested already. Suggest some down time for both parties to think. Make an action plan based on what has been agreed upon.

Violence Violence is an assault on someone, which can be in the form of:  Physical Injury: e.g. the victim’s body is injured.  Verbal Harassment: e.g. calling the victim names.  Property Damage: e.g. the victim’s car is vandalized. 80

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Violence results from hostility and aggression when perpetrators feel they will get more satisfaction out of hurting someone than they would get out of out of resolving and/or tolerating a situation. Since it is almost impossible to predict when hostility and anger will lead to violence, Home Care Assistants need to be alert for any signs that clients may become violent. If HCAs have some skills and knowledge, they may be able to defuse the situation. The first thing they should do is ask themselves if they can handle the situation. If they don’t feel they can, they should call “9-1-1”. If they think they can handle it, they can initiate defusing actions. Either way, they will have to rely on their better judgment to determine which option to take initially. How HCAs Might Defuse Violence in Older Adults

 Understand where they are coming from. As they are compelled to talk about their dissatisfaction (real or perceived), be sure to take time to listen at that moment.  Create an atmosphere of cooperation.  Do not display anger, fear or anxiety.  Speak in a calm and low voice.  Be totally truthful to maintain credibility.  Expect and accept angry outbursts, as defusing will begin after venting.  Listen without comment or judgment.  If you do speak, ask questions that require a long answer, as it will show that you are interested and will help the defusing process.  Maintain eye contact to demonstrate that you are paying attention.  Do not play down the importance of their concerns.  Be understanding.  Show respect.  Don’t be threatening.  Ask what can be done to relieve the situation.  Work towards a resolution that will benefit both sides.  Allow them to maintain their dignity. Note:

Older Adults, who show violence tendencies, may have mental problems or may be taking drugs. In such situations, defusing techniques may not work, as their comprehension and understanding might be affected.

Negativity Negativity is not uncommon in the Older Adults. Some are chronically pessimistic and are negative most of the time. Others may have episodic periods when negative attitudes take the forefront. Negativity can be due to dispositions, attitudes or it can be caused by certain events 81

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or individuals. Although not usually threatening, negative people can be difficult to be around and can become a “thorn in one’s side”. How HCAs Can Deal with Negative Attitudes in Older Adults

    

Realize that it is useless to argue with them. Understand that they are feeling insecure. Don’t push them, as they will only get worse. Wait until another time to pursue the task or discussion, if they find the situation is stressful. Determine if they are always defensive or attacking others. If they are, it may not be possible to change their attitude.  Keep your self-confidence.  Don’t allow verbal abuse.

Negotiating Negotiating simply means to consult with another for purposes of coming to terms with something. Negotiations occur between parties at all levels; e.g. between heads of state, corporations, companies, organizations, and individuals. Negotiating involves the following principles:     

Focus on how both parties can win. Remember the other person must be satisfied with what they get. Focus on the problem itself and not on the emotions surrounding it. Know the negotiation style of the other party to promote a positive outcome. Focus on interest and not on positions; i.e. positions may be set, but both parties may have interests, which need to be met.  Keep emotions under control.  Listen and question the other person, as they may have a better option than what you are proposing. How HCAs Can Negotiate with Older Adults       

State your point of view. Get the client’s point of view. Identity both person’s goals. Offer and listen for potential solutions. Choose the best solution for both of you. Evaluate the outcome. Make changes as indicated. 82

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Summary Just as people come with different physical traits such as color, size and shape, they also come with different personalities, dispositions, behavioral patterns and attitudes. One of the main sources of stress is dealing with people who are not easy to be around. This is especially true for Home Care Assistants. Older Adults usually do not function at par due to age, frailty, illness or injury. If they are also difficult to interact with, the challenges of caring for them are compounded. While changing a person’s traits is not an option, Home Care Assistants can control and modify their own reactions and attitudes towards them. They do this by understanding what individuals are about and what makes them tick. This knowledge empowers HCAs to manage their own stress levels and to obtain more cooperation from those they serve.

Section 8 Personal Care

SECTION 8: PERSONAL CARE

This section provides some highlights of personal care. It is not a substitute for a Care Aide Certification Course but rather is an overview of the main points of personal care. Home Care Assistants are responsible for ensuring their personal care skills are kept honed and they maintain personal care standards. Should HCAs feel they need reinforcement training or additional training to competently carry out their duties, they must seek assistance from their Supervisor or Instructor.

Need for Personal Care Home Care Assistants provide practical support to Older Adults and individuals with disabilities, who have difficulty conducting their activities of daily living. While they also work with children and people with physical or learning disabilities, the majority work with the Older Adult. They provide care to clients in their own homes or in care facilities. Personal Care services are a “24-7” (24 hours per day, 7 days a week, 365 days per year) need, which has increased the demand for Home Care Assistants. The escalation in need is because:  Patients are being discharged from hospital earlier with some short-term assistance.  People are living longer with debilitating conditions and diseases.  Improvement in medications and treatments enables people, who previously would have required facility care, to be treated and maintained at home if assistance with activities of daily living is provided.  People are electing to remain at home instead of going into care facilities.  Patients are being discharged from institutions because of high costs and/or the client’s preference to be at home.

Personal Care Skills To provide competent personal care, HCAs need theoretical and practical skills in:    

communications; observing, reporting, and documenting client care; basic elements of body functions; infection control procedures; 84

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       

reading and recording vital signs; safe transfer techniques; basic nutrition; normal range of motion and positioning; personal hygiene and grooming; physical, emotional, and developmental characteristics; maintenance of a clean, safe and healthy environment; and, recognition of emergencies and procedures for handling them.

HCAs must also be:  physically fit;  able to lift heavy objects; and,  committed to client rights.

Activities of Daily Living Activities of daily living are activities necessary for normal self-care. They include:      

bathing; toileting; dressing; eating; transferring/walking; and, continence.

Grooming Good grooming habits are very important to some people, while others do not give them the same value. To the first group, it is tied into their body image and self-esteem. Men in this category will feel better, if they are clean-shaven or if their beards and mustaches are trimmed. Women are concerned how their hair, nails and clothing look and are perceived. The second group “goes with the flow”, so to speak, and are not overly concerned about how they look. They adopt the “take me as I am” attitude. When dealing with clients, Home Care Assistants generally adapt to the clients’ standards. Sometimes, if grooming habits are poor, suggestions might be made on how they might improve their appearance and what the benefits would be. However, these individuals need to be receptive and must not be forced or shamed into changing their habits.

Section 8 Personal Care

Hair Care Many Older Adults are not able to care for their own hair due to lack of strength and limited abilities to raise their hands to their head. Painful and restricted movements caused by arthritis and other conditions make these actions difficult, if not impossible. To some people, it is important that their hair be maintained at a certain standard, as they want it not only to be clean but also styled. Others will just want it clean and cut, while a third group really doesn’t care how clean and or disheveled their hair is. Routine hair care involves washing, drying, combing and styling. While some will use the services of hairdressers or barbers, hair care is often delegated to Home Care Assistants. When HCAs provide hair care, they need to consider the individual’s:    

culture; personal choice; health history; and, maintenance ability.

Brushing & Combing Hair should be brushed and combed as often as required but at least during the morning and at bedtime. This prevents the hair from tangling or matting. Many people have preferences as to what types of products they want used and how they want they want their hair care done. Hair type determines which tools to use; e.g. curly hair responds to large-toothed combs. How HCAs Can Assist Older Adults with Brushing & Combing Hair Brushing Hair

 To remove tangles, brush from bottom of the hair shaft and work up towards the root.  To distribute scalp oils, brush down the length of the hair.  Do not brush hair while it is wet. Use a wide-tooth comb. Combing Hair

 After brushing use a comb, to return hair to its style.  If hair is wet, use a wide-tooth comb, working from the ends of hair on up to the shaft.

Shampooing Depending on individual’ preference, health, mobility, safety factors and energy, shampooing can be done: 86

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   

during bath/shower; at the sink; in bed or, on a stretcher.

Basic Shampooing Procedures      

Apply shampoo to hair starting at roots. Use vertical strokes with medium pressure. Rinse well. Add conditioner, to maintain hair health and minimize tangling. Rinse unless conditioner is a “leave-on” type. Dry and style as soon as possible after shampoo.

Note: Dry shampooing is an alternative for wet shampooing. How HCAs Can Assist Older Adults with Shampooing Bathtub or Shower Shampoo

 Assist individuals into the bathtub or shower.  Use a hand-held nozzle to wet hair. If not available, improvise; e.g. use a water pitcher.  Have them tip their head back. • Support their head with one hand and shampoo with the other hand.  If head cannot tip back, have them lean forward and cover their eyes with a folded facecloth. • Support forehead with one hand and shampoo with other.  Follow Basic Shampooing Procedures. Sink Shampoo

    

Sit individual in a chair or wheelchair with his/her back against the sink. Place a folded towel against the edge of the sink. Tilt their head over the sink. Wet hair with hand-held nozzle or water-pitcher Follow Basic Shampooing Procedures.

Bed Shampoo

 Move individual’s head and shoulders to the edge of the bed.  Place a plastic shampoo trough under their head. • Use a rolled towel and plastic garbage bag if a trough is not available.  Place a basin on a chair next to the bed. 87

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 Ensure trough is positioned properly so water drains into the basin.  Follow Basic Shampooing Procedures. Stretcher Shampoo

   

Wheel stretcher in front of sink. Lock stretcher wheels and safely straps. Ensure far side rails are up. Proceed with shampoo as outlined in Sink Shampoo.

Hair Conditions Dandruff

Dandruff is flakes of dead skin that form on the scalp. As it is normal for skin cells to die and flake off, a small amount of dandruff is normal and common. Some people, chronically or because of certain triggers, experience an unusually large amount of flaking, which can not only be a visual nuisance, but also can be accompanied by redness and irritation. Most cases of dandruff can be treated with the proper shampoo or by using common household products such as apple cider vinegar. Pediculosis

Pediculosis is a condition wherein lice infest the hair. They attach themselves to hair shafts, where they lay their eggs. This causes severe itching. Lice are easily spread to other people via clothing, furniture, bed linen and sexual contact. Treatment consists of using medicated shampoos, lotions and creams. Additionally, it is important to bathe thoroughly and to wash linens and clothing in hot water. Alopecia

Alopecia is the temporary or permanent loss of hair. It can occur due to the aging process, heredity, medication (such as chemotherapy for cancer), skin diseases, poor nutrition, pregnancy, stress and hormonal changes. It can also result from improper hair care and prolonged use of certain hair-styling techniques. Cosmetic treatments; e.g. dyes, tints, bleaches, permanents) are generally safe unless the procedures are not done correctly. Hairstyles that pull the hair tightly, and excessive shampooing or brushing can also cause hair loss. Braiding, permanents, excessive heat and hair straightening cause the hair shaft to weaken. Hair styling techniques such as hair weaves, corn rows, dreadlocks and straightening procedures can cause permanent hair thinning and scarring.

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Usually alopecia, caused by the aging process. is not reversible. Treatments vary depending on the type of alopecia, e.g.:  wearing a wig or hairpiece;  applying cortisone ointments to the scalp; or,  using hair growth products such as Rogaine. Hirsutism

Hirsutism in an excessive increase in hair growth. It is not a disease. The condition usually develops during puberty and becomes more pronounced as the years pass. However, it can appear at any age from inherited genes, over-production of male hormones (androgens), medication or disease. Women who have Hirsutism usually have irregular menstrual cycles. They sometimes have small breasts and deep voices, and their muscles and genitals may become larger than women who do not have the condition. Treatment for hirsutism is conducted manually and includes:  cutting;  bleaching;  electrolysis;  shaving;  tweezing;  waxing; and,  using hair-removing creams (depilatories).

Shaving Shaving is not usually necessary for medical or sanitation reasons. Many men simply prefer a clean-shaven face while others must have a beard. Hair is generally removed for comfort, aesthetics, fun, cultural and/or religious reasons. It is not shaved for the same reasons. Shaving is a personal choice. Many females start shaving their legs and underarms at puberty. Some will develop coarse, facial hair as they grow older. When individuals are no longer able to shave themselves, they require assistance. Tools required for shaving include:    

razor (either electric or disposable); gel, foam or shaving lotion; warm water; and, optional items such as: • scissors • hair conditioner 89

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tweezers dry skin lotion or baby oil

Shaving tools are a matter of preference or are based on conditions a client might have; e.g. Some prefer an electric razor while others want a razor with a blade. Note: Clients who are on anticoagulants (blood thinners) should not use a razor blade because nicks and cuts are common and can cause bleeding problems. How HCAs Can Help Older Adults with Shaving Pre-Shaving

 Use a sharp blade, as dull blades will pull the hair and increase the chances of ingrown hairs.  Cut long hair with scissors before shaving it.  Let the hair soak in warm water for about 3 minutes before shaving. This softens the hair, opens the hair follicle and relaxes the skin.  When using gel, apply it at least 4 minutes before shaving, as this will help keep the hair erect, moisturized and will condition the skin.  Always use a foamy product for shaving to prevent razor burn (bumps, irritation or red, raw skin).  Don’t shave for at least 20-30 minutes after lying down because body fluids make the skin puffier. By waiting this amount of time, the skin will tighten up and more of the hair shaft will be exposed. Shaving

 Wear disposable gloves when shaving a client with a blade razor.  Using one hand, pull the skin taut and shave with the other hand.  Shave in the direction of hair growth. While shaving in the opposite direction will give a closer shave, it also increases the chances of developing ingrown hairs or razor burns.  When shaving use: • long, upward strokes on the legs; • short side-to-side strokes on the underarms; and, • upward strokes on the pubic area.  Rinse the blade often, as hair sticking to it will interfere with shaving.  Ensure foam is applied any place that is being shaved.  Work slowly, especially if using a disposable razor and be careful around bony areas.  When shaving more than one part of the body, apply shaving gel to all areas and then start shaving the finest hair first (usually the legs or stomach).  A good angle between a disposable razor and the skin is around 30 degrees. Electric razors usually state what angle to use but most are at least 45 degrees. 90

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After Shaving

   

Rinse the shaved area with warm water. Rinse with the coolest water that is comfortable. Pat skin dry with a clean towel. Don't rub. Apply a dry skin lotion to the shaved areas, as it will reduce irritation and itching and soften skin and hair follicles. Lotion will also reduce the discomfort caused by stubble in between shaves.

Note: Use a separate razor for each person unless it is an electric razor, which has been disinfected. Sharing razors could transfer skin infections.

Oral Hygiene The purpose of maintaining good oral hygiene is to:     

keep the mouth and teeth clean to help prevent bad breath and infections; enhance a person’s well-being; make food taste better; reduce tooth cavities; and, help prevent periodontal disease.

Most people look after their own oral hygiene but sometimes assistance is needed to either gather the necessary tools for them or do the oral care for them. Tools needed for oral hygiene include:    

Toothbrush Tooth Paste (or Denture Paste for False Teeth) Dental Floss Mouth Wash

Brushing Teeth Basics of Brushing Teeth  Teeth should be brushed 2-3 times a day, usually after breakfast, lunch and supper and/or at bedtime. The recommended duration is 2-3 minutes. At a minimum, teeth should be brushed in the morning and at bedtime.

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 The ideal toothbrush should: • have rounded bristles; • be soft; • not be worn or dirty; • be shaped and sized to reach the back of the teeth; • be replaced at least every 6 months or every 3 months, depending on its condition; and, • not be shared to prevent spreading germs.  Toothpaste should contain fluoride.  Use effective brushing methods: • circular; • horizontal; and, • vertical.  Change the method of brushing periodically to ensure that all the tooth surfaces receive a thorough brushing.  Electric toothbrushes are very popular, as a motorized head conducts brushing. The user only needs to make sure that it reaches all surfaces of the teeth. These brushes have timers and will shut off automatically after 2 –3 minutes. How HCAs Can Assist Older Adults with Brushing Teeth  Apply recommendations provided in Basics of Brushing Teeth.  Hold the toothbrush at a 45-degree angle and direct the bristles between the neck of the tooth and their gums.  Gently move the brush back and forth in short, tooth-wide strokes. Focus on brushing along the gum line, which is the point where the teeth meet the gums. This area is a breeding ground for tartar and bacteria.  Brush the outer surfaces, the inner surfaces, and the chewing surfaces of the teeth.  To clean the inside surfaces of front teeth, tilt the brush vertically and make several up-anddown strokes.  Don’t scrub tooth enamel, as brushing teeth too hard can cause the gums to recede.

Flossing Flossing loosens and removes food particles and plaque between the teeth where a toothbrush can’t reach. An ideal time to floss is just before bedtime. The important thing is to develop a routine schedule for flossing and stick to it.

Basics of Flossing  Floss thoroughly either before or after brushing teeth. 92

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    

Maintain a disciplined flossing schedule. Use generous amounts of floss. Be gentle. Do one tooth at a time. If floss is hard to handle use: • a dental pick; • pre-threaded floss; • water flosser; • plaque remover; or, • tiny brushes that reach between teeth.

How HCAs Can Assist Older Adults with Flossing When Older Adults are unable to floss their teeth, Home Care Assistants may need to floss for them:  Wrap ends of an 18-inch piece of floss around one middle finger on each hand. The second finger will take up the floss as it becomes dirty.  Hold the floss tightly between the thumbs and forefinger.  Guide the floss between teeth using a gentle, rubbing motion. Don’t snap the floss into the gums.  At the gum line, curve the floss into a C-shape against one tooth. Slide it into the space between the gum and the tooth.  Hold the floss tightly against each tooth.  Rub all sides of the tooth, moving the floss away from the gum. Use up and down motions  Floss one tooth at a time.  Discard floss when finished.

Denture Care Dentures, like real teeth, require regular cleaning and maintenance to:  reduce the accumulation of bacteria, which could cause: • additional tooth loss; • swollen and bleeding gums; and, • infections.  staining;  gum irritation; and,  bad breath.

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Basics of Denture Care These basics apply to full and partial dentures:  Use a denture cleaner at least twice per day like your normal brushing routine. A good rule of thumb is to brush, then soak, and then brush them again. Be careful not to drop the dentures while they are being cleaned, as they may chip or crack. By placing them over a towel or over a sink full of water, unfortunate accidents may be prevented.  Soak dentures in a special denture cleaner, which can speed up the cleaning process. As they are scrubbed and wiped dry, use light circular motions to avoid scratching or grooving the surface. Though all surfaces must be thoroughly cleaned, the key area is where the denture touches the gums. This is important especially if an adhesive is used.  Use a mid-size toothbrush. The denture cleaner solutions help remove stains and bacteria but should not be used for soaking overnight. For an overnight soak, use regular tap water. Never try to bleach dentures with strong household cleaners. Not only do these cleaners weaken the plastic but also, they can be poisonous. Never use extremely hot water, as it can cause dentures to warp. Warm water is ideal.  Take dentures to a denturist for professional cleaning if serious stain builds up or tartar develops. How HCAs Can Assist Older Adults with Denture Care Denture care is provided for Older Adults who are not able to perform the task themselves.  Follow the guidelines outlined under Basics of Denture Care.  Always wash hands and wear disposable gloves.  Ask individual to remove the dentures: • In he/she is unable to remove them, grasp the dentures with a piece of gauze, tissue or facecloth using thumb and forefinger of one hand. • Move denture up and down to break seal.  Check mouth for: • broken or loose teeth; • irritation; • bleeding; • sores; and, • swelling.  Place dentures in a container filled with cool water.  Line sink with a washcloth and/or fill sink with water.  Clean dentures over skink to prevent breakage should the dentures accidently drop.  Apply denture cleaner or toothpaste to brush.  Using toothbrush on dentures: • brush the outer surfaces using back and forth motion; • position the toothbrush vertically to clean the inner surface of teeth; 94

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• use upward strokes; and, • clean palate.  Rinse dentures under cool, running water.  Place dentures into container filled with cool water.  Have individual rinse mouth.  Apply denture cream or adhesive to dentures if individual wants them reinserted.

Bathing The purpose of bathing is to:    

remove perspiration, dead skin, excess oils and bacteria from the body; increase circulation; do range of motion exercises; and, relax and become refreshed.

The frequency with which a person bathes is usually a personal choice, although incontinency issues can create a need. While some people bathe daily, others may only bathe once or twice a week. There are many options for bathing. The method used is determined by the person’s preference and his/her abilities and disabilities. Regardless of the method used, the individual should be encouraged to do as much as possible for him/herself.

Bathing Methods:  Tub Bath: individuals bathe in a bathtub. They may or may not require assistance getting in and out. Due to the susceptibility of falling, Older Adults and disabled individuals should not bathe in bath-tubs.  Shower: individuals can stand in a shower, sit on a bath bench in a shower, or have their wheelchair wheeled into the shower (if it is designed for easy access). If they cannot get in and out of shower themselves, then a shower seat should be used.  Sink Wash: individuals either stand at the sink and wash or they sit on a chair/wheelchair in front of the sink.  Complete Bed Bath: individuals have their entire body washed while in bed. It is utilized for people who are not capable of bathing themselves because of weakness, reduced endurance, respiratory problems or conditions that keep them bedridden.

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 Partial Bed Bath: individuals either wash or have washed portions of their body (usually the face, hands, underarms, back, buttocks and perineal areas).

Basics of Bathing        

Collect all necessary items; e.g. wash cloths, towels, soap, lotions, shampoo, conditioner. Fill wash basin. Check temperature of water. Wear disposable gloves. Ensure privacy. Prevent or reduce drafts. Have room warm. Protect individual from falling. Use good body mechanics. Use 2 facecloths: • first one for washing; and, • second one for rinsing.  Wash from the cleanest area to the dirtiest area.  Re-check water temperature regularly to ensure it is still comfortable.  Keep soap in soap-dish when not lathering.  Encourage individual to help as much as possible.  Rinse skin thoroughly to remove soap.  Dry skin well.  Bathe skin whenever fecal material or urine is on it.  Observe the condition of body and skin; e.g.: • presence and location of rashes; • bruises; • open areas; • red or pale areas, especially over bony parts; • color; e.g. skin, lips, whites of eyes & nail-beds; • dryness and/or flakiness of skin; • swelling of legs and/or feet; • calluses; • skin temperature; • painful areas; and, • signs of bleeding or discharge.  Take safety precautions: • ensure bottom of tub and/or shower are “gripped”; e.g. bath mats or non-skid strips; • use grab bars for support; • avoid bath oils; • place personal care products within individual’s reach; • drain the bathtub before the individual gets out

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don’t run water while a person is bathing; e.g. dishwasher, washing machine, toilet or sink.

How HCAs Can Assist Older Adults with a Bed Bath  Apply principles outlined in Basics of Bathing.  Place 2 towels on individual’s body: • first towel covers shoulders to waist; and, • second towel covers waist to toes.  Remove top sheets.  Wash face, ears and neck. Rinse and pat dry.  When washing eyes: • do not use soap; • wipe from inner eye to outer eye. • use separate sections of face cloth for each eye.  Place towel lengthwise, under arm.  Wash arm, shoulder and underarm. Rinse and pat dry.  Place their hand in basin to wash hands.  Repeat process for second arm.  Lift the top towel. Wash, rinse and pat dry chest, especially under breasts. Recover with towel.  Lift bottom part of towel. Wash, rinse and pat dry abdomen. Re-cover with towel.  Place towel lengthwise, under leg. Wash, rinse & pat dry. Re-cover with towel.  Place foot in wash basin. Wash, rinse & pat dry, ensuring areas between toes are dry.  Repeat process on other leg.  Turn individual on side. Wash shoulders, back and buttocks. Rinse and pat dry.  Return individual onto back.  Change water and encourage individual to wash genital area. If unable to do, provide pericare. • Women: - Position her on her back. - Separate labia. Check for crusts, abnormal drainage or secretions. - Swipe from front to back. Use a separate part of cloth and swipe again. Repeat until clean. - Rinse and dry the area thoroughly - Apply cream to help guard against skin irritations. • Men - Position him on his back. - Retract foreskin, if uncircumcised. - Grasp penis shaft and cleanse from tip of penis down shaft, using circular motion. Use a separate part of cloth and repeat from head of penis to shaft. - Return foreskin to original position, if uncircumcised. 97

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   

- Wash scrotum. - Rinse and dry well. Turn individual on side. Wash, rinse and pat dry rectal area, working from front to back. Use separate sections of cloth for each swipe. Apply moisturizer, deodorant or antiperspirant. Help dress. Brush and comb hair.

Urinary System Care The Urinary System consists of the kidneys, ureters, bladder, and the urethra. Its purpose is to:    

eliminate waste from the body; regulate blood volume and blood pressure; control levels of electrolytes and metabolites; and, regulate blood pH (the acidity or alkalinity of blood).

The Urinary System is the body's drainage system for the eventual removal of urine. About 3 pints of urine are excreted a day, with variations being influenced by age, the amount of fluids ingested, medications, and the amount of salt consumed. The ability to hold urine depends on individuals having anatomically and functionally normal urinary tracts and nervous systems. They must also be able to recognize the need to urinate and know what to do.

Urinary Incontinence Urinary incontinence is the loss of voiding control, which can range from being an occasional leak of urine to a total inability to hold urine. This type of incontinence can be short-term or long-term. Types of Urinary Incontinence  Urge Incontinence: occurs when individuals have an urgent need to urinate but cannot hold their urine long enough to get to the bathroom. It can be caused by diseases such as Diabetes, Alzheimer’s, Parkinson’s Alzheimer’s, Multiple Sclerosis or Stroke.  Stress Incontinence: occurs when urine leaks from pressure on the bladder, which can result from sneezing, jogging, coughing, laughing, exercising or lifting. It is most common in younger and menopausal women.  Overflow Incontinence: occurs when a bladder is too full and small amounts of urine leak from it. Diabetes enlarged prostates, and spinal cord injuries are major reasons for overflow. 98

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 Functional Incontinence: often occurs in Older Adults who have normally functioning bladders but have difficulty getting to the bathroom in time. Its main causes include Arthritis, Multiple Sclerosis and other disorders that make fast movement problematic.  Unconscious/Reflex Incontinence: is the loss of urine at predictable intervals. This can happen when individuals do not realize their bladders are full and thus do not have an urge to empty it. Central Nervous System disorders and injuries can create this type of incontinency. Causes of Urinary Incontinence

In addition to those identified in Types of Urinary Incontinence, other causes include:         

Urinary Tract Infection/Inflammation Prostate Infection/Inflammation Constipation (puts pressure on the bladder) Medications Pregnancy Weight Gain Short-term Bed Rest Dementia Physical Conditions including: • spinal cord injuries; • neurological conditions; • weakness of muscles, which hold urine intact; • abnormal structure of the urinary tract; • enlarged prostate; and, • bladder cancer.

Treatment of Urinary Incontinence  Pelvic/Kegel Muscle Exercises: are performed to work muscles used to stop urinating. By strengthening pelvic muscles, urine can be held in the bladder longer.  Lifestyle Changes: may help with incontinence; e.g. losing weight, reducing the amount of caffeine consumed, limiting drinks before bedtime, avoiding alcohol and quitting smoking.  Timed Voiding: establishes and maintains a schedule for urinating; e.g. every hour, every 2 hours. The length of time between bathroom trips is gradually increased over an extended period. 99

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 Biofeedback: uses sensors to make individuals aware of signals from their body. It can help them regain control over their bladder and urethra muscles and learn Pelvic/Kegel exercises.

Bowel Care Bowel elimination is a physical process in which waste products from the gastro-intestinal tract are normally excreted through the rectum and anus. People who have required surgical removal of portions of the intestine are given a colostomy, which enables fecal material to pass through an opening in the abdomen.

Common Bowel Problems  Constipation: is a condition in which too much water is absorbed from the large intestine back into the bloodstream, leaving the feces dry, hard and difficult to expel. It is caused by a lack of fiber in the diet. (Fiber holds water, preventing the feces from becoming too hard.)  Fecal Impaction: is an accumulation of hardened feces stuck in the rectum or lower colon, which can’t leave the body. It can cause pain and vomiting and may require emergency treatment.  Diarrhea: is a condition characterized by watery stool or increased frequency (or both) when compared to a normal amount. It may last a few days and disappear on its own.  Fecal Incontinence: is the inability of the body to control bowel movements.  Flatulence: is the presence of excessive gas in the bowel.

Causes of Bowel Problems Factor Diet Fluid Intake Personal Habits Activity Medications

Reason High fiber foods and a balanced diet are needed for maintaining regular bowel habits. Often, Older Adults do not get enough fruits and vegetables. Also, they tend to avoid certain foods if they have problems with their teeth/dentures. The bowels depend on an adequate intake of liquids to work effectively. Otherwise, constipation sets in. Between 6-8 glasses of fluid should be taken daily. Relaxation enhances defecation. Achieving the required state of relaxation may be achieved by eating, walking, reading or having a hot drink. Exercise and movement maintain muscle tone and stimulate the bowels. A frequent side effect of conditions which make a person inactive; e.g. disease, surgery, injury, etc.) can render a person to become inactive. Many medications list constipation or diarrhea as side effects, which make maintaining regular and good bowel habits a challenge.

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Factor Aging Process Disability Lack of Privacy

Reason As one ages, illness and slowing down occur. They, in turn, affect bowel control. Also, older people do not always empty their rectum, so they may need to go again, shortly after their first bowel movement. People who are quadriplegic or paraplegic do not have voluntary control of their bowel movements. It is beneficial to help them develop regular bowel habits to prevent or lessen impaction, constipation and incontinence. It is not uncommon for people to have difficulty defecating or voiding, if others are around. This is usually easily remedied, by providing privacy.

Treatments for Common Bowel Problems  Bowel Training: includes a combination of selecting the proper food and encouraging bowel movements at specific times to develop a regular pattern of elimination.  Enemas: are fluids drained into the rectum to remove feces and relieve constipation. There are various kinds of enemas, each with different purposes.  Suppositories: are cone-shaped medications which are inserted into the rectum. As they dissolve, they stimulate a bowel movement.  Rectal Tubes: are tubes inserted 6-inches into the rectum for 20-30 minutes to relieve flatulence.  Stool Softeners: are simple ways to evacuate the bowels. They are taken orally, with varying frequencies.  Laxatives: are products that promote bowel movements. Note: A Physician or Registered Nurse usually prescribes treatment for bowel problems.

Assistive aids for Elimination and Incontinence  Bed pans are generally used by people who are bedridden for short-term or long-term periods.  Urinals are generally used by people in bed or in a wheelchair.  Commodes are chair-like, mobile toilets either on wheels or stationary. They are used at the bedside or at a more secluded location.  Devices for external care are used primarily by men. A rubber bag is attached to the individual’s calf and is connected to the penis with a condom.

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 Catheters are sterile devices, which are inserted into the bladder. The urine drains from the bladder into a bag on the outside of the body.  Disposable garment protectors such as panty liners and padded undergarments are used to trap urine and feces. How HCAs Can Assist Older Adults with Urine and/or Fecal Incontinence  Manage urinary and bowel incontinency effectively and regularly to: • prevent discomfort; • skin problems; and, • possible infections.  Maintain their dignity with privacy and support.  Be sensitive to their feelings; i.e.: • embarrassment from: - loss of independence; - wet clothing; - odors; - skin breakdown; - falls (trying to get to the bathroom quickly); • loneliness & social isolation; • decreased self-esteem; and, • depression.  Protect furniture and bedding.  Choose discreet and comfortable products to catch urine and stool.  Prevent skin breakdown by changing soiled incontinency items immediately.  Clean the perineal and rectal areas to help prevent urinary infections and to minimize odors: • after each incontinent episode • after each bowel movement • when vaginal drainage is present; and/or • as part of regular body cleansing. Note: See “How HCAs Can Assist Older Adults with Bed Bath”  Be proactive: ask if they need to use the bedpan/urinal/commode.  Offer to help them get to the bathroom.  Encourage them to wear clothing that is easily removed.  Discourage them from drinking fluids near bedtime.  Ensure diuretics are taken early in the day (if ordered).  Encourage urination at scheduled intervals.  Follow their bladder training program (if in place).  Help prevent urinary infections by encouraging them to: • wear cotton underwear; • keep their perineal and rectal areas clean; and • drink an adequate amount. 102

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Skin Care The skin is the largest organ in the body and is responsible for:  protecting the body against environmental changes;  regulating the body’s temperature; and,  protecting the body from invading microorganisms, which can cause infection. Meticulous skin care is crucial to:  prevent skin breakdown to:  promote skin healing; and,  to increase circulation. Two common skin problems of Older Adults:  Skin Tears  Pressure Sores

Skin Tears Skin tears result when the skin is torn because of shearing, pulling or direct pressure on the skin; e.g. bumping an arm against a chair. Skin tears can be prevented by close and safe monitoring. How HCAs Can Help Prevent Skin Tears in Older Adults      

Keep the skin well lubricated with lotions and oils. Ensure they drink sufficient fluids. Ensure clothing has long sleeves. Place padding over elbows. Ensure toenails and hand-nails are kept short and filed. Place padding on bed rails and arms of wheelchairs.

Pressure Sores Pressure ulcers are red sores on the skin, which are caused by pressure, friction and skin breakdown. They can occur over any bony part of the body. If severe enough, they can result in damage to the bone, muscle or supporting structure. Pressure ulcers occur when an individual has been lying or sitting in one position for too long. Circulation is impeded by pressure and, if it is not relieved, the red area will turn into a pressure ulcer or sore. It is much easier to prevent a pressure sore than it is to heal one. 103

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How HCAs Can Help Prevent Pressure Sores in Older Adults  Maintain cleanliness.  Move and/or shift positions regularly (at least every 2 hours).  Practice good skin care, which includes: • inspecting the skin daily; and, • keeping the skin clean and moisture free.  Give extra care to individuals who are incontinent: • change wet clothing frequently; and, • apply ointments, powder or other barriers.  Use devices to reduce pressure (; sheepskin, foam padding, powder).  Ensure a healthy and balanced diet is provided.

Nail & Foot Care Nails are composed of a protein called keratin. Its function is to protect the ends of fingers and toes from trauma. Nail care is also conducted for cosmetic reasons. If the skin breaks down, because of hangnails or ingrown nails, infections can result. Dirty feet and/or clothing attract microbes, which can create odor. Home Care Assistants must consult with their Supervisor BEFORE providing nail care to an individual, as agency and state regulations about nail care vary. Some states and agencies allow accredited HCAs to clip nails while others do not. Nail care should NOT be performed by anyone other than a skilled professional such as a Physician, Registered Nurse or Podiatrist to individuals who:     

have circulatory problems; have medical conditions such as diabetes and calluses; take blood thinner medications; have very thick nails; and/or, have ingrown toenails.

Basics of Nail Care  Follow a strict washing and drying regime to prevent infection.  Do basic manicuring once a week  Try to provide manicure after a bath or shower, since much of the dirt will have been removed from under the nails.  Don’t use nail polish remover more frequently than once a week, as it causes the nails to dry out, crack and split. 104

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 Apply a clear nail polish to the nail, or, if colored polish is used, place a clear top coating to minimize chipping or cracking of the nail.  Apply cream or lotion after washing hands and keep the cuticles well lubricated.  Moisturize nails and hands at bedtime. How HCAs Can Assist Older Adults with Nail Care Fingernails

 Remove nail polish (if present): • Wipe nail with a cotton ball that has been moistened with nail polish remover. • Work from the base of the nail to the tip.  Soak hands in warm, soapy water for a few minutes to remove dirt.  Clean under the free edge of the nail using an orange stick, emery board or nail file.  Clip fingernails straight across using nail clippers (if clipping is permitted).  Shape fingernails with a nail file or emery board: • File each nail tip from corner to center. • Avoid filing file back and forth since that action may cause nail ridges and nail splitting.  Push cuticle; i.e. the skin that grows from the finger onto the base of the nail, back with a washcloth or orange stick, Leave the cuticle intact, as it helps prevent infection.  Apply nail polish (if wanted).  Apply moisturizing cream or lotion to hands and cuticles to prevent nails from splitting. Toenails

Generally, the same techniques used for fingernails are used for toenails:    

Soak nails and feet in warm water or apply a moistening cream. If toenail clipping is permitted, follow the same process as outlined for fingernails. Scrub calloused areas with washcloth. Check feet carefully for: • cracks and sores between toes; • blisters; • callouses; and, • reddened or irritated areas.  Check for: • nail discoloration; • extra thick nails; and. • loose nails.  Dry feet thoroughly, especially between toes.  Apply lotion or petroleum jelly to tops and soles of feet. Do not apply between toes.  Ensure toes are clean and dry before applying polish (if wanted). 105

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 Change shoes, socks, or hosiery daily to prevent fungus infections.

Dressing and Undressing Older Adults have the right to choose the clothing they want to buy and/or wear. Clothing has a psychological effect on how people feel about themselves and these feelings should not be treated lightly. Some clothing might take a little longer to put on and take off than an item designed for easy access would take. However, for their self-esteem, it is worth the extra effort to help them to wear garments they select. How HCAs Can Assist Older Adults with Dressing  When dressing an individual, who has a one-side weakness (usually the result of a stroke or an injury): • Place the garment over that weak side first; e.g. if an arm is broken, put the clothing on the broken arm to start with and then stretch the good arm around to complete dressing. • Do the reverse when clothing is removed; i.e. take the clothing off the good side first and then remove it from the weakened or injured side.  When pulling garments over the head: • Put the head through the neck of the garment first. • Slide each arm individually through the opening slot. • Follow the procedures listed above if there is a weak or injured side.  When putting on pants or slacks: • Slide pants over feet and up legs. • If they are lying down, ask them to raise their hips and buttocks off the bed. • If they are unable to raise hips and buttocks: - position them on their strong side and pull pants over hips and buttocks on the weaker side. - position them on their weak side and pull garment over the hips and buttocks on the strong side.  Three places a client may be dressed or undressed are: • on a bed; • in a wheelchair; or, • partially on a bed and partially on a chair. Note: Older Adults who have difficulty with zippers, buttons and snaps due to arthritis or other restrictive problems, may benefit from clothing that uses Velcro. By providing Velcro closures, they often can dress themselves without assistance.

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Turning and Repositioning Frequent and proper positioning of bedridden individuals is important to:      

Maintain proper alignment. Prevent pressure sores and skin breakdown. Prevent foot-drop and contractures. Provide comfort. Relieve strain. Have a turning and positioning schedule; i.e. they should: • be positioned in correct body alignment; • be supported with positioning aids; and, • be turned at least every 2 hours.

Home Care Assistants need to be trained before attempting tuning and repositioning individuals because certain need to be considered; e.g.:  the individuals condition; e.g. arthritis, spinal injury, spinal surgery; and,  the Home Care Assistant’s application of proper body mechanics.

Lying Positions The goal of good body alignment is to ensure there is no undue stress placed on the muscles or skeleton. By positioning individuals into the appropriate lying position, these goals usually can be achieved. Determining which position to use is partially based on:  personal preference;  condition; and/or,  treatment for illness. Common Lying Positions        

Supine Prone Simms Lateral Fowler Semi-Fowler Trendelenburg Reverse Trendelenburg

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 Supine: individual lies flat on back, facing upwards. Head is supported by a pillow and hands lay at the sides. It is the most common position used for surgical procedures often involving the chest, abdomen, peritoneal, head and neck areas.

 Prone: Individual lies on stomach with head turned to the side. Pillows may be placed under head, abdomen and lower legs. It is used for spinal surgeries treatment of burns and for drainage of the mouth after oral or neck surgery. It also allows for full flexion of knee and hip joints.

(Image Source: http://open.bccampus.ca)

 Simms: Individual lies on left side, left hip and lower extremity are kept straight, with right hip and knee bent. Arms should be comfortably placed at the side and not underneath. It is usually used for rectal examination, treatments and enemas.

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 Lateral: Individual lies on one side. Flex upper leg over bottom leg. Place pillows under head, upper arm and between thighs and upper legs. Pillows may also be placed at back. This position takes pressure off coccyx (tailbone).

 Fowlers: Individual is placed at a 45-degree angle, using pillows or raising the head of the bed. Hips may or may not be flexed. This is a common position to provide individual comfort and care.

(Image Source: http://open.bccampus.ca)

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 Semi-Fowlers: Individual’s is placed at a 30-degree angle using pillows or raising the head of the bed. This position is used for individuals who have cardiac or respiratory conditions, and for individuals with a nasogastric tube.

 Trendelenburg: The head of the bed is lower than the feet. This position is used in situations such as hypotension and medical emergencies. It helps promote venous return to major organs such as the head and heart.

(Image Source: http://open.bccampus.ca)  Reverse Trendelenburg: The head of the bed is higher than the feet. This position is used for abdominal and gynecological surgeries. How HCAs Can Assist Older Adults with Repositioning Some bedridden Older Adults are not able to reposition themselves, but they must be turned regularly to prevent skin break down. Since Home Care Assistants often work alone they can reposition them by: 110

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 moving their body in segments; i.e. first the upper body and then the lower body; or;  by using a lift sheet. Reposition Towards Head of Bed

     

Place bed in a flat position. Roll them to one side. Place a half-rolled lift sheet against their back. Roll them onto sheet with head shoulders and hips on sheet. Grab lift sheet on side closest to you. Put one foot forward and pull sheet towards head of bed. If working alone, pull one side up and then pull the other.

Reposition from Back to Side

          

Raise the bed, if bed is capable of rising. Ask him/her to cross his/her arms over their chest. Stand at side of bed, facing the person. Place a pillow between his/her knees. If bed has siderails, ask him/her to grab it the siderails, if capable. Roll edge of lift sheet from your side of bed. Firmly grasp it and pull it up slowly to turn him/her from his/her back to a side position. Place a pillow against back and a second pillow against buttocks. Maintain alignment of top hip. Leave ankles and knees separated, supported by a pillow. Ensure lower arm and shoulder are not tucked under one side. Support upper arm with pillow.

Reposition in a Wheelchair or Chair

 If in Wheelchair: • Ensure wheelchair brakes are locked and castors point forwards. • Remove footrests or swing them to side.  If in Chair: • Ensure chair is secure so it does not move or tip.  Stand in front of person with his/her left leg between your legs.  Make sure person’s weight is on the side that is not being repositioned.  Place your right arm under person’s left thigh while placing slight pressure on person’s left knee with your knee.  Use your entire body to push them person toward back of char.  Repeat steps for other side. 111

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     

If person is not far enough back in chair repeat procedure. Position them in an erect position to support alignment. Ensure the back and buttocks are against the back of the chair. Place feet flat on floor or on wheelchair footrests. Place a pillow/foam positioner between lower back and chair for support, if needed. Place pillows under paralyzed arms.

Transferring Sometimes individuals need assistance when moving from a bed to a chair/wheelchair/commode and back again. The amount of assistance varies depending on the individual’s capabilities. Transferring may require one person, two or more people, or it may require a mechanical lift. Safety is of utmost importance to prevent an individual from falling and HCAs from being injured. Transfer techniques vary depending on the individual’s age, flexibility and strength.

Basics of Transferring      

  

Discuss procedures with the individual before attempting any transfer. Respect his/her transferring preferences unless safety is an issue. Don’t try to transfer anyone who is too heavy to safely handle. Ensure the surface is firm and level before attempting any transfer. The transfer surface should be at the same level or height, as the surface being transferred from. When wheelchairs are used, ensure the foot pedal is out of the way, the brakes are locked, and the armrest is removed from the side the individual will be shifting from. The surfaces of equipment, used in the transfer process, should be placed as close as possible to a 90-degree angle before transferring; e.g. have the chair next to and at a 90-degree angle to the bed when preparing to move an individual from the bed to the chair. Don’t grab, lift or pull him/her by their wrists, elbow or shoulders, as this action may injure their joints. Don’t allow him/her to put their hands around your neck. Use good body mechanics.

Pivot Transfers A pivot transfer is used when moving an individual from one surface to another and is done at a right angle closest to the point of transfer. During the transfer the client stands, turns or pivots and then sits down on a new surface. Use a Transfer Belt when:  transferring to the toilet;  transferring to the bathtub;  transferring to the shower, 112

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 the individual is wearing tight clothing; or,  the individual is not fully dressed. How HCAs Can Assist Older Adults with Pivot Transfers  Position their stronger side closest to the chair (or whatever place they are transferring onto).  Have them sit at the edge of the bed with their feet flat on the floor. Place the stronger foot slightly behind the weaker one.  Place your hands on the backside of the Transfer Belt, which has been placed around their waist.  Place your feet and knees outside their body to prevent their legs from collapsing.  Ask them to grasp their arms around your upper back or elbows. Do not allow them to place their arms around your neck or you could be injured.  Tell them you will “rock” them back and forth counting as you go. On the count of 3, assist them to stand.  Pivot (turn) your feet towards the chair and rotate them to a position where they can sit on the chair. Ensure they are standing up straight and are under control before pivoting.  Lower their body slowly to the chair. At the same time, have them reach backwards to grasp onto the armrest or chair.

Note: If they are unable to do pivot transfers, supportive equipment is available; e.g. sliding board, trapeze bar (attached to the bed), or a Hoyer Lift. How HCAs Can Assist Older Adults with “One-Person” Transfers One-person transfers are conducted when Older Adults only need one person to help them move. Following are some techniques for one-person transfers from bed to chair, wheelchair or commode:        

Position the chair next to and even with the headboard. Get them into a sitting position with legs and feet dangling over the edge of the bed. Prevent them from sliding or falling by blocking their knees and feet with your own. Have them put his/arms around your elbows or upper back (if capable); Place your hands under their arms and around their shoulder blades; Support them as they grasp the far arm of the chair; Have them hold onto the armrests of the chair and lean forward; Direct them to bend their elbows and knees, as they are being lowered into chair.

Assistive Transferring Devices Individuals who have health or other conditions that affect their mobility need assistance from others to move from place to place. Some of these transfers must be performed numerous times

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a day. Using transfer devices can reduce shear force on an individual’s skin, which could lead to bruising and skin breakdown. They also prevent injuries that often occur when their arms or legs are pulled Assistive transferring devices allow individuals to participate with their own transfers. This activity is beneficial to them because it:  exercises their muscles;  makes them take deeper breaths; and,  engages their minds. Such devices can be used for manual transfers, repositioning and mobility; e.g. sit-to-stand or gait training. They also assist those with limited weight bearing abilities. The use of assistive transfer devices requires:  careful attention to proper body mechanics to protect the Home Care Assistant and the individual; and,  a focus on the centers of gravity for the Home Care Assistant and the individual.

Transfer Belts Transfer Belts (also known as Gait Belts) are strips of fabric or vinyl, about two inches wide, with an adjustable buckle. Some have handles to improve grasp. Transfer Belts can be used for individuals who are partially ambulatory, have some weight-bearing capacity and are cooperative. They can also be used in conjunction with Transfer Boards when sliding from one level surface to another; e.g. bed to wheelchair; wheelchair to chair, toilet or car.  Transfer Belts are used to: • transfer individuals with mobility issues: - from one position to another; - from one location to another; or, - to maintain balance, when walking. • provide safety for individuals and HCAs; • provide a feeling of comfort for individuals; • give HCAs control if individuals start to slip or fall; • prevent injury to individuals or HCAs.  Transfer Belts should not be used for individuals who have certain conditions such as: • colostomy; • feeding tube going directly into stomach; • pregnancy; 114

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• abdominal aortic aneurysm; • recent abdominal surgery; • fractured ribs; and, • severe cardiac or respiratory disease. How HCAs Can Use Transfer Belts to Assist Older Adults  Position Transfer Belt around their waist, above the pelvic bone and below the rib cage.  Place belt snugly around their body leaving enough space between belt and clothing for HCA’s fingers to fit side-by-side.  Don’t place belt directly onto skin. Place it on top of clothing.  Use belts with padded handles, if possible. They provide a secure surface for HCA to grasp.  Apply a rocking motion to lift them instead of lifting in one move.  Walk behind them and keep a firm grasp on the underside of the Transfer Belt.

Transfer Boards Transfer Boards (also known as Slide Boards) are long, smooth boards about 2-feet long. They are used to help individuals transfer from a seated position onto a chair, bed or wheelchair and are appropriate for those who can bear weight with their arms and can understand and follow directions. They should not be used by individuals who are:      

unable to sit up independently; combative; sleepy; dizzy; disoriented; or, off-balance

How HCAs Can Use Transfer Boards to Assist Older Adults    

Ensure Transfer Board is no higher or lower than ½ inch of the other surface; e.g. wheelchair. Place Transfer Board and the other surface close together. Secure Transfer Belt above their pelvic bone and below rib-cage for safer handling. Have them hold onto a stable surface using: • one arm and one hand; • arm of chair; • braked wheelchair; grab-bar; or, • HCA’s shoulder.

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Mechanical Lifts Mechanical Lifts are used for individuals whose mobility is limited and need maximum transferring assistance. They are used for transfers to chairs, wheelchairs, bath-tubs, showers, toilets, stretchers, cars, whirlpools and, beds. Manual and Powered Types are available:  Manual versions have hydraulic cylinders and a handpump.  Powered lifters have rechargeable battery-packs and pushbutton hand controls. Types of Mechanical Lifts  Ceiling Lift: is directly mounted into the ceiling. The unit glides along the railing to transport individuals, secured in slings.  Hoyer (Portable) Lift: utilizes a crane-like, lifting arm to transfer individuals secured in slings. They have a wheel base which enables them to be moved easily.  Hoyer Lift Sling: is designed to be suspended from and attached to the lift boom and swivel bar of the Hoyer Lift.

Basics of Mechanical Lifts            

Follow the manufacturer’s directions. Ensure the lift is working. Ensure the sling is the correct one for the lift. Ensure maximum weight levels of lift and sling will support individual being transferred. Ensure sling is not frayed, stressed at the seams or damaged in any way. If damaged, don’t use it. Ensure individual is not agitated before starting transfer. Ensure the lift legs are spread out as far as possible. Place the individual’s arms within the sling straps. Ensure all clips, latches and hanger bars are securely fastened. Ensure individual must is centered over the lift base always. Lock wheels of wheelchair, bed or other destination item, before transferring. Use a helper, other than the individual being transferred.

How HCAs Can Transfer Older Adults Using Mechanical Lifts Note: HCAs must never use a mechanical lift device before receiving hands-on training for the specific device being used. In addition to learning the technicalities of its operation, 116

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HCAs need to know and understand how the lifter will feel with a person in it. HCAs are responsible for ensuring they are trained prior to using any mechanical lift.            

Follow the guidelines provided in Basics for Mechanical Lifts. Center sling under the individual by turning him/her from side to side. Position lower end of sling under individual’s knees. Raise the lift and position it over individual. Spread legs of lift to their widest position. Lock the lift wheels. Cross individual’s arms over chest and have him/her grasp the sling straps. Pump lift until individual and sling clear the surface he/she was lying or sitting on. Ask helper to support individual’s legs while you move and lift him/her to desired location. Position the lift so individual’s back is toward the destination; e.g. chair, toilet, bed. etc. Lower and guide individual onto new location; e.g. chair, toilet, bed. etc. Lower swivel bar to unhook sling.

Body Mechanics Body mechanics refers to the use of proper body movement in daily activities, the prevention and correction of problems associated with posture and the enhancement of coordination and endurance. The purposes of good body mechanics are to prevent:     

excessive fatigue; muscle strains or tears; skeletal injuries; injury to the individual being moved; and, injury to HCs.

Basics of Good Body Mechanics  Maintain a stable center of gravity approximately 4-inches below navel, near the top of the hip bones: • keep center of gravity low; • place feet a shoulder’s width apart with one foot ahead of the other; • keep back straight; and, • bend at the knees and hips.  Wear closed, non-slip shoes and keep back straight.  Get close to whatever is being moved, without stretching. 117

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        

Bend from the hips and knees and not from the waist to lift objects. Do not bend or reach unnecessarily. Don’t lift objects higher than chest level or above shoulders. Lift with strong muscles in legs. Do not lift with back. Lift upward in one movement. When carrying objects, keep them close to body. Use both hands. Use body weight to push or pull an object. Do not twist body. Move feet slowly around to the new position. Maintain proper body alignment: • Pull abdomen in and up. • Tuck in buttocks. • Keep back straight. • Keep head up. • Keep chin in. • Keep weight forward. Support weight on outsides of feet. • Sit on a hard chair with a straight back. Use a back support; e.g. pillow.

How HCAs Can Apply Good Body Mechanics to Move Objects         

Follow the principles outlined in Basics of Good Body Mechanics Adopt a stable base of support in front of object. Grasp object at its center of gravity Use arm and leg muscles to pull object towards your center of gravity Re-establish base of support and proper body alignment. Pivot towards the direction of travel. Re-establish base of support and proper body alignment. Squat and place object on lower location. Use leg muscles to stand up.

Range of Motion Exercises “Range of Motion” (ROM) is a term used to describe the amount of movement in a joint. Every joint in the body has a "normal" range of motion, which is maintained through movement. It is important that all joints be moved every day. Stiff joints can cause pain and can make it hard to carry out the activities of daily living. Range of Motion exercises preserve the flexibility and mobility of the joints. The exercises reduce stiffness and will slow down the rate at which joints freeze. There are two types of ROM exercises:  Active Range of Motion Exercises: can done by individuals themselves, if they have the muscle strength to move their joints through their complete ranges.

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 Passive Range of Motion Exercises: are done for an individual by a caregiver. Note: Often a combination of both types of ROM exercises will be used.

Basics of ROM Exercises  Physicians, Physiotherapists or Occupational Therapists prescribe the type(s) and frequency of ROM exercises.  Generally, ROM exercises are done at least twice a day preferably: • while bathing, as warm water reduces tightness and stiffness of muscles and joints; and, • at bedtime.  Immobile persons should have or do ROM exercises every 8-hours to prevent contractures.  If joints are painful and swollen, move them gently.  Do the exercises slowly and steadily.  Do not force movement. If exercise causes pain, stop.  If too much force is applied, the joint space can be damaged.  ROM exercises are conducted one joint at a time, starting at the neck and moving down.  When executing the full ROM, place one hand just above the joint and the other hand below the joint.  Do each exercise 3-5 times (or more) to the point of resistance and hold for 30 seconds.  Begin exercises slowly, doing each exercise a few times only and gradually build up.  Try to achieve full ROM by moving until a slight stretch is felt.  Support the limbs throughout.  Move slowly, watching the individual’s face for responses to the exercises. Note: A Physiotherapist usually determines the number of repetitions and duration of ROM exercises. How HCAs Can Assist Older Adults with ROM Exercises When trained and instructed to assist or conduct Range of Motion Exercises, Home Care Assistants can play a valuable role. It bears repeating that ROM exercises:  need to be authorized/prescribed by a Physician, Physiotherapist or Occupational Therapist; and,  HCAs must receive specific instruction and demonstration on the ROM program designed for each person before performing the exercises. ROM Exercises for Shoulder

 Exercising Shoulder: Support arm, holding under elbow and wrist joint areas.

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 Shoulder flexion/extension: Raise straightened arm from bed towards head of bed then return arm back towards bed, as one repetition  Shoulder abduction/adduction: Move straightened arm away from side of body towards head of bed and return toward side, as one repetition  Provide rotation exercise to the shoulder. ROM Exercises for Knee

 Support knee and ankle joints while exercising knee.  Knee flexion/extension: Bend knee back to point of resistance and then follow by straightening knee, as one repetition ROM Exercises for Ankle

 Support ankle, holding under ankle area and foot, while exercising ankle.  Ankle flexion/extension: Push foot forward towards leg, and in separate motion push the foot pointed down toward the foot of bed, as one repetition  Provide three (3) repetitions of each shoulder, knee and ankle ROM exercise.  Ask individual about comfort level throughout exercises.  Provide controlled, slow, gentle movements when exercising shoulder, knee and ankle. Home Care Assistants are generally not permitted to do ROM exercises on an individual’s neck due to the risk of neck injuries. The individual’s Physiotherapist or Occupational Therapist usually determines, on a case-by-case basis if HCAs will be asked to do ROM neck exercises. When HCAs are not permitted to do neck exercises, usual practice is that the Physiotherapist or Occupational Therapist will do them.

Mobility Older Adults should be encouraged to walk to:  maintain muscle strength;  exercise their body; and,  prevent contractures. (Contractures occur when muscle and tendons shorten, which causes a deformity or subnormal range of movement of a joint.) Because some clients are weak and unsteady, they have difficulty walking without assistance from either a device or another person(s). There are various devices available, which will provide the support they need. Manually operated and power-driven devices are also available for individuals who cannot walk, even with walking aides.

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Assistive Devices for Mobility The type of mobility aid needed by an individual is determined by:  physical condition;  amount of support needed; and,  type of condition/disability. There are several types of mobility aids. Generally, they are ordered by a Physician, Nurse or Physical Therapist:

Assistive Device Transfer Belts Crutches

Handrails

Canes

Braces

Walkers

Wheelchairs

Electric Scooters

Description Transfer Belts are placed around the individual’s waist. The HCA grasps the belt to support the individual while he/she walks or transfers. Crutches are used when a person does not have the use of one leg or when a leg(s) needs to gain strength. They are usually made of wood or metal and extend from the underarm to the ground. It is important that an individual be measured properly to decrease the risk of falling. Handrails, installed on walls/stairs, give the individual something to grasp onto as he/she walks. Cane are often used when there is weakness on one side of the body. They can be single tipped, 3-pronged or 4-pronged. The latter provides the most support. Canes are used on the strong side of the body. When the individual takes a step, he/she places the cane a few inches ahead of his/her body and then moves the weaker leg forward first. Then the stronger leg is brought forward and placed ahead of the cane and weaker leg. Braces are used to support body parts that are weak. They also prevent or correct deformities. They can be made of metal, plastic or leather and are applied over the ankle, knee or back. To prevent skin breakdown, ensure that the skin under the brace is clean and dry. Walkers provide more support than canes. They have 4-points. Some walkers have wheels, which enable the individual to propel the walker along. The walkers without wheels must be lifted by the individual as he/she takes a step forward, Other walkers come equipped with a seat and basket. They allow the individual to sit down when feeling tired or unsteady and enables them to transport small items. Wheelchairs are movable chairs, which are mounted on large wheels. They are used by people who cannot walk. They can be manual or electric. Manual wheelchairs are propelled by the person sitting in them or by a second person pushing the wheelchair. Electric wheelchairs utilize a battery for movement. Electric scooters (also known as ECV or electric convenience vehicle), are batterypowered, 3-wheeled or 4--wheeled vehicles designed for individuals who have difficulty walking. Scooters are versatile and can be used both indoors and out.

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How HCAs Can Assist Older Adults with Walking               

Point out destination. Instruct them to lean forwards on the seat of the chair prior to standing up. Place their knees at 90-degree angle, with feet flat on floor. Tell them when it is time to stand up. Instruct them to push up with their arms when going from a sitting to standing position. Put hands on their waist, back or arm, as they stand. Provide aid, as necessary when walking. Walk slightly behind and to one side of them. Ask them when standing and when walking about how they feel. Walk to destination. Instruct them to center their legs against the seat of the destination chair before sitting. Advise them to reach for chair before sitting. Put hand on their back, waist or arm before they sit. Position their hips against the back of the chair seat to ensure safety. Be sure they are secure and comfortable.

Falls Falls are the main cause of serious injuries and accidental deaths in Older Adults. Falls can result in broken bones and/or head injuries. They can affect their quality of life, as fear causes them to restrict their activities.

Causes of Falls     

Age-related diseases and conditions; e.g. poor eyesight or poor hearing. Physical conditions can affect strength and balance; e.g. weakness, dizziness. Shoes without adequate grip. Hazards in the home environment; e.g. poor lighting, throw rugs, wet floors. Medication: • side effects can; - upset balance; e.g. medication for depression, sleep problems and high blood pressure; and, - cause unsteadiness on feet; e.g. medication for diabetes and heart conditions. • changes can cause falls within the first few weeks; and, • combinations and numbers can increase risk of falls.

Note: Refer to Section 10 – Health & Safety

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How HCAs Can Assist Older Adults During a Fall When Older Adults start to fall, may automatically try to prevent the fall. This action could result in injury to both parties. What HCAs should do is:  Ease them to the floor, which will help control their direction of fall; i.e.: • if possible, get behind their body; • bring them close to your body; • grab onto the Transfer Belt (if they are wearing one); or, • wrap your arms around their waist; or, • hold them under the arms; • use your leg for support and allow their buttocks to rest on it. This will enable them to slide down your leg to the floor.  Protect their head on the way down and when they are on the floor.  Do not move them once they have landed.  Do what you can to keep them calm and comfortable.  Check for injuries.  Don’t allow them to stand up if they are disoriented or injured.  Obtain help as needed.  Stay with them until emergency help arrives.  Give First Aid and/or CPR, if needed.  Document details of fall in their file and complete an Incident Report.

Meal Assistance Objectives of Good Eating Programs The objectives of a good eating program are to:     

provide a balanced diet; prevent choking; make the experience pleasurable; improve quality of life; and, maximize independence.

Impacts on Food Consumption Factors that may impact an Older Adult’s food consumption:  Food Preferences  Religious Beliefs 123

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   

Health Status Special Diets Food Consistency Denture Need or Problems

Note: An Occupational Therapist can assess Older Adults’ functional ability to determine if special adaptive devices would enhance their eating ability.

Adaptive Eating Devices Some individuals have difficulty eating independently, which may cause them to lose their appetite or even stop eating. Adaptive utensils, plates, and cups make it easier to for them to eat. These devices promote their chances of staying well nourished. Adaptive devices will also make their mealtime experience more enjoyable. Some common adaptive eating devices are:  Easy-grip handles on utensils: helpful for individuals with shaking hands.  Easy-grip handles that can bend to the right or left: helpful for individuals with limited hand movement or arthritis.  Velcro straps that go around hand: helpful for individuals with weak hand muscles or are unable to grip utensils.  Foam tubing for easy-grip handles: helpful for individuals with arthritis.  Rocker Knife with serrated blade: helpful for individuals who have trouble cutting food.  No-spill, easy-grip cups: helpful for bedridden individuals and individuals with shaking hands.  Red-colored utensils and dishes: helpful for individuals with dementia, as that color increases food and fluid consumption. How HCAs Can Assist Older Adults with Meals  Set-up eating area: • Place a non-slip placemat on the table surface. • Ensure utensils are clean and in good shape. • Ensure utensils are suited to their needs. • Use smaller spoons to offset spilling. • Use straws and special cups, if fluid flow is an issue. • Provide appropriate feeding utensils; e.g. fork or spoon instead of chopsticks. • Place all utensils within their reach. • Ensure assistive devices are within reach.  Preserve their dignity and ensure their safety.  Ensure they are alert before and during feeding.  Ensure they are positioned properly; i.e.: • Body is straight and in an upright position; 124

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• head is flexed slightly; and, • chin is pointing downward to reduce the chances of choking.  Protect clothing with a cover; e.g. towel, apron before feeding unless they decline the cover.  Encourage them to self-feed to the extent of their capability.  Sit in a chair facing them if they need to be fed.  Make sure that food is not too hot or too cold.  Be sure everything has been swallowed and mouth is empty before offering next bite.  Ask which food item they want for the next bite. If not told, vary choice from bite-to-bite.  Give bite-sized servings, as opposed to larger amounts of food.  Talk to them during the meal; i.e. make the eating experience enjoyable.  Allow them sufficient time to eat. Do not rush them. If they don’t want to eat, determine the reason why and try to rectify the problem; e.g. not hungry, don’t like the food, sores in mouth.  Watch for coughing, dribbling or aspiration of food into the nose, as this could indicate swallowing problems.  Signs and symptoms of aspiration. (Aspiration is the accidental sucking in of food particles or fluids into the lungs.): • difficulty breathing; • engorged face and neck veins; and, • face turning blue with loss of consciousness in severe cases.  If a they choke or aspirates, call emergency services, if indicated.  Ensure they are well hydrated by encouraging and/or assisting them to drink fluids.  When finished eating: • Check their mouth for food remnants. • Provide wipes for washing face and hands. Assist as necessary. • Wash mouth and clean teeth/dentures, if assistance is required. • Remove clothing protector and dispose of any garbage. • Leave eating area; e.g. table, over-bed table clean, dry and free of dishes and utensils.

Self-Care Self- care refers to the basic actions or activities of daily living involved to care for one’s self and body, including personal care, mobility and eating. Some Older Adults are inclined to sit back and let others tend to their self-care needs when they are capable of at least participating. How HCAs Can Promote Self Care to Older Adults  Encourage them to do as much of their own personal care as possible to: • give them exercise; • promote their independence; and, • develop their feelings of participation. 125

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 Make suggestions on how their environment might be adapted to assist them with their selfcare such as: • installation of grab-bars near the toilet, bathtub and/or shower; • installation of railings on stairs; • use of bath-bench in shower or bathtub and, • making their home wheelchair accessible.  Include them in planning their self-care by: • taking their feelings and suggestions into consideration; • encouraging their involvement; and, • adjusting the action pace to whatever works best for them.  Become knowledgeable about their disability or condition to determine what else might be done to enable them to function as independently as possible. Help them function at the top of their capabilities.

Vital Signs Vital signs are taken to monitor the body’s performance in respect to temperature, breathing and heart function. Vital signs are measured by four different methods:

Temperature The human body normally maintains a constant temperature within a few degrees of 98.6° Fahrenheit (37° Celsius). Older Adults generally have a lower reading. Therefore, a 98.6 measurement for them, could indicate a slight temperature. Temperature is measured by inserting a monitor into the mouth, ear, rectum or underarm.

Pulse A pulse is a beat of the heart as blood passes through the artery. It is felt by pressing down on the artery and counting the number of beats in a given length of time (usually 1 minute). If the pulse is regular, it need only be counted for 15 seconds and then multiplied by 4. A watch or clock, with a second hand, is required to measure pulse rate.

Respirations Respiration refers to the act of breathing air into and out of the lungs. An adult has 10-20 respirations a minute. They are usually quiet, effortless and regular. The best time to measure respiration rate is when an individual is at rest. Count the number of rises and falls of the chest for 30-seconds and then multiply that figure by two.

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Note: Count respirations immediately after taking the pulse; i.e. when fingers are still on the pulse. This way, individuals think their pulse rate is still being measured, should they plan to alter their breathing rhythms.

Blood Pressure Blood pressure refers to the force blood exerts against artery walls. When the heart is contracting, (called systolic pressure) the amount of blood being forced out of the heart into the body’s circulation is being measured. The pressure exerted on the walls of the arteries when the heart is at rest is called diastolic pressure. A normal blood pressure for adults is 90 to 120 (systolic) over 60 to 80 (diastolic). Blood pressure is measured by a monitor. Some monitors require the assistance of a stethoscope. Other monitors, such as digital monitors, do not require a stethoscope. Note: Practical training is required to learn how to take vital signs.

Medication Management The role Home Care Assistants have in medication management depends on their training, state regulations and employer’s policy.

HCAs Certified in Medication Administration Some states have authorized Home Care Assistants to administer medications under certain conditions:  They complete additional specialized training and become certified in medication administration.  They be restricted on what medications they can administer. How Specially Trained HCAs Can Administer Medications to Older Adults  Before administering medications to Older Adults, HCAs must: • be employed in a state that allows HCAs to administer medications; • have the approval of the Home Care Agency or facility that employs them; • obtain written authorization from the Supervisor or Registered Nurse; and, • be familiar with which medications they can and cannot administer.  Follow the “6 Rights” of medication administration: • Right Individual • Right Drug • Right Dose 127

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• Right Time • Right Route • Right Documentation  Review their medication needs and timetable.  Tell them when it is time to take their medication.  Select the medication(s), which are labelled with their name.  Select the medication (s) to be given at that time.  Examine the label on the medication container before removing medication from container.  Dispense pill(s) into container, without touching them.  Dump correct medication amount from container cap directly into their hand, without touching medication.  Advise them to take medication.  Help them take medication but avoid: • putting your hand over their hand; • tipping their hand to put pills into their mouth; and, • placing pills directly into their mouth.  Hand them a glass of fluids to swallow medication.  Advise them to drink the whole glass of fluid.  Ensure that all the medication has been swallowed.  Put container lid back on medication and return it to its storage area.

HCAs Not Certified in Medication Administration Home Care Assistants, who have not been certified in medication administration may play an assistive role if they have received written instructions from their Supervisor or a Registered Nurse to do so. Many Older Adults now use Blister Packs to manage their medications. Blisto Packs are containers that have pockets, which have been divided into days of the week and times of the day, (usually breakfast, lunch, super and bedtime). The Pharmacy dispenses prescribed medication into the appropriate day and time slots. This way, Older Adults do not have to gather and dispense their own medications, thereby reducing their chances of making errors and/or becoming confused over whether they took their medications at the designated times. How HCAs Can Provide Medication Assistance to Older Adults  Check label on Blister-pack or other medication administration aid to ensure it is for the

correct person.  Ensure that all Blister-packs and medication containers are labeled, as a minimum, with: • name and telephone number of Pharmacy that prepared medication; • date of preparation; • name of consumer; 128

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• name & dosage of medication; • instructions for taking medication; • important side effects; • identification number; and, • appropriate warnings.  Remind clients that it is important to store medication properly; i.e.: • in accordance with any instructions on the label; • in their original containers; • in a cool, dry and secure place; • at the correct temperature; and, • refrigerated, when required.  Watch for signs they may be having difficulty administering their medications. Advise Supervisor if there seems to be a problem.  Encourage them to keep an up-to-date list of their prescription and non-prescription medications. Help them or have them record: • their name, address and date of birth; • their Physician’s and Pharmacy’s contact information; • details of medications; i.e.: - name; - dosage; - frequency; - duration; and, - method of administration. • allergies and previous adverse drug reactions; • details of any vaccinations received; and, • informed consent to share information with others who are involved in their care. How HCAs Can Monitor Older Adults Who Manage Their Medications When Older Adults are responsible for taking their own medication, HCAs role is to:  Ensure they have taken their medication as scheduled.  Document pertinent information; i.e.: • time and date each medication is taken; • refusal to take medication as prescribed; • wrong medication taken; • insufficient or too many tablets taken; • medication supply has run out; and, • other reason medication was not taken.  Advise Supervisor whenever clients have not taken their medication, as prescribed, or when an anomaly has occurred.

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HCA Working Tools Home Care Assistants require specific items to perform their duties. When working in a facility, these items are usually provided (except a watch). Whether working for a Home Care Agency or as a Self-Employed Home Care Assistant, it is wise to have certain items in your personal stock:         

Uniform or Scrubs Transfer Belt: to assist clients in and out of chairs and to provide support while client walks. Digital Thermometer: to determine and monitor body temperature. Watch or Clock with a Second Hand: to take pulse and observe respirations. Blood Pressure Monitor: to measure blood pressure. Stethoscope: take blood pressure, listen to lungs and hear heartbeat. Blood Pressure Cuff Solid Shoes with Good Grips: to prevent slipping and back strain. Protective Gear; e.g.: • disposable gloves; • masks; • gowns; • face and eyewear; and, • alcohol wipes.

Generally, it is the Older Adult’s responsibility to have personal care products on hand. However, Home Care Assistants should have a few supplies for those individuals who unexpectedly require help when the Home Care Agency’s supplies or local stores are not available; i.e. during times of closure. If HCAs have some incontinency items in their personal stock, they will be able to respond to unscheduled calls for assistance; e.g.:  disposable soaker pads;  disposable peri-wipes (or other disposable cloths like baby wipes); and,  disposable incontinence pads; e.g. Depends.

Summary Home Care Assistants often provide personal care to Older Adults by assisting them with their activities of daily living. These activities include grooming, bathing, dressing, toileting, transferring, feeding, exercising and ambulation. All require a certain degree of knowledge and skill for HCAs to perform their duties efficiently and competently. An important goal of providing support to Older Adults is to encourage them to participate in their own self-care to the extent of their capabilities. In so doing, they will maximize their functioning ability, maintain some independence, keep some control over their lives and enhance their self-esteem and self130

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validation. It is especially important that Home Care Assistants know and adhere to the limits of their expertise and not do anything that is beyond the scope of HCA duties.

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SECTION 9: NUTRITION

This section deals with nutrition and diet. The Home Care Assistant will learn about the Food Guide Pyramid, dietary guidelines, servings, special diets, eating practices and factors which influence nutrition, particularly as they relate to Older Adults. This information will enable Home Care Assistants to provide nutritional services to clients such as meal planning, food preparation and food shopping.

Nutrition Nutrition is a process in which food material is taken into the body and utilized. Foods that are great sources of nutrition are called nutrients. There are six types of nutrients:      

Carbohydrates Fats Proteins Vitamins Minerals Water

Nutrients are vital to health because they:    

give energy; promote growth; help repair body tissues; and, regulate body functions.

Energy is needed for all human activities, including sleeping. The energy used is called calories. A calorie is a measure of the energy content in food. The more calories a person consumes, the grater the amount of energy he/she will have.

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Dietary Guidelines Dietary guidelines were established to improve health and reduce the risk of disease with the focus being on disease prevention rather than disease treatment. Guidelines for improving health and preventing disease include:  Eat an appropriate number of calories to: • obtain and maintain a healthy body weight; • support nutrient deficiency; and, • reduce the risk of chronic disease.  Balance the food eaten with physical activity to reduce or maintain weight and to reduce the chances of developing diseases.  Include a lot of grains, fruits and vegetables in the diet, as they provide vitamins, minerals and fiber.  Choose a diet low in fat, saturated fat and cholesterol.  Limit sugars in the diet, as they have no other nutrients and can keep healthier foods out of the diet. Sugars can also cause tooth decay.  Choose a diet with moderate amounts of salt to help reduce the risk of high blood pressure.  Drink alcohol in moderation; i.e. two drinks per day for men and one drink per day for women. Alcohol supplies calories but few or no nutrients.  Help create and support healthy eating patterns throughout the community.

Food Guide Pyramid The Food Guide Pyramid is an outline of what should be eaten each day for optimum health. It is a general guide that enables people to select foods according to their individual tastes and, at the same time, ensure they:  obtain the essential vitamins, minerals and other nutrients;  reduce their risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis; and,  contribute to their overall health and vitality. The Food Guide Pyramid consists of 5 major food groups:     

Milk, Yogurt and Cheese Meat, Poultry, Fish, Dried Beans, Eggs and Nuts Vegetables Fruit Bread, Cereal, Rice and Pasta

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USDA Food Guide Structure

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Food Servings A healthy diet should include foods from each level. The amount of food needed each day depends on several factors:      

Age Body Size Activity Level Gender Pregnancy Breast Feeding

The Food Guide Pyramid recommends the following number of servings per day for each food group: Food Group

No. of Servings/Day

Milk, Yogurt Cheese

2-3

Meat, Poultry, Fish, Dry Beans & Eggs

2-3

Vegetables

3-5

Fruit

2-4

Bread, Cereal, Rice & Pasta

8 - 11

Fats, Oils & Sugar

One Serving Size    

¾ cup yogurt 1 cup milk I piece hard cheese just under 2 oz. 2 cheese slices

 2–3 oz. of cooked lean meat, poultry or fish  ½ cup of cooked dry beans  The following are equivalent to 1 oz. of meat: • 1 egg • 1/3 cup nuts • 2 tablespoons of peanut butter  1 cup of raw, leafy vegetables  ½ cup of other vegetables – cooked, frozen or raw  ¾ cup vegetable juice  1 medium apple, orange or banana  ½ cup chopped, cooked, canned or frozen fruit  ¾ cup fruit juice (6 oz.)  1 slice of bread, bagel, bun or pita bread  1 oz. ready to eat cereal  ½ cup cooked cereal, rice or pasta

 Use sparingly  Limit fat to 30% of calories

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When making food choices, try to select:  Grain Products: choose whole grain and enriched products more often.  Vegetables and Fruit: choose dark green and orange vegetables and fruit more often.  Milk Products: choose leaner meats, poultry and fish, as well as dried peas, beans and lentils more often.

Types of Diets Omnivorous Diet An omnivorous diet includes animal and vegetable foods. Most people are omnivorous. This type of diet is the easiest one to maintain because there are no restrictions. Advantages of Omnivorous Diet  Includes from all five major food groups.  High likelihood of getting all essential nutrients. Disadvantages of Omnivorous Diets  Does not guarantee improved health or optimal nutrition.  Higher rates of cancer, diabetes, and heart disease.  Increased risk of abdominal fat, higher Body Mass Index (BMI), obesity, unhealthy stools, and accelerated aging.  Unhealthy convenience foods and processed products are often chosen.

Carnivorous Diet A carnivorous diet includes animal flesh or meat, such as poultry, fish, seafood, beef, pork and eggs. Advantages of a Carnivorous Diet:  It is high in protein, which is beneficial for growth and tissue repair.  It provides iron. Disadvantages of a Carnivorous Diet:  It contains hardly any fiber, which increases the risk of colon diseases.

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 The high-fat types of meat increase the risk of cancer, atherosclerosis (hardening of the arteries), heart disease, and other problems.  It is low in vitamins and minerals and thus requires Vitamins B, C, E and minerals (which can be found in the vegetable foods).

Vegetarian Diet A vegetarian diet has no animal products such as red meat, poultry, fish and shellfish. However, it may include dairy products and eggs. Advantages of a Vegetarian Diet:  Vegetarians generally have lower blood pressure and weight than people who eat meat.  The incidence of hypertension, obesity, high cholesterol, atherosclerosis, heart disease, cancer and osteoporosis are all reduced with a vegetarian diet.  The high fiber and lower fat in the vegetarian diet help keep cholesterol levels down.  The incidence of digestive tract diseases is minimal. Disadvantages of a Vegetarian Diet:    

Risk of vitamin, mineral and omega-3 deficiencies. Potential for low B12 levels. Higher incidence of reduced iron and anemia. Supplementation may be required.

Lacto-Ovo-Vegetarian Diet A lacto-ovo-vegetarian diet is the most common of the vegetarian diets. It does not include meat but does use the products of chickens and cows; e.g. egg and milk products. Usually vegetable foods are the largest part of this diet, which consists mainly of fruits, vegetables, grains, legumes, nuts, and seeds.

Vegan Diet This is the strict (or pure) form of vegetarianism. In the vegan diet, no animal products are consumed, only fruits, vegetables, legumes, grains, nuts, and seeds. Eggs, cheese, yogurt, ice cream, butter and other milk products are also avoided. Vegans do not use animal products in any other aspects of their lives. There is a potential for nutrient deficiencies in the vegan diet. The main one is Vitamin B12, but iron and calcium may also be low. Protein levels may be satisfactory if the person is very conscious of protein intake and complementing food. Vitamin A may be low unless 137

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considerable amounts of orange, yellow, and green vegetables are consumed. Vitamin D is often low, but this deficiency can be helped by sunshine. Zinc may also be low unless seeds and nuts are consumed regularly. Advantages of a Vegan Diet:        

Higher intake of vitamins, minerals, fiber and antioxidants. Lower risks of certain diseases and illnesses. Healthy weight management. May help lower cholesterol: May help lower blood pressure: Increases antioxidant intake: Less animal cruelty. Better impact on the environment, as slaughter and animal product processes decrease.

Disadvantages of a Vegan Diet:       

Learning curve is challenging. Close monitoring and discipline required. Diet may not be balanced Potential interference with existing medical conditions: Difficulties finding correct food when dining out. Potential for Vitamins B12 & D, Calcium and Folic Acid deficiencies. Unrealistic expectations for improved health.

Raw Food Diet A raw food diet consists primarily of unprocessed and uncooked food and is potentially very healthy. The belief is that heating food destroys enzymes and diminishes nutritional value. The diet utilizes organically grown fresh vegetables and fruit, seeds, nuts, grains, beans, nuts, dried fruit, seaweed, and purified water. All stimulants, chemicals, and alcoholic beverages are avoided. Advantages of a Raw Food Diet:      

Can potentially be very healthy as it provides good nutrients. Provides increased energy. Improvement in the appearance of the skin. Aids digestion. Reduces the risk of heart disease. Promote weight loss.

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Disadvantages of a Raw Food Diet:  Is usually low in protein, calcium and iron.  May initially precipitate a detoxification process, in some people, which can cause: • headaches; • nausea; and, • cravings. The Raw Food Diet is not recommended for:    

people at risk for osteoporosis (decreased bone mass and porous bones); people with anemia (deficiency in red blood cells); children; and, pregnant or nursing women.

Special Diets Special diets (also called therapeutic diets) are usually prescribed by a Physician for people who have certain diseases or medical conditions. They are different from the “regular” diet. Individuals may be put on special diets because they have:         

diabetes; kidney, gallbladder, liver, stomach or intestinal disease; difficulty swallowing (dysphagia); allergies; excess weight; a need to reduce their salt (sodium) level; been injured or are recovering from surgery; a need to reduce their cholesterol and/or fat level; and, constipation or diarrhea problems.

Home Care Assistants should be aware that different diets exist because they will inevitably have Older Adults who are on special diets. The intent of this section is to provide an overview of the more common diets and not go into a detailed listing of individual foods that can and cannot be eaten. Clients on special diets should possess written documentation/pamphlets about their diets. Home Care Assistants, who are involved in food preparation, meal planning and/or shopping, should refer to the client’s documentation/pamphlets for the diet details. The following outlines some special diets, a brief description of the diet and the conditions/ diseases for which they are usually prescribed.

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Diet

Diabetic Diet

Low-fat/ Cholesterol

Restricted Sodium/ Low Salt Diet

High Protein

Low Protein

Description A diabetic diet helps to manage the amount of sugar in the blood. It does this by:  controlling the amount of carbohydrates eaten  ingesting a certain amount of carbohydrates every day at the same time each day, as determined by a Physician. A Dietician develops a diet, especially for the individual. Low-fat/Cholesterol diets limit the amount of fat and cholesterol by:  eating foods which are low in fat such as fruit, vegetables, grains, nuts & low-fat dairy products  cooking without using fat (Cholesterol is a waxy, fat-like material used by the body to produce hormones & other vital chemicals.) Sodium restricted diets are diets wherein salt and sodium are restricted. (Salt is 40% sodium)  Low Sodium Diet contains 2000 – 3000 mg. per day of sodium. A small amount of salt may be used when cooking but cannot be added to the plate.  Medium Sodium Diet contains no more than 1000 mg. of sodium per day. Food is cooked without salt & high sodium foods are not included in the diet.  Strict Sodium Diet contains no more than 500 mg. of sodium per day. Food limits are: • 1 egg per day • no more than 4 ounces of meat per day • only fresh vegetables are permitted • no more than 2 cups of milk per day  Foods to avoid include canned, deli, pickled, cheese, meats/meat alternatives, packaged foods, soups, seasonings, sauces & salad dressings. High protein diets build, repair & maintain body tissues. It is found in foods such as meat, poultry, fish, eggs, dairy products, tofu & beans.

Condition/Diseases  Diet is prescribed for people who have Diabetes Mellitus (a chronic disease caused by a lack of insulin).  Insulin is injected into the body on a regular basis. Diet is prescribed for people who have:  heart disease  gallbladder disease  fat digestion disorders  liver disease

Diet is prescribed for people who have: o heart disease  kidney disease  liver disease  hypertension (high blood pressure)  fluid retention

Diet is prescribed for people who have:  high fever  infection  burns  liver disease (some) Low protein diets are designed to reduce the Diet is prescribed for people who amount of nitrogen and ammonia in the body. A have: Physician determines the amount of protein that  kidney disease can be consumed.  toxic bowel (poisonous bowel)

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Diet

High Iron

High Calorie

Low Calorie

Bland

High Fiber

Low Residue

Soft

Liquid

Description Condition/Diseases High iron diets include foods which have high iron Diet is prescribed for people who:  have inadequate dietary intake content such as meat, fish, poultry & seafood.  have decreased intestinal (Iron is an important mineral in the body) absorption  have blood loss  are older adult  are adolescent  are menstruating  are pregnant High calorie diets provide 4000 calories per day. Diet is prescribed for people who: Calories are attained by eating three full meals a  are underweight day plus between meal snacks.  have thyroid problems Low calorie diets provide less than the minimum Diet is prescribed for people who daily requirements, which are: need to lose weight.  1600 for Older Adults & sedentary women  2200 for children, teenage girls, active women & sedentary men  2800 for teenage boys, active men & very active women Bland diets consist of foods that are low in Diet is prescribed for people who roughage & are without strong seasonings or have: condiments.  ulcers  gallbladder disorders  intestinal disorders  undergone abdominal surgery High fiber diets consist of foods that increase the Diet is prescribed for people who amount of residue in the colon, which helps the have: bowels move. High roughage foods include  constipation vegetables, fruit, & whole grain cereals.  colon disorders (The colon is the lower 6 – 8 feet of the bowel.) Low residue diets consist of foods that leave little Diet is prescribed for people who residue in the colon. The diet includes such foods have: as refined bread/crackers/cereal; cottage cheese;  diseases of the colon strained & cooked vegetables; eggs (not fried);  diarrhea canned fruits. Fresh vegetables & fruits are to be avoided. (Refined refers to a process wherein machinery has been used to remove the high fiber bits from the grain.) Soft food diets consist of semi-solid foods, which Diet is prescribed for people who are easily digested such as liquids, eggs (not have: fried), shredded meat, fish & poultry, mild  difficulty chewing cheeses, cooked cereal, fruit & vegetables.  gastrointestinal disorders Sometimes the food needs to be pureed (stomach & bowel disorders) (blended). Liquid diets consist of foods which are liquid at Diet is prescribed for people who room temperature or that melt at body have: temperature. Foods consist of custards; eggnog,  been on a clear diet after strained soup, strained fruit & vegetable juices; surgery milk, creamed cereals, plain ice cream & sherbet.  stomach irritations 141

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Diet

Clear Liquid

Description

Condition/Diseases  fever  nausea  vomiting Clear liquid diets consist of water, tea & coffee Diet is prescribed for people who: (without milk or cream), gelatin (Jell-O), clear fruit  have undergone surgery juices (apple, grape, cranberry), broth, hard  have an acute illness candy, sugar & popsicles.  are nauseas  are vomiting

Influences on Nutritional Practices The food Older Adults eat is often influenced by factors gained over a lifetime and include those born into and those acquired through living. If Home Care Assistants know the factors which guide the eating habits of Older Adults, then Home Care Assistants are better armed to help Older Adults eat nutritionally. Some of these factors are:

Personal Choice The likes and dislikes that Older Adults have for certain foods often got their origin in infancy and were modified throughout life, as they were exposed to different foods. Allergies also have an impact on food choices.

Appetite Many Older Adults do not have an appetite or a desire for food and drink because of:      

illness; medication; decreased ability to taste and smell; anxiety; pain; depression; and/or, not feeling hungry.

Finances Often Older Adults have limited income, which reflects on the types, quality and amount of food they purchase. They tend to buy carbohydrates, which are cheaper than protein, vegetables and fruit. Consequently, their nutritional needs are negatively affected.

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Culture Culture is learned behaviors, which are common to certain ethnic groups. It influences food choices, dietary practices and food preparation. Examples of Cultural Food Choices are:         

sushi is popular in Japan; organ meats are popular in England; low-fat and high sodium dishes are popular in China; high-fat and starchy foods are popular in Poland; pasta is popular in Italy; fish is popular in the Scandinavian countries; rice is popular in the Philippines; beans and rice are popular in Mexico; and, beef is not eaten in India;

Religion Food preferences can also be based on a person’s religious beliefs. When it comes to following the food guidelines of their faith, some people are very strict, while others semi-conform or do not conform at all. Whatever their religious practices are, Home Care Assistants need to respect them. The best way to determine their practices is to ask the clients or their families directly. Some eating practices of different religions are outlined below:  Roman Catholic • Some do not eat meat on Fridays. • Meat is not eaten on Ash Wednesday and Good Friday. • Fasting is required at least one hour before receiving communion.  Islam (Muslim) • Pork and pork products are forbidden. • Alcohol is forbidden except for medical purposes.  Greek Orthodox Church • Fast on Wednesdays, Fridays & Lent. (Lent is 40 weekdays from Ash Wednesday until Easter. It is observed by Christians as a season of fasting and penitence in preparation for Easter.)  Judaism • Foods must be kosher. (Kosher refers to the proper methods of food preparation & the dietary laws governing its consumption.)

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•

Foods that are allowed: -- all fruits & vegetables -- meat from kosher animals; e.g. cows, goats & sheep -- meat from kosher fowl; e.g. chicken, ducks & geese -- fish that have scales & fins; e.g. tuna, salmon, carp & sardines -- milk products & eggs from kosher animals & fowl Foods that are not allowed: -- shellfish -- pork -- blood Some practices of Judaism -- milk & milk products cannot be eaten with or immediately after eating meat. -- kosher and non-kosher foods cannot be prepared using the same utensils. -- breads, cake, cookies, noodles & alcoholic drinks cannot be consumed during Passover. (Passover is a Jewish religious festival, which is celebrated according to the Jewish Calendar (corresponds to March - April).

 Mormon • Alcohol, coffee and tea are not permitted. • Meat is not to be eaten very often, but it is still permitted.  Christian Scientist • Alcohol and coffee are not permitted.  Baptist • Some groups forbid alcohol, tea and coffee.  Seventh Day Adventist • Coffee, tea and alcohol are not permitted. • Drinks containing caffeine are prohibited. • Some groups forbid the consumption of meat.

Nutritional Needs of Older Adults Nutritional needs change with age. A basic understanding of these changes can help Home Care Assistants avoid nutritional snags, which are common in Older Adults, and ensure they get sufficient nutrients to be healthy. A nutritional diet for Older Adults provides foods that:  have a high level of nutrition (as recommended in the Food Guide Pyramid);  have an appropriate number of calories (minimum of 1600 calories per day); 144

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    

can be eaten in smaller amounts; can be digested easily; can be chewed and swallowed without difficulty; provide some fat to help fight disease; and, can be tolerated by existing diseases and/or conditions.

Causes of Malnutrition in Older Adults Malnutrition is the condition that develops when an individual does not get sufficient amounts of vitamins, minerals and nutrients to maintain healthy tissues and organ function. This condition is often found in Older Adults and is usually caused by a combination of physical, social and psychological issues:  Loss of Appetite: can be caused by: • reduced food intake; • changes in hormone levels, which affect appetite; and, • changes in the Central Nervous System, which affects the amount of food eaten .  Inability to Eat: can be caused by: • reduced levels of consciousness; • confusion; • difficulty feeding oneself due to weakness, arthritis or other conditions such as Parkinson’s Disease, dysphagia, vomiting, painful mouth conditions and poor oral hygiene. • dental problems such as poorly fitting dentures or missing teeth make chewing difficult.  Digestive Illnesses: such as Ulcerative Colitis, Crohn’s Disease or Malabsorption Syndrome can affect the assimilation of nutrients. Medical and surgical problems can also impair absorption, which may increase the need for Calcium, Vitamins D, B6, B12 and Folic Acid.  Taste and Smell: certain medications, conditions and fewer or malfunction of taste buds can reduce the desire to eat.  Dietary Restrictions: limits on salt, fat, protein and sugar, which are often prescribed when medical conditions such as heart disease, diabetes, high blood pressure, kidney disease exist, can contribute to inadequate eating.  Medications: can affect the body’s ability to absorb nutrients and excrete minerals effectively. They can also cause side effects such as decreased appetite, nausea and vomiting, diarrhea, dry mouth, malabsorption of nutrients and alterations in taste and smell.

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 Insufficient Physical Exercise: can reduce energy levels and appetite stimulation.  Psychological & Mental Issues: • Depression is a common cause of weight loss and malnutrition. • Stress and anxiety can reduce the amount of food consumed. • Dementia and confusion can reduce the desire to eat and the ability to feed oneself by interfering with choosing which foods to eat, getting food into their mouth and chewing.  Loneliness: can cause a loss of interest in cooking and eating, which can affect the amount and variety of food consumed.  Mobility Problems: can affect the ability to prepare meals or go shopping.  Drug and Alcohol Abuse: consumption of too much alcohol or drugs can interfere with the digestion and absorption of nutrients. Nutrients might also be lacking if alcohol or drugs are substituted for meals.  Limited Income: the inability to afford food is a factor that makes it difficult to get adequate nutrition.

Signs & Symptoms of Malnutrition in Older Adults The signs of malnutrition in Older Adults can be hard to detect initially. Red flags to watch for include:         

sudden weight loss (more than 5% of body weight in one month or 10% in six months); weight gain; nausea; vomiting; chronic illness; loss of appetite; weakness; dizziness; and, fainting.

Consequences of Malnutrition in Older Adults Good eating habits and proper nutrition are essential for healthy aging. As people grow older, their nutritional needs change, which may cause them to become malnourished. Malnutrition can have physical and psychosocial affects: 146

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 Physical Affects • reduction in heart mass & subsequent output; • reduced kidney function; • weakened gastrointestinal function; • reduced immunity with lower resistance to infection; • impaired respiratory function; and, • delayed wound healing.  Psychosocial Affects • apathy; • depression; • anxiety; and, • self-neglect.

Hydration Water is essential for life. Therefore, it is essential that sufficient amounts of fluids are taken in daily to be healthy. Although certain drinks and foods such as milk, juice, broth, soups coffee and tea also provide hydration, water is the best choice. A reasonable amount of fluids to consume daily is 8 glasses. However, people differ in the amounts they need to remain hydrated. Fluid promotes health and provides energy. It also:      

controls body temperature; aids digestion; carries nutrients around your body; cushions organs and joints; gets rid of waste; and, keeps bowels regular.

Dehydration Dehydration occurs when the doesn’t have as much water as it needs. Without enough, it can’t function properly. Dehydration can range from mild to severe depending on how much fluid is missing from the body. Older Adults often don’t drink enough because they do not feel thirsty and/or they are trying to offset the unwanted effects of incontinency. If they don’t drink enough liquids (at least 8 cups per day) or if they are putting out a lot of urine, they may become dehydrated. Illness and medication may also lead to dehydration

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Signs and Symptoms of Mild Dehydration

                   

thirst; headache; fatigue; muscle weakness or cramps; dry lips, mouth and tongue; flushed skin; irritability; restlessness; trouble sleeping; dry skin; sunken eyes; lethargy; nausea; vomiting; diarrhea; dark and strong-smelling urine; weigh loss; low blood pressure; increase in heart beat; and, light-headedness.

Signs and Symptoms of Severe Dehydration

       

lack of energy; cold hands and feet; blue lips; blotchy skin; confusion; rapid breathing; high fever; and, unconsciousness.

Dehydration can cause serious problems such as electrolyte imbalance and can even result in death. Therefore, it is important that Home Care Assistants ensure their clients are drinking enough and keep alert for signs of dehydration. This condition is easily treatable and enables, Older Adults to return to their normal life. The key is to prevent dehydration from occurring in the first place.

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How HCAs Can Encourage Older Adults to Consume Adequate Food & Fluids Encourage Eating

There are several things Home Care Assistants can do to encourage Older Adults to eat properly including:  If they wear dentures, suggest they consult with a denturist to determine if they fit properly and are in decent shape.  If they have their own teeth, suggest they consult with a dentist to determine if they have enough teeth and there are no cavities, as these factors can: • affect chewing; • affect nutrition; • give food a strange taste.  If they have trouble chewing, provide foods that are minced, soft and well-cooked.  Serve small meals several times a day instead of giving three larger ones.  Cater to their food choices. Ensure they follow the guidelines of special diets.  Add herbs and spices, which they like to enhance flavor.  Present food in an appealing manner.  Dine in a pleasant area.  Set a nice table.  Sit with them, to make eating a social event.  Use regular dishes and regular cutlery, as opposed to plastic or paper ones. Use linen napkins instead of paper ones. Encourage Drinking

Getting Older Adults to consume enough water to prevent dehydration can be a challenge for Home Care Assistants. Following are a few tips that may help:       

Encourage sips of water several times during the day. Offer fluids other than water. Serve fruits and vegetables with a high-water content. Keep water within arm’s reach so it is readily available. Determine whether hot or cold drinks are preferred and cater to choices. Make popsicles from fruit juice. Offer smoothies, milkshakes sport drinks or liquid supplements.

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Dysphagia Dysphagia means having difficulty swallowing. Age-related diseases play a prominent role in the presence and severity of dysphagia with stroke and dementia being particularly vulnerable. Dysphagia can present serious repercussions for Older Adults, as they:  may not be able to get enough food and fluids to maintain good nutrition and hydration; and,  are susceptible to aspiration (inhaling food or fluid into the lungs).

Signs and Symptoms of Dysphagia The most common symptoms to dysphagia include:        

difficulty swallowing; breathing in food while swallowing; food spilling out at corners of the mouth; getting food pocketed within the cheeks of the mouth; getting food stuck; coughing during or after swallowing; choking or breathing saliva into lungs while swallowing; regurgitating food after meals; (Regurgitation is the backward flow of food from the stomach to the mouth.)  regurgitating liquid through nose;  weight loss; and,  weak or harsh voice after eating.

Food Preparation for Dysphagia Older Adults with dysphagia are placed on diets wherein food thickness is regulated to adapt to the individual’s needs. Since Home Care Assistants may be asked to prepare food for clients with dysphagia, they should be familiar with the various diets and food preparation methods.  Minced Diet: food is chopped into little pieces for easier swallowing or chewing.  Pureed Diet: food is put through a blender until it reaches the consistency of baby food.  Thickeners: such as tapioca, flour, instant potato flakes or commercial thickeners are added to hot or cold fluids to reach the desired consistency level.  Liquid Supplements: nutritional drinks and liquid supplements; e.g. Ensure, are consumed to provide extra nutrition.

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 Tube feedings: food is delivered into the stomach via a tube, which is either inserted through the nose for short-term feeding or is inserted directly into the stomach for long-term or permanent use.

Summary Food and water are basic human needs, as the nutrients they supply are essential to maintaining life. When insufficient nutrients are ingested, repercussions occur in the body such as poor health, infections, chronic diseases and ineffective healing. Therefore, it is important that an appropriate diet is followed and that good eating habits are practiced. The Food Guide Pyramid provides details on what should be eaten each day to maintain health. Regular diets and therapeutic diets are extracted from these food choices -- the regular diet to maintain healthy eating; and therapeutic diets to meet the needs of certain diseases and medical conditions. Since factors such as physical and emotional problems, food preferences, appetite, culture, religion and finances can affect eating habits, it is important to keep alert for signs of nutritional deficiencies. By being aware of these factors and taking corrective actions as needed, Home Care Assistants can help their clients attain and/or maintain healthy eating practices which will improve their quality of life.

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. SECTION 10: HEALTH & SAFETY SAFETY In this section, Home Care Assistants will learn to identify hazards and take steps to reduce risk, prevent injury and promote safety, which will be of benefit to them and their clients. Home care provides services to people in their own homes. Promoting the safety of residents and HCAs can be challenging for many reasons:       

home environment hazards; spread of infection; medication errors; uncontrolled conditions; resident and worker safety; little or no direct supervision; and, workplace protections for workers and residents may not be in place or be readily available,

Safety Hazards in the Home Environment Not all homes are hazard free, which means there is always the risk of illness or injury. Because Home Care Assistants are exposed to both safe and unsafe working environments, they should be aware of possible hazards. Following are some safety hazards that may exist: SAFETY HAZARDS

YES

ENTRANCE TO HOME  Are there outside lights covering the sidewalks and/or other entrance ways?  Are the steps & sidewalks in good repair and free from debris/material?  Is a ramp needed?  Are the railings on the steps secured?  Is there a functional peephole in the front door?  Does the door have a deadbolt lock that does not require a key to open it from the inside (unless client tends to wander)?  Does the door have a deadbolt lock that does not require a key to open it from the inside (unless client tends to wander)? GENERAL  Is there an emergency plan in place?  Are working smoke detectors installed?  Is there a “ready-to-use” fire extinguisher(s) on the premises? 152

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SAFETY HAZARDS  Are inside halls and stairways free of clutter/debris?  Are throw rugs removed?  Are there sturdy handrails or banisters by all steps and stairs?  Are electrical cords non-frayed and placed in a manner to avoid tripping?  Are electric outlets/switches overloaded; e.g. warm to the touch?  Are rugs secured around the edges?  Are hazardous products labeled and kept in a secure place?  Is there a need for a stool to reach high shelves/cupboards?  Is smoking paraphernalia handled safely; e.g. cigarettes put out?  Does anybody smoke in homes where oxygen is in use?  Are all animals, on-site, controlled?  Is the home free from bugs, mice and/or animal waste?  Are materials stored safely and at a proper height?  Does the client wear an emergency response necklace/bracelet?  Are polished floors waxed or waxed-free? MEDICATIONS  Are all medications marked clearly?  Are medications named?  Are medications dated?  Are instructions given on how medications are to be taken?  Are instructions given as to when medications are to be taken? MEDICAL EQUIPMENT/SUPPLIES  Are used needles placed in a sharp container?  Is oxygen tubing kept off the walking path?  Is medical equipment properly stored? LIVING AREAS  Are doorways wide enough to carry loads through and get a wheelchair/walker through?  Are light switches accessible so they can be turned on/off without walking across a dark room?  Are sofas & chairs high and firm enough for easy sitting and rising?  Is there an accessible telephone in the room?  Is there a list of emergency telephone numbers by the telephone?  Do telephone cords/electronic wires run across walking areas?  Are there castors or wheels on furniture?  Do sitting furniture have armrests, which are strong enough for getting in and out?  Are phone & extension cords out of the foot traffic area?  Is the room clutter-free?  Are heaters at least 12 inches from furniture and drapes? BATHROOM  Are there glass doors on the bathtub/shower?  Is there a non-skid surface/mat in the bathtub/shower?  Are there grab-bars on the bathtub/shower and adjacent to the toilet?  Is there a raised toilet seat (if client has trouble getting on/off toilet)?

YES

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SAFETY HAZARDS  Is a hand-held shower spray required?  Is the water temperature below scalding; e.g. below 120?  Is there a shower bench/bath seat with a hand-held shower wand available?  Does the bathroom have a night light?  Are there unsafe loose rugs, carpet or tiles on floor? BEDROOM  Are there any scatter rugs?  Is the bed lower than “back-of-the-knee” height?  Is there a chair with armrests & firm seat (to reduce falls while dressing)?  Does furniture have castors, or does it roll?  Is there a telephone in the room that is easily accessible from the bed?  Is list of emergency telephone numbers by the telephone?  Is there a flashlight, light switch or lamp beside the bed?  Is there a night light? KITCHEN  Is the floor waxed or in a slippery condition?  Are there any flammable items near the heat source?  Do the “ON” buttons work on all appliances?  Are stove controls accessible and easy to use?  Are items used the most stored between eye and knee level?  Is there an uncluttered work space near the cooking area (to avoid having to carry items)? Are dishcloths, dishtowels & oven mitts away from stove burners/flames? LIGHTING  Is there adequate lighting in all stairways and hallways?  Is there a light switch at both the top and bottom of stairs?  Is there a night light between bedroom and bathroom? CLIENT’S/RESIDENT’S POTENTIAL FOR VIOLENCE  Is there a history of violence?  Are there violence fantasies or plans of violence?  Is there a level of support from significant other?  Are there signs & symptoms; i.e.:  staring and eye contact;  tone & volume of voice;  pacing;  anxiety; and/or,  mumbling? NEIGHBORHOOD HAZARDS  Is there sufficient lighting?  Can individuals be heard if they call for help?  Are there people nearby who can help?  Are there improvements that can be made to enhance safety?

YES

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How HCAs Can Help Minimize Risks in the Home Environment  Conduct safety checks and make or recommend cautionary solutions.  Take precautions, when Oxygen is in the home, to ensure there are no open flames; e.g. burning candle, and nobody is smoking.  Do not use products around oxygen that contain petroleum; e.g. petroleum ointment, either for lubrication of equipment or for labeling.  Clean up spills as soon as they occur.  Conduct an inventory of hazardous products that are in the home and advise clients how to handle them safely (if they don’t already know).  Always read the labels before using a product.  Where necessary, ensure pets are restrained when Home Care Assistant is present. If an animal bites, wash the wound with soap and water and seek medical attention.  Ensure that all weapons are kept out of view and preferably locked up.

Falls Falls are a real threat to Older Adults because of the increased possibility that bones will be broken. Because people lose fat and muscle mass as they age, their bones do not have the cushion they once had for protection. Compounding the problem are fragility and osteoporosis. (Osteoporosis is an abnormal loss of bony tissue resulting in fragile, porous bones.) It is important for Home Care Assistants to be aware of the reasons why Older Adults fall and know how to reduce their chances of falling.

Causes and Preventions of Falls The causes of falls are called risk factors. The more risk factors individuals are exposed to, the greater their chance of falling becomes. Falls can threaten independence. The following outlines the common risk factors of falls for Older Adults and suggests preventative measures that can be taken: Risk Factor Osteoporosis

Lack of Physical Activity

Impaired Vision

Reason

Preventative Measure  Osteoporosis is a condition  Consume sufficient calcium and Vitamin D.

wherein the bones become more porous.  Failure to exercise regularly  Exercise regularly. results in decreased strength,  Take safety precautions when conducting daily activities. poor muscle tone, loss of  Wear shoes with rubber soles & grips. bone mass & flexibility.  Eye conditions such as  Visit the Ophthalmologist (eye specialist) regularly to check for cataracts & glaucoma. cataracts & glaucoma can affect sharpness of vision, 155

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Risk Factor

Reason

Preventative Measure

depth perception, peripheral vision & susceptibility to glare. Medications

Environmental Hazards

 Anti-depressants, anti-psychotic & sedatives drugs can reduce mental alertness, affect balance & gait and cause a drop-in blood pressure.

 Environmental hazards are the cause of 1/3 of all falls: • tripping over objects on floor • poor lighting • loose rugs • lack of (or poorly installed) handrails • furniture that is not sturdy

 Be familiar with the side effects of medications.  Ask a Physician: • if medication is needed • to prescribe the lowest dosage • about the need for continued use • limit alcohol intake  Outdoors: • When the weather is bad, use a walker or cane for extra stability. • Wear skidded boots with rubber soles for added traction. • If sidewalks look slippery, walk on the grass for better traction. • Sprinkle rock salt, kosher salt, or kitty litter on sidewalks or streets that are slippery.  Indoors: • Be alert for wet, floor surfaces and avoid them where possible. • Keep rooms free from clutter. • Keep floor surfaces smooth but not slippery. • Avoid walking around in socks or stockings. • Ensure that carpets or area rugs have skid-proof backings. • Use at least 100-watt bulbs, • Keep a flashlight beside bed. • Ensure that stairwells are well lit. • Install handrails and grab-bars.

HCA Safety Home Care Assistants are at risk for their personal safety because they usually work alone and are vulnerable to threats not only on the “job-site” but also when traveling to and from the workplace. There are some precautions they might take to reduce their risk.

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How HCAs Can Help Protect Their Personal Safety Scenario

Precautions

 Scout out the area where the home is located.  Travel the safest route and know the locations of safe places such as Safety Precautions to take hospitals and police detachments. before going to a new client’s  Carry a cell phone or determine the locations of public pay phones. (If pay home. phone is in a potentially dangerous area, do not use it.)  Carry a list emergency numbers; e.g. police detachment, paramedics, fire station, search and rescue)  Carry transportation schedules and numbers of taxi companies.  Dress safely; e.g. unrestrictive clothing, non-skid shoes, limited jewelry.  Stand in the designated waiting area of a subway.  Ensure a taxi driver’s picture and identification are displayed. Safety Precautions to take  Don’t park in underground parking lots or in out-of-the-way areas. when traveling to a client’s  Keep car doors locked and roll up windows. home.  Don’t leave items lying around in the car; e.g. medications, purse.  Avoid any parked cars, which have people sitting in them.  Stick to well-traveled and lit streets.  Walk quickly and try to avoid walking through crowds.  Place your vehicle keys in your hand before leaving the home.  If necessary, have someone walk you to your car.  Check the inside and outside of the car before getting in.  Lock the car doors as soon as you are in. Safety Precautions to take  Don’t use bank machines in the evening or during the night. when leaving a client’s  If you suspect you are being followed head for a police/fire/gas station home.  Don’t hitchhike or pick up hitchhikers.  If somebody tries to rob you, don’t resist – instead, shout “FIRE”.  If somebody tries to assault you near your vehicle, roll under the vehicle.  If somebody tries to force you into a vehicle, fight back; e.g. holler and kick.  If client lives in a condominium apartment or other multi-residence complex:  Be cautious in elevators; e.g. stand close to the control panel with your back against the wall. Get out immediately, if you are feeling uneasy.) • Walk down the middle of the hallway & avoid alcoves. Safety Precautions to take • Keep count of floors when using stairways. when working in a client’s  Do not go into homes where it appears that: home. • your safety may be at risk; e.g. weapons, drugs, alcohol, guard dogs • people are inebriated • people are abusive • sexual comments/gestures are made  Make a note of where the telephone and exit are located.  Be alert for changes in the behavior of people in the home, as changes could indicate impending danger.  Don’t make promises you can’t keep.

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HCA Risk of Injury Home Care Assistants are very susceptible to injury during the performance of their duties primarily from:    

repetitive lifting and moving; chemical exposure; infection; and, threat of violence.

Most injuries occur in the back, ligaments, tendons, muscles and joints. How HCAs Can Help Protect Themselves from Injury       

Learn and apply the basics of body mechanics. Request that qualified people demonstrate transfer procedures for individual clients. Ensure that equipment and mobility aids are in good condition. Ensure there is sufficient lighting. Ensure that the environment is kept at a comfortable temperature. Check flooring to determine the most suitable means for maneuvering clients. Be aware of and seek input about any changes in the client’s condition, which could mean transfer techniques may need to be modified.  Apply safe work practices when handling clients and materials.  Ensure bathrooms and bedrooms are organized for easy access to client and personal care items.

HCA Risk of Being Abused Home Care Assistants may face threat or acts of physical violence, harassment, intimidation, or other threatening disruptive behavior when on the job-site. These actions can range from threats and verbal abuse to physical assaults and even homicide. Therefore, HCAs must know to recognize and respond to these situations. What HCAs Can Do if Verbally Abused To prepare HCAs for potential verbal abuse during the performance of their duties, they need to be equipped with conflict-management techniques and training to help defuse tense situations. Regardless of the reason(s) behind verbal abuse, HCAs should confront their abusers by using conflict management skills:  Prepare for potential verbal abuse by: • ensuring they receive conflict management training; 158

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• becoming familiar with their employer's workplace violence and harassment policies; • asking how conflict is handled during the hiring interview.  Respond to active verbal abuse by: • refusing to tolerate the abusive behavior; • not being tongue-tied when confronted with abuse. • making clear and direct statements; e.g.: “I deserve to be treated with respect,” • remaining silent when the abuser is on a tirade; • continuing the conversation in a private location; • asking the abuser what is wrong; • changing his/her focus to the real problem, if relevant; and, • working together to try and find a solution to the issue(s).  Write an incident report about the abuse, even if you fear reprisal, hopes of reconciliation plain fatigue.  Follow up to find out how the situation is being addressed. Note: Refer to Section 7 – Challenging Behavior What HCAs Can Do if Threatened with Physical Attack Should Home Care Assistant find themselves in dangerous situations, they should try to find a discreet way of removing themselves from the situation and avoid triggering emotions that could provoke attacks. If an attack does occur, HCAs should:    

Escape and call for help, if possible. Stay calm. Think rationally and evaluate options. Choose a response option based on: • the circumstances; • the location of the attack; • their personal resources; • the characteristics of their attacker; and, • the presence of weapons.

What HCAs Can Do if Under Physical Attack HCAs must rely on their own judgment to choose the most effective strategies for their situation during physical attacks; e.g.:  Don’t Resist: not resisting can be the proper choice in a given situation; e.g. an attacker with a weapon may encourage you to cooperate.  Stall for Time: appear to go along with the attacker, which may provide time to assess the situation and provide an opportunity to try to escape. 159

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 Distract and Flee: divert the attacker’s attention and flee, is possible. Assess ability to flee, taking into consideration: • footwear and clothing • physical stamina; • proximity to your attacker; and, • terrain.  Be Aggressive: shout aggressively and/or use body movements to demonstrate willingness to fight back.  Act quickly and decisively: throw the attacker off guard. Get away from the home/area immediately.  Observe attacker carefully: Note features and clothing to help provide an accurate description for authorities (if the attacker’s identity is not known).

HCA Wellness Wellness is an ongoing process of becoming aware of and making choices to achieve and maintain a healthy and fulfilling life. It is not just being free from illness, but also is a process of change and growth. Wellness involves:    

maintaining proper nutrition, exercise, stress-control, and, good personal, family and social relationships.

Because of the stresses presented in performing their duties, Home Care Assistants are susceptible to physical and mental strain, which can affect the HCAs’ overall wellness.

HCA Stress Risks Home Care Assistants are at risk of mental health problems and face many stresses during the performance of their duties because:         

Clients are frail and ill with heavy care needs. There is limited equipment and supplies. Additional personnel are not available to assist. The home may not be clean. Supervision is not available or is not on site. Clients are demanding because of the number and complexity of their needs. There is a probability for disagreements among family members. Assistance may be difficult to summon. Multi clients require care during the working day. 160

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How HCAs Can Help Reduce their Own Stress Levels  Manage stress by: • relaxing; • talking about problems with a trusted person; • laughing; • seeking assistance; • managing time effectively; • stopping smoking; • limiting alcohol consumption; • being alert for stress causes and try to counteract them; and, • delegating, where possible.  Practice relaxation exercises such as deep breathing.  Learn to set limits.  Keep physically active.  Maintain a healthy diet.  Get sufficient rest and sleep.  Ensure there is a balance between work and family obligations.  Take time for “self” every day.

Food Safety USDA Basics for Handling Food Safely The following guidelines for safe food handling are provided by United States Department of Agriculture: Safe steps in food handling, cooking, and storage are essential to prevent foodborne illness. You can't see, smell, or taste harmful bacteria that may cause illness. In every step of food preparation, follow the four steps of the Food Safe Families campaign to keep food safe:    

Clean — Wash hands and surfaces often. Separate — Don't cross-contaminate. Cook — Cook to the right temperature. Chill — Refrigerate promptly.

Shopping

 Purchase refrigerated or frozen items after selecting your non-perishables.  Never choose meat or poultry in packaging that is torn or leaking.  Do not buy food past "Sell-By," "Use-By," or other expiration dates. 161

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Storage

 Always refrigerate perishable food within 2 hours—1 hour when the temperature is above 90 °F (32.2 ºC).  Check the temperature of your refrigerator and freezer with an appliance thermometer. The refrigerator should be at 40 °F (4.4 ºC) or below and the freezer at 0 °F (-17.7 ºC) or below.  Cook or freeze fresh poultry, fish, ground meats, and variety meats within 2 days; other beef, veal, lamb, or pork, within 3 to 5 days.  Perishable food such as meat and poultry should be wrapped securely to maintain quality and to prevent meat juices from getting onto other food.  To maintain quality when freezing meat and poultry in its original package, wrap the package again with foil or plastic wrap that is recommended for the freezer.  Canned foods are safe indefinitely if they are not exposed to freezing temperatures, or temperatures above 90 °F. If the cans look ok, they are safe to use. Discard cans that are dented, rusted, or swollen. High-acid canned food (tomatoes, fruits) will keep their best quality for 12 to 18 months; low-acid canned food (meats, vegetables) for 2 to 5 years. Preparation

 Always wash hands with warm water and soap for 20 seconds before and after handling food.  Don't cross-contaminate. Keep raw meat, poultry, fish, and their juices away from other food. After cutting raw meats, wash cutting board, utensils, and countertops with hot, soapy water.  Cutting boards, utensils, and countertops can be sanitized by using a solution of 1 tablespoon of unscented, liquid chlorine bleach in 1 gallon of water.  Marinate meat and poultry in a covered dish in the refrigerator. Thawing

 Refrigerator: The refrigerator allows slow, safe thawing. Make sure thawing meat and poultry juices do not drip onto other food.  Cold Water: For faster thawing, place food in a leak-proof plastic bag. Submerge in cold tap water. Change the water every 30 minutes. Cook immediately after thawing.  Microwave: Cook meat and poultry immediately after microwave thawing. Cooking

Cook all raw beef, pork, lamb and veal steaks, chops, and roasts to a minimum internal temperature of 145 °F (62.8 ºC) as measured with a food thermometer before removing meat from the heat source. For safety and quality, allow meat to rest for at least three minutes before

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carving or consuming. For reasons of personal preference, consumers may choose to cook meat to higher temperatures. Ground Meats

Cook all raw ground beef, pork, lamb, and veal to an internal temperature of 160 °F (71.1 ºC) as measured with a food thermometer.  Poultry

Cook all poultry to an internal temperature of 165 °F (73.9 °C) as measured with a food thermometer. Serving

 Hot food should be held at 140 °F (60 °C) or warmer.  Cold food should be held at 40 °F (4.4 ºC) or colder.  When serving food at a buffet, keep food hot with chafing dishes, slow cookers, and warming trays. Keep food cold by nesting dishes in bowls of ice or use small serving trays and replace them often.  Perishable food should not be left out more than 2 hours at room temperature—1 hour when the temperature is above 90 °F (32.2 ºC). Leftovers

 Discard any food left out at room temperature for more than 2 hours—1 hour if the temperature was above 90 °F (32.2 ºC).  Place food into shallow containers and immediately put in the refrigerator or freezer for rapid cooling.  Use cooked leftovers within 4 days.  Reheat leftovers to 165 °F (73.9 °C). Refreezing

Meat and poultry defrosted in the refrigerator may be refrozen before or after cooking. If thawed by other methods, cook before refreezing.

Emergency Preparedness Emergency preparedness involves planning what actions to take in the event of a possible disaster. We all live with the threat of emergency and should know a few basics on what to do when such situations confront us. Some of the more common types of emergencies that may develop are: 163

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 Larger-Scale Natural Disasters: can affect thousands of people: • Wildfire • Flood • Earthquake • Hurricane • Tornado  Smaller-Scale Disasters: usually affect a limited number of people: • House Fire • Power Outages • Electrocution • Medical Emergencies Note: Refer to Section 11 - Basics of Emergency Care Often, there is little warning that an emergency is about to develop. Therefore, it is highly possible that Home Care Assistants will be at their clients’ homes when one strikes. They need to know what to do when an emergency develops.

Smaller-Scale Disasters House Fire Planning for a Possible House Fire

    

Install smoke detectors on each level of the home. Create an escape plan and practice using it. Practice evacuation procedures by establishing fire drills. Place a ladder or rope on all floors above the first one. Check windows that would be used in an escape to ensure they open easily.

What HCAs Can Do in The Event of a House Fire     

Get everyone out of the house. Know where exits are (doors and windows) Designate a meeting place outside the house, which will help determine if anyone is missing. Phone the fire department using a cell phone outside or using a neighbor’s phone. Never go back inside for any reason. (Stay at the meeting place and wait for the fire department.)  If caught in smoke, crawl along the floor, as the air is less toxic at that level.  If clothing catches on fire, Stop, Drop and Roll”. 164

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Power Outages If there is an unexpected disruption in electrical power, for whatever reason, there are some things Home Care Assistants need to know: Effects

Food Safety

Safe Drinking Water

Safety Measures  Food in the refrigerator or freezer will remain safe for consumption if power is out for less than 2 hours. If less than two hours: keep the refrigerator and freezer doors closed to retain colder temperature.  If more than two hours: • A freezer that is half full will hold food safely for up to 24 hours • A full freezer will hold flood safety for up to 48 hours. • Place items for refrigerator in a cooler surrounded by ice. • Check temperature of food prior to cooking: if 40 degrees F. or more, discard. Note: Refer to Section 10 for the USDA Basics of Food handling.  Do not use contaminated water to wash dishes, brush teeth, wash & prepare food, wash hands, make ice, or make baby formula.  Boil water (length depends on what state or health departments consider appropriate for the area).  To kill bacteria, treat water with: • chlorine tablets (follow directions) • iodine tablets (follow directions) • household chlorine bleach (1/8 tsp./gallon if water is clear; ¼ tsp/gallon if water is cloudy)  Rinse containers with water treated with bleach before using them. Note: • • •

Power Line Hazards & Vehicles

Boiling water will kill parasitic organisms. Chlorine, iodine and bleach will not kill parasitic organisms. Chlorine, iodine and bleach will kill bacteria.

 If a downed power line touches a vehicle, remain in the vehicle and: • warn people not to touch the vehicle • phone or ask someone to phone 9-1-1 or the utility company  If the vehicle catches on fire, open the door and: • jump free of the vehicle so the body clears the vehicle before touching the ground; • walk in a shuffling manner to at least 50 feet from the vehicle. Note: Do not step out of the vehicle onto the ground! Be alert for heat stroke, heat exhaustion, heat cramps and fainting. To avoid heat stress:  Drink a glass of fluid every 15 to 20 minutes and at least one gallon each day.  Avoid alcohol and caffeine, as they cause dehydration. 165

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Effects

Extreme Heat

Extreme Cold

Safety Measures  Wear light-colored, loose-fitting clothing.  When indoors without air conditioning, open windows if outdoor air quality permits and use fans.  Take frequent cool showers or baths.  If dizziness or overheating occurs: • seek a cool place • sit or lie down • drink water • wash head and face  Work during cooler hours or distribute the workload evenly throughout the day. (See Section 11 for First Aid Procedures)  Hypothermia happens when a person’s core body temperature drops at least 2 degrees Fahrenheit below the normal body temperature of 98.6 degrees Fahrenheit.  Ways to prevent hypothermia: • Ensure adequate food, clothing, shelter, and sources of heat are available. • Use electric blankets & heating pads. • Wear layers of clothing, which help to keep in body heat. • Move around because physical activity raises body temperature.

Electrocution Electrocution is the passage of a low frequency electric current through the body, often resulting in death. The most common causes of electrocution are overhead power lines. Utility lines are not usually insulated, which means the lines are bare. People usually die when they come into contact with a live utility wire because they contact the earth and the wire at the same time. This creates a pathway for the electricity to travel through. (When birds sit on a live wire, they are not electrocuted because they are only in contact with the line.) Electrocution can also occur in the home. Home Care Assistants can help prevent shock or electrocution by taking/following certain safety precautions: Effects Electrical cords Extension cords Plugs

Safety Measures       

Ensure cords are in good condition. Don’t place them under carpets or allow furniture to rest on them. Use only on a temporary basis. Ensure cords are not overloaded. Ensure plugs fit the electric outlet. Don’t remove the third prong to make it fit into a 2-prong outlet. Don’t force a plug into an outlet if it doesn't fit. 166

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Effects

Electrical Outlets Light Bulbs

Appliances

Computers & Entertainment Items Breakers & Fuses Water

Space Heaters Halogen Floor Lamps

Safety Measures  Avoid overloading outlets with too many appliances.  Check for outlets that have loose-fitting plugs, as they can overheat and cause fire.  Replace any broken or missing wall plates.  Ensure light bulbs are the correct wattage for the fixture.  Replace bulbs that have higher wattage than recommended.  Ensure bulbs are screwed in securely, as loose bulbs may overheat.  Have the appliance repaired or replaced if it:

• • •

blows a fuse; trips a circuit breaker; or, gives a shock.

     

Ensure equipment is in good condition and working properly. Watch for damaged wiring, plugs, and connectors. Use a surge protector. Ensure they are adequate for the circuit. When replacing the fuse, replace it with one that is the same size. Don't leave plugged-in appliances where they might come into contact with water. (Never reach into water to retrieve an appliance that has fallen in, even if it is unplugged. Instead, turn off the power source at the panel board and then unplug the appliance.)  If an appliance gets wet, have it checked before using it.  Keep space heaters at least 3 ft. away from any combustible material.  Turn heaters off and unplug them when not in use.  Don’t place halogen floor lamps where they can come into contact with materials that are combustible.  Don’t leave the lamp on when the room is vacant.  During an electrical storm:

•

Lightning

• •

don’t use electrical appliances, including telephones (except for emergencies). don’t take a bath or shower. use surge protectors on electronic devices.

 Don’t use electric equipment:

• • • •

Outdoor Equipment     

when the ground is wet when it is raining on we grass; or, in wet conditions Check equipment for frayed cords, broken plugs & damaged housings. Use extension cords, which are designed for outdoor use. Unplug all portable tools when not in use. Be alert for power lines when using metal ladders.

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Larger-Scale Natural Disasters Wildfire Wildfire is an unplanned and unwanted fire burning in a natural area such as a forest, grassland, or prairie. It can occur at any time throughout the year, but the potential is always greater during high-temperature periods, as brush, grass, and trees are dry and will burn more easily. High winds can also contribute to spreading fire. Wildfires can start in remote wilderness areas, in national parks, or even in backyards. They can be started by natural causes: e.g. lightning, but most are caused by humans, either accidentally from cigarettes, campfires, or outdoor burning or intentionally. Guidelines for Wildfire Protection Federal Emergency Management Agency (FEMA) provides guidelines for wildfire protection in its document: How to Prepare for a Wildfire. Excerpts from it are provided below. Before Wildfire Erupts  Know how to keep informed by: • monitoring weather reports; • determining what alert systems exist for the area; e.g. email or texts; • being able to stay informed during power outages; e.g. extra batteries for radio and cell phone);  Become familiar with evacuation routes, travel modes and destinations.  Choose a phone number or Social Media source for all family members to contact, preferably out of the area.  Make a list of items to take and prepare an emergency bag.  Take or review training for first aid and emergency response actions.  Know where fire extinguishers are located and how to use them. FEMA’s 5 “Ps” of Evacuation

 People  People and, if safely possible, pets and other animals/ livestock.  Prescriptions  Prescriptions, with dosages; medicines; medical equipment; batteries or power cords; eyeglasses; and hearing aids.  Papers  Papers, including important documents (hard copies and/or electronic copies saved on external hard drives or portable thumb drives).   Personal needs—such as clothes, food, water, first aid kit, cash,  Personal phones, and chargers— and items for people with disabilities and Needs others with access and/or functional needs, such as older adults, children, and those with Limited English Proficiency.

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 Priceless Items

 Priceless items, including pictures, irreplaceable mementos, and other valuables.

During a Wildfire  If Wildfire is Nearby or Approaching: • Call 9-1-1 • If there is time before evacuation: - Turn lights on outside and in every room. - Reduce drafts by closing windows, vents, doors and fireplace screens. - Disconnect automatic garage door openers so they can be opened by hand if power fails. - Remove flammable inside and outside furniture to center of room. - Remove flammable curtains and window treatments. - Connect garden hoses. Fill garbage cans, tubs, or other large containers with water. - Shut off natural gas from its source. Move propane or fuel oil supplies away from the home.  If Trapped in Home: • Call 9-1-1. Provide location and details of situation. • Turn lights on to increase visibility through smoke. • Unlock doors. • Reduce drafts by closing windows, vents, doors and fireplace screens. • Move flammable materials and furniture from windows and sliding glass doors. • Fill sinks and tubs with water. • Keep away from outside walls and windows.  If Trapped in Vehicle or Outdoors: • Call 9-1-1 immediately to provide location and details • Decide whether to remain in vehicle or take cover, based on: - distance from the fire; - direction of the fire; - whether there is fuel; e.g. brush and trees, near your vehicle, and, - the potential for rescue. • Try to stay away from fuel sources. • Stay in a rocky area or roadway, or near a water source. • Keep low to reduce the effects of heat and smoke. • Breathe through cloth to avoid inhaling smoke. • Take cover under a wool blanket, coat, or dirt.

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After a Wildfire  Inside Safety: • Use caution when entering burned areas. • Avoid walking on smoldering surfaces. • Check the attic for smoke or fire. • Wear leather gloves to protect hands and heavy, thick-soled shoes to protect feet.  Outside Safety: • Avoid damaged structures and watch for aftershocks. • Be alert for unstable power poles. • Stay away from downed power lines and report them to 9-1-1 or the power company’s emergency number. • Watch for ash pits, charred trees, smoldering debris, and live embers. Mark them for safety. Warn family and neighbors to keep clear. • Check the roof and gutters. If possible, wet them down to completely put out any smoldering sparks or embers. If fire is still present, call 9-1-1.  Communications: • Use local alerts, radio, and other information sources, such as FEMA or Red Cross apps, to get information and advice. • Use text messaging, apps or social media to communicate with family and friends. Since telephones and cellular phone systems are often overwhelmed following a disaster, use them only for emergency calls.

Flood A flood is the arising of water levels and overflowing onto normally dry land. Floods can appear

suddenly, or they may be predicted hours or days in advance. Either way, it is important for Home Care Assistants know what to do if there is a flood threat or if a flood unexpectedly occurs, as they may need to aid. A flood, which rises and falls quite rapidly with little or no warning is called a Flash Flood. It is usually the result of intense rainfall over a relatively small area. Flash floods can be caused by situations such as a sudden, excessive rainfall, the failure of a dam or the thaw of an ice jam. What HCAs Should Do When a Flood Warning is Issued    

Listen to radio, TV, social media and apps for flood warnings. Move pets, vehicles, and valuables to a secure place. Warn neighbors. Put sandbags or flood boards in place. 170

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     

Ensure there is adequate ventilation. Plug sinks and bathtubs. Put a sandbag in the toilet bowl to prevent backflow. Be ready to turn off gas and electricity (get help if needed). Unplug electrical items and move them to a higher level, if possible. Do as much as possible during daylight in case the power fails. Co-operate with local authorities – if they say evacuate, then evacuate.

What HCAs Can Do During a Flood       

Listen to the radio TV, social media and apps for information. Fill bathtubs, sinks, and plastic bottles with clean water. Bring in outdoor furniture and/or secure any items that could be swept away by floodwaters. Move valuable items to higher floors in your home. If you are advised to evacuate, then leave immediately. Avoid valleys, low-lying areas, and canyons. Don’t attempt to walk through a flowing stream that is above ankle level.

What HCAs Should Not to Do During a Flood 

Don't try to walk or drive through floodwater because: • six inches of flowing water can knock a person down; • two feet of water will float a car; • manhole covers may become dislodged; and, • other hidden dangers may be present.  Don’t try to swim through fast flowing water because you may: • be swept away; or, • be struck by an object in the water.  Don't walk on sea guards; e.g. dams on riverbanks or cross river bridges because they may: • collapse; • enable large waves to sweep you away; and, • not be able to prevent stones and small rocks from bombarding you.  Don’t consume or come into contact floodwater, as it may be contaminated with sewage.

Earthquake An earthquake is the sudden movement of the earth’ surface, which can be caused by:  the wrinkling and folding of the earth’s crust, as it cools. If it breaks during the process, a shock can occur miles below the surface of the earth.  gas or stem exploding below the surface of the earth; and,  volcanoes.

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What HCAs Can Do During an Earthquake  If indoors: • Duck or drop down to the floor. • Take cover under a sturdy piece of furniture. Hold on to it until the shaking stops (be prepared to move with it, if necessary). • Stay clear of windows, fireplaces, woodstoves, and heavy furniture/appliances that may fall over. • Stay inside to avoid being injured by falling glass or building parts.  If outdoors: • Get into the open, away from buildings and power lines.  If driving: • Stop if it is safe but stay inside vehicle. • Stay away from bridges, overpasses and tunnels. • Move vehicle as far away from the normal traffic pattern as possible. • Avoid stopping under trees, light posts, power lines or signs.  If in a mountainous area, or near unstable slopes or cliffs: be alert for falling rock and other debris that could be loosened by the earthquake.  If at the beach: move quickly to higher ground or several hundred yards inland. What HCAs Can Do After an Earthquake  Check for injuries: do not move seriously injured people unless they are in immediate danger of further injury.  Perform a safety check for: • fire or fire hazards; • gas leaks: - shut off the main gas valve only if a leak is suspected or identified by a natural gas odor; and, - wait for the gas company to turn the gas back on once the damage is repaired. • damaged electrical wiring: shut off power at the control box; • downed or damaged utility lines: stay away from downed lines even if power appears to be off; • fallen objects in closets and cupboards: be alert for displaced objects, that may fall when doors are opened; • downed or damaged chimneys: approach chimneys with caution, as they may be weakened and could topple during an aftershock.

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 Check telephones: ensure each phone is on its receiver, as telephones that are off the hook tie up the telephone network unnecessarily; and,  Clean up potentially harmful materials and/or medicines which may have spilled.

Hurricane A hurricane is a tropical storm with winds that have reached a constant speed of 74 miles per hour or more. The center of the storm is called the “eye” of the hurricane. It is usually 20-30 miles wide and may extend over 400 miles. A hurricane can last for 2 weeks or more over open water and can run a path across the entire length of the Eastern Seaboard. The dangers of a storm include:  torrential rains;  high winds; and,  storm surges. What HCAs Can Do If a Hurricane Warning is Issued  Listen for information and instructions on radio.  Ensure family members discuss what needs to be done.  Make sure everyone knows where to meet and who to call in case you are separated from one another.  Determine the needs of family members or neighbors who may need your help.  Secure home: close storm shutters and board up windows.  Secure outdoor objects or bring them indoors.  Moor boats, if time permits.  Gather emergency supplies.  Arrange care for pets, as they are not usually permitted in emergency shelters.  Turn off utilities at the main valves, if instructed to do so.  If instructed to evacuate, follow instructions as to where to go and which routes to take.  Ensure vehicle is fueled and emergency supplies are taken.  Leave immediately to avoid being marooned by flooded roads and fallen trees, especially if in a low-lying area, at a beach front, or in a mobile home.  Stay away from coastal areas, river banks, and streams.  If there is time, tell others where you are going. What HCAs Can Do During a Hurricane If not required to evacuate or are unable to evacuate:  Stay indoors during the hurricane and away from windows.  Go to the basement or storm cellar. If there is no basement: • Go to an interior room on the lower level such as closets and interior hallways. 173

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•

In a high-rise building, go to a small, interior room or hallway on the lowest floor possible. Do not stand directly under heavy appliances that are on an upper floor.  If flooding threatens: • Turn off electricity at the main breaker. • Turn off major appliances, if power is cut off. • Do not use electrical appliances of any kind. • Stay away from electrical equipment.  Watch for lightening.  Do not be fooled if there is a lull in the storm. It most likely is the eye-of- the-storm, and winds may soon pick up again.  Avoid using the phone except for serious emergencies, as local authorities need priority on telephone lines.

Tornado A tornado is a violently rotating column of air, which extends from a thunderstorm to the ground. The most powerful tornadoes can produce speeds greater than 250 miles per hour. Damage in the path of a tornado can spread more than one mile wide and 50 miles long. They are formed by winds changing direction during a storm. Before thunderstorms, it's common for winds to change direction and speed, which creates a spinning effect in the lower atmosphere. As warm air rises within the thunderstorm, updrafts tilt and begin to rotate vertically, as they are met by colder streams of air. What HCAs Can Do During a Tornado  If at home: • If you have a tornado safe room or engineered shelter, go there immediately. • Go at once to a windowless, interior room; storm cellar; basement; or lowest level of the building. • If there is no basement, go to an inner hallway or a smaller inner room without windows, such as a bathroom or closet. • Stay away from windows. • Get under a piece of sturdy furniture such as a workbench or heavy table or desk and hold on to it. • Use arms to protect head and neck. • If in a mobile home, get out and find shelter elsewhere.  If at a community facility • Go to the designated area, if there is one. • Avoid places with wide-span roofs such as auditoriums, cafeterias, large hallways, or shopping malls.

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• •

Get under a piece of sturdy furniture such as a workbench or heavy table or desk and hold on to it. Use arms to protect head and neck.

 If outdoors: • If possible, get inside a building. • If shelter is not available or there is no time to get indoors, lie in a ditch or low-lying area or crouch near a strong building. • Be aware of the potential for flooding. • Use arms to protect head and neck.  If in a car: • Never try to out-drive a tornado in a car or truck. • Get out of the car immediately and take shelter in a nearby building. • If there is no time to get indoors, get out of the car and lie in a ditch or low-lying area away from the vehicle. Be aware of the potential for flooding.

Disaster & Emergency Assistance Contact your local government for disaster and emergency assistance. The U.S. Government website is: https://www.usa.gov/after-disaster This site provides information on:  finding shelter or rental housing;  finding family;  returning home;  gas price gouging;  radiation exposure;  Americans in foreign disasters; and,  replacing lost or destroyed documents;

Summary Although several medical and non-medical people can be involved in the delivery of home care services, Home Care Assistants are the ones who spend the greatest amount of time with Older Adults either in their homes or during outings. Therefore, they most likely will be the person on duty and thus becomes responsible for assistance and direction. To promote a safer home and working environment, certain skills are essential to reduce risks, to prevent injuries and to promote health and safety. Skills can be gained by becoming 175

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knowledgeable on assessing the home environment for health and safety issues; by knowing how to prevent unsafe conditions from developing; by being able to identify potential danger threats; and, by knowing what to do if unsafe or unhealthy conditions arise. It is important that Home Care Assistants gain this knowledge prior to commencing work because disasters often strike without warning and actions must be taken immediately. HCAs usually will not have the opportunity to research emergency preparedness once an emergency strikes. Most federal governments provide disaster relief assistance.

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SECTION 11: BASICS OF EMERGENCY CARE

In this section, Home Care Assistants will learn the basics of some common medical emergencies. The section does not go into first aid procedures such as minor wounds and fractures. Instead, its focus is to emphasize those situations which can be life-threatening. The section is not a substitute for formal First Aid and CPR courses. Instead, its purpose is to give Home Care Assistants an overview of emergency care. This will enable them to recognize emergency situations and initiate prompt action to help victims receive t care when they need it. This section will also provide guidance on what to do and what not to do when providing emergency care. Home Care Assistants should know the basics of providing emergency care and first aid. Home Care Assistants who want to work as Home Care Assistants, either as self-employed workers or as employees of an agency should/must take formal First Aid and Cardiopulmonary (CPR) courses. Certified training is available from organizations such as St. John’s Ambulance and the Red Cross. Most Home Care Agencies make it a condition of employment that applicants successfully complete certified First Aid and CPR courses. Home Care Assistants must not deem themselves as qualified First Aid Attendants because they have read the information in this Home Care Assistant Guide.

Objectives of Emergency Care Emergency care is assistance given to people who have developed severe life-threatening conditions, which require immediate attention. It provides temporary assistance or treatment until medical help is available. The objectives of emergency care are to:  Keep the injured/ill individual alive.  Prevent the injury or condition from worsening.  Promote recovery. These goals may be achieved by:  maintaining breathing  stopping bleeding  maintaining circulation  preventing shock

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General Rules of Emergency Care While each case is individual and unique, there are some general rules which Home Care Assistants can apply to any emergency:  Know the limits of your knowledge and abilities.  Remain calm and focused.  Don’t move the victim or change his/her body position until you can get a better understanding on what the problem(s) is. (He/she may need to be moved immediately if the situation is life-threatening; e.g. the head and/or body are underwater, or fire breaks out.  Check breathing, bleeding and pulse.  Perform emergency procedures as indicated.  Call for assistance or if another person is on hand, direct them to call for assistance. The following information should be provided: • location of where you are; e.g. address, landmarks • telephone number you are calling from • what has happened; e.g. fall, accident • what condition the victim is in; e.g. breathing, not breathing, conscious, unconscious, bleeding, fractures • life-threatening situations  Stay on the phone until the person on the other end of the line hangs up or until emergency services arrive.  If signs and symptoms indicate a specific problem, follow the guidelines for that condition: • If it appears the victim may aspirate (inhale blood, vomit or water into the lungs), position him/her on his/her side or back with the head turned to one side and placed lower than the feet. It the substance gets into the lungs, he/she may choke to death. • If the victim is having trouble breathing or has an obvious injury to his/her chest, then position him/her on their back with their head slightly lower than the feet. • Don’t remove clothing unless necessary -- if it is then tear the clothing along the seams. When clothing is removed, protect the victim from the cold. By cutting shoes off, instead of pulling them off, you can reduce the chances of additional pain and injury. • If the victim has an injury, try not to let him/her see the injury. • Do not touch open wounds or burns without sterile bandages unless it is necessary to stop severe bleeding. • Protect from shock by covering the victim with something warm such as a blanket or coat – whatever is handy. • Keep the victim warm enough to maintain normal body temperature. • Reassure the victim that help is on the way. • Do not give the victim water or food. • Keep onlookers away from the victim. • When transporting a victim, be sure his/her feet point forwards, as this will enable the attendant in the rear to watch for signs of distress. 178

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ABCs of Assessing Person’s Condition When an emergency develops, the first thing that should be done is a quick assessment of the person’s condition. This involves checking the status of certain body functions in a specific order:  “A” is for airway. Determine if the individual can breathe effectively: • If conscious, ask if he/she can breathe and evaluate how well he/she responds. • If unconscious, tilt the head by pushing forehead backwards and lifting the chin. • Note: Do not tilt the head if a spinal cord injury is suspected. Support it by placing your hands on each side of the jaw, keeping it pulled in a straight alignment. • Remove anything in the mouth that may be obstructing breathing.  “B” is for breathing. Once the airway is opened, check for breathing by placing your ear close to the individual’s nose and mouth and listen for a few seconds.

• •

If there is no breathing, give two slow breaths and check for a carotid pulse. (The carotid is the artery on both sides of the neck, which deliver blood to the brain.) If there is not a pulse, give cardio-pulmonary resuscitation (CPR)

 “C” is for circulation. Ensure that there is effective circulation: • If there is profound bleeding; i.e. blood is spurting out or gushes out, give first aid to control it. • Check for shock by:

•

- looking to see if the skin is pale or has a bluish tinge - checking the body’s temperature by feeling the forehead, cheek or neck - looking for signs of sweating

Check the entire body by feeling the head, neck, shoulder, arms, hands, chest, abdomen, pelvis, buttocks legs and feet. Be alert for signs of pain or bleeding.

Recovery Position The Recovery Position is a lying-on-the-side position. It is used for a semi-conscious or unconscious individual who is breathing and has a pulse. This position will keep the airway open and prevent substances from being inhaled into the lungs. To place an individual in the Recovery Position:  Log-roll him/her onto his/her side, keeping the head neck and spine straight.  Place the individual’s hand on his/her upper arm under his/her face and extend the lower arm along his/her other side.  Bend the knee of the leg on top.

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Note: Do not place an individual in the Recovery Position if he/she has a neck injury or other trauma.

Image Source: http://www.mydr.com.au )

Artificial Respiration Artificial Respiration is the process of supplying air to the lungs of a person who is not breathing effectively or is not breathing at all. When he/she is not breathing, then he/she needs to be resuscitated.

Resuscitation Methods

Method

Mouth to Mouth

When to Use

Procedure

 This is the commonest form of resuscitation and is the method used most frequently.

 Pinch the individual’s nose shut with thumb & forefinger.  Take a deep breath and place your mouth tightly over the individual’s mouth.  Slowly blow the air from your lungs into the individual’s mouth.  As the individual exhales, the air can be heard & felt escaping.  Remove your mouth from the individual’s mouth.  Take another deep breath and repeat the process.

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Method

When to Use

Procedure

 Mouth to nose is used when the mouth does not allow blowing into it because: Nose to Mouth

• •

•

 Close individual’s mouth, if open.  Tilt head back and lift chin.  Hold individual’s mouth shut by pressing on the chin. mouth is injured; hard to make a seal  Take a deep breath between mouths;  Place your mouth over the individual’s nose.  Slowly blow air from your lungs into the and, individual’s nose. the mouth cannot  Remove your mouth from the individual’s nose. open  Listen & feel for air escaping.  Take another deep breath & repeat the process.

Note: When giving mouth to mouth or mouth to nose resuscitation, if possible use a shield, facemask or barrier device between your mouth and the individual to protect both of you from germ transmission

Breathing Emergencies A breathing emergency is any respiratory problem that generally occurs when air cannot travel freely and easily into the lungs. There are three primary reasons why breathing can be affected:  lack of oxygen  blocked airway  impairment in heart and lung function Home Care Assistants should be alert for signs of breathing distress. They need to be able to determine if there is no breathing at all or if the breathing function is affected:  If breathing is present, but is not effective: • breaths may be slow and shallow, or they may be fast and shallow • the individual is gasping for air • the skin has a bluish tinge • the individual becomes more tired • the individual is sweating • the individual may lose consciousness.  If breathing has stopped altogether then: • the chest does not rise and fall • the breath cannot be heard or felt 181

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Asthma Asthma is a respiratory illness wherein a person has repeated attacks of shortness-of-breath, which is often accompanied by wheezing and coughing. When the individual isn’t having an attack, he/she can breathe normally. Signs & Symptoms of Asthma Attack       

shortness-of-breath with breathing difficulties individual must sit in an upright position to breathe wheezing may or may not be present the skin is a bluish color fast pulse rate anxiety restlessness, which progresses to fatigue

Emergency Care for Severe Asthma Attack  Place the individual in the most comfortable position, which usually is sitting upright with arms on a table.  Hand him/her prescribed medications; e.g. inhaler, which usually comes in a canister-like container.  Reassure him/her, as anxiety will increase the breathing and make the attack worse.  Stay with the individual until medical help arrives.

Hyperventilation Hyperventilation is a condition in which a person is breathing much more quickly than usual. Normally, it is caused by extreme anxiety, and can happen at the same time as a panic attack. This makes the blood lose more carbon dioxide than usual, which can make them feel weak and dizzy. Causes of Hyperventilation      

panic attacks excitement, fear, or anxiety asthma injuries, especially to the head exercise life-threatening bleeding

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Signs & Symptoms of Hyperventilation        

rapid, shallow breathing feelings of suffocation confusion attention-seeking behaviour or anxiety dizziness feeling faint muscle cramps, numbness tingling in the hands and feet

Emergency Care for Hyperventilation  If the person in in respiratory distress, Call Emergency Services immediately and provide care as outlined below while awaiting medical assistance.  If the person is not in respiratory distress: • Offer to help him/her take respiratory medication if they have it. • Take him/her to a quiet area, if possible. • Encourage him/her to do breathing and relaxation exercises. • Sit him/her in a comfortable, leaning forward position. • Speak to him/her firmly, in a kind and reassuring manner. • Encourage him/her to consult with a Physician about preventing and controlling hyperventilation. • Monitor his/her condition. • If their symptoms do not improve or worsen, Call 9-1-1.

Allergic Reactions An allergy is the body’s unexpected reaction to a foreign substance (allergen). The body sees it as a threat and attempts to fight it off. Allergic reactions can range from mild to severe and can become life-threatening within seconds. Causes of Allergic Reactions There are many causes of allergic reactions, with the most common being:     

plant pollen animal hair insect stings dust mites medications,

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 foods: • nuts • shellfish • eggs • soy beans • milk • wheat Signs & Symptoms of Allergic Reaction The signs and symptoms of an allergic reaction depend on the trigger. They typically affect the airways, skin, sinuses, cardiovascular system and digestive system. Signs and symptoms include:      

difficulty breathing (tight chest and wheezing) swelling of the tongue and throat itchy or puffy eyes blotchy skin anxiety shock

Emergency Care for Allergic Reaction  Mild allergy symptoms do not require emergency care. The person with the allergic reaction may want to treat the symptoms. Examples of how mild allergy symptoms might be treated include: • Hay Fever or Hives: over the counter antihistamine • Stuffy Nose: over the counter decongestant • Itchy, Watery Eyes: over the counter allergy drops • Itchy Rash: cold compresses and over-the-counter hydrocortisone cream  Watch for worsening symptoms, including signs of anaphylaxis.

Anaphylaxis Some types of allergies can trigger a severe reaction known as anaphylaxis. It is a lifethreatening medical emergency and can cause a person to go into shock. Signs & Symptoms Anaphylaxis Some types of allergies, including allergies to foods and insect stings, can trigger a severe reaction known as anaphylaxis, which is a life-threatening emergency. Signs and symptoms of anaphylaxis include: 184

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 severe shortness-of-breath • tightness in the chest or throat • coughing • wheezing, • high-pitched noises  stomach issues • nausea • vomiting • cramping • diarrhea  drop in blood pressure  rapid, weak pulse  skin changes • swelling of the lips, face, neck, ears, and/or hands • raised, itchy, blotchy rash • flushing of skin • hives  reduced alertness • weakness • dizziness • loss of consciousness Emergency Care for Anaphylaxis  Call 9-1-1 immediately, even if the symptoms are mild or have stopped. If known, provide information on what triggered the allergic reaction.  If the person has an epinephrine auto-injector, help him or her to use it.  Assist him/her into a comfortable, sitting position, leaning forward slightly to promote breathing.  If his/her condition does not improve within 5 minutes of the initial dose of epinephrine being given, and emergency aid has not arrived, help them take a second dose (if available). Inject into the leg that was not used for the first dose.  If he/she becomes unresponsive, open their airway and check the breathing. If he/she is not breathing, follow the emergency care procedures for unresponsive individuals.

Hemorrhage Hemorrhage is an excessive loss of blood in a short period of time, which generally occurs as a result of deep cuts and injured or severed/torn blood vessels. The severity of it depends on the size of the blood vessel(s) that has been damaged. If bleeding is not stopped, the individual will die. 185

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Signs & Symptoms of Hemorrhage    

pale, cold and clammy skin rapid pulse which becomes progressively weaker feeling lightheaded, dizzy, thirsty and/or nauseous shallow breathing and difficulty getting air

Hemorrhage can occur internally or externally.  Internal hemorrhage takes place inside the tissues and body cavities. Its signs include: • bruising in the injured area • soft tissues are tender, swollen or hard • vomiting blood • coughing up blood • bleeding from the ear or nose • eyes appearing black or bloodshot • severe thirst • bloody or black stools • red or smoky urine • loss of consciousness. Note: If internal bleeding is severe, the individual will show progressive signs of shock.  External hemorrhage can be seen outside the body and may be life-threatening. Large amounts of blood flow freely from a wound or spurt out of an artery. Immediate action is required.

Emergency Care for Hemorrhage With Internal Hemorrhaging, there is little that can be done except summon medical help and treat for shock. Do not give anything by mouth, as this can cause serious complications. External Hemorrhaging requires immediate emergency procedures:    

Have/assist the individual to sit or lie down. Remove clothing to see how serious the wound is. Cover wound with a clean cloth or sterile dressing. Apply direct pressure over the cloth/dressing. If the wound is large and gaping, bring the edges together first.  If dressings are not available, have the individual use his/her own hand to apply pressure.  If direct pressure does not stop the bleeding, apply pressure to the artery above the bleeding site using your first three fingers. 186

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   

When the bleeding is controlled, maintain pressure with dressings and bandages. If blood soaks through the cloth/dressing, do not remove it but apply others on top of it. Raise the injured wound above the level of the heart unless the limb is broken. Place the individual in a restful position to slow the heart rate down.

Choking Choking occurs when there is an obstruction in the airway and air cannot get to the lungs. This causes the body to be deprived of oxygen, which can lead to cardiac arrest. The most common cause of airway obstruction is eating because:  Food (especially meat) is not chewed sufficiently.  People are laughing and talking. Older Adults are particularly prone to choking because:    

Their dentures don’t fit properly. They have poor swallowing reflexes. They have chronic illnesses. They are weak.

Sign & Symptoms of Choking  Partial Obstruction: some air can be inhaled and exhaled. Usually, forceful coughing will dislodge the item.   Complete Obstruction: air cannot be inhaled or exhaled. The individual with the obstruction will normally: • clutch at throat • have a panic look and wide eyes • be unable to cough, speak or breathe • make high-pitched, squeaking noises • have flushed skin, which becomes blue or paler than normal.

Emergency Care for Choking It is important for Home Care Assistants to recognize the signs of choking and to know what actions to take if a person is choking. Once they have determined a person is choking, they must immediately try to dislodge the object by combining any two of three emergency care measures:

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 Back Blows • Stand or kneel, in a stable position, behind the choking person and wrap one arm diagonally across the person’s chest. • Bend the person forward at the waist until the upper airway is at least parallel to the ground. • Using the heel of your other hand, deliver 5 firm back blows between the person’s shoulder blades.  Abdominal Thrusts • Stand or kneel, in a stable position, behind the choking person. • Wrap your arms around the person’s waist, make a fist, and place it just above the belly button. • Cover your fist with your other hand and give up to 5 quick, inward and upward thrusts into the person’s abdomen.  Chest Thrusts • Stand or kneel behind the choking person and wrap both your arms around the person’s chest, just under the armpits. • Make a fist and place it in the middle of the person’s chest, with your thumb facing inward, and place your other hand over your fist. • Give up to 5 chest thrusts by pulling straight back towards you, pulling sharply and deeply if needed.  If the choking individual is lying down: • Position him/her on his/her back. • Kneel next to his/her thigh with your head facing forward. • Place the heel of one hand against the abdomen at a spot which is above the navel and below the breastbone. • Place one hand on top of the other. • Press your fist and hand into the abdomen and give a swift, upward thrust. If the choking individual is unresponsive: • Lower him/her to the ground as safely as possible. • Immediately begin CPR, starting with chest compressions.  If the choking individual is obese or pregnant: • Alternate between 5 firm back blows and 5 chest thrusts. Emergency care should be continued until:  the object comes out,  the choking person begins to breathe, or,  the choking person becomes unresponsive.

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Post Choking Medical Follow-Up  Individuals, who have suffered complete choking, should seek medical attention, as damage may have occurred from the choking and/or the blows and thrusts delivered to dislodge the obstruction.  Individuals, who have partially choked, should seek medical attention if they have respiratory distress after the incident. Even if there are no signs of injury, they should still be monitored for a few hours.

Heart Attack A heart attack (Myocardial Infarction or MI) occurs when the blood supply to the heart is cut off or impaired and heart tissue dies. Causes of Heart Attack  The most common causes of a heart attack are: • plaque buildup in the arteries (atherosclerosis) • blood clots • torn blood vessel • blood vessel spasm  The main cause of heart attacks is hardening of the arteries.

Signs & Symptoms of Heart Attack             

feelings of heavy pressure or squeezing pain in the chest pain radiating down the arms or into the jaw shortness-of-breath pale skin sweating weakness nausea and vomiting abdominal discomfort with indigestion and belching fear denying anything is wrong shock unconsciousness cardiac arrest

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Emergency Care for Heart Attacks  Phone 9-1-1 or other emergency service to get prompt medical attention.  Provide rest by helping the individual assume a semi-sitting position, or whatever position is most comfortable. He/she may find it easier to sit or lie down.  Hand a person his/her medication only if he/she asks you to and the medication has been prescribed for him/her.  Reassure the individual and let him/her know that help is on the way.  Loosen collar, belt and tight clothing.  Keep individual quiet but do not restrain him/her while waiting for medical help.

Cardiac Arrest Cardiac arrest is a condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood stops flowing to the brain and other vital organs. If not treated, death usually occurs within minutes.

Causes of Cardiac Arrest Cardiac Arrest can occur by several means, including:  cardiovascular disease  severe blood loss  drowning  choking  suffocation  electrocution  severe chest injuries  irregular heart rhythms  heart disease  drug overdose

Signs & Symptoms of Cardiac Arrest  Signs & symptoms that may precede a sudden cardiac arrest include: • fatigue • fainting • blackouts • dizziness • chest pain • shortness-of-breath • weakness 190

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• heart palpitations • vomiting  Cardiac arrest can occur suddenly and without warning. Symptoms include: • collapse • no pulse • no breathing • loss of consciousness

Emergency Care for Cardiac Arrest Cardiac arrest requires immediate Cardiopulmonary Resuscitation (CPR), which is a combination of artificial respiration and artificial circulation. The goal of emergency CPR is to keep oxygenated blood circulating to the brain and other parts of the body until the pulse returns or until medical help can take over. Since Home Care Assistants are often alone with their clients, they need to be familiar with CPR, so that they know what to do and the order in which actions should be taken. When faced with this situation:  Determine if the individual is responsive by: • asking if he/she is okay • tapping on his/her shoulder  If there is no response: • check for breathing and pulse • call 9-1-1 or other emergency service for medical help  If the pulse and breathing are absent, commence CPR, if trained to do so. CPR should only be performed if the individual is unconscious and is not breathing and does not have a pulse.  Position self to commence CPR: • Kneel beside the individual. • Slide your fingers to the notch where the ribs meet. • Interlock fingers and keep the underside fingers straight. • Position your shoulders directly over your hands & keep elbows locked.  Place both hands on the center of the person’s chest. • Do 30 compressions steadily. pushing down at least 2 inches, without leaning on the chest. • Allow the chest to fully move back after each compression, without removing hands from the chest. • The chest compression rate should be between 100 and 120 beats per minute.  Give 2 rescue breaths: • Open the airway by doing a head-tilt/chin-lift. • If using a barrier, such as a face mask or plastic face shield, place it over the person’s mouth and nose. 191

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• If using a plastic face shield, seal lips tightly over the person’s mouth and pinch the nose. • If using a face mask, ensure it is fitted tightly over the mouth and nose.  Give 2 rescue breaths: • Each breath should last 1 second, with just enough volume to make the chest start to rise. • If both breaths go in, repeat the cycle of 30 compressions and 2 breaths • If there are two First Aiders present, they should alternate breathing and compressions every 5 cycles (about every 2 minutes).  Keep providing CPR until: • individual starts breathing; • another attendant takes over; • medical help arrives; or, • you are too exhausted to continue

Stroke A stroke (Cerebrovascular Accident or CVS) occurs when blood stops flowing to any part of the brain and damages brain cells. The effects of a stroke depend on the part of the brain that was damaged, and the amount of damage done. Severe strokes can result in death.

Causes of Strokes The main cause of strokes is hardening of the arteries, but they can also be caused by:  Ruptured Brain Aneurysm: causes bleeding in the surrounding brain tissues, which kills brain cells.  Blood Clot: becomes lodged in an artery of the brain, preventing blood from reaching the brain cells.  Brain Tumor: presses on an artery, decreasing the blood blow to part of the brain.

Signs and Symptoms of Stroke        

paralysis of the face muscles difficulty speaking dizziness sudden fall numbness or weakness in the arm and leg on one side of the body decreased level of consciousness double vision or loss of vision mental confusion 192

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   

loss of bladder and bowel control unequal size of eye pupils blurred vision severe headache

F-A-S-T Assessment To help determine if a person is having a stroke, apply the acronym F-A-S-T:

Face: facial numbness or weakness, especially on one side. Arm: arm numbness or weakness, especially on one side. Speech: abnormal speech, difficulty speaking, loss of speech or difficulty understanding others. Time: call 9-1-1 or another Emergency Response immediately Emergency Care for Strokes  Call 9-1-1 or another emergency service.  Position the individual at rest, usually in a semi-sitting position.  Place the individual in the Recovery Position if he/she: • is unconscious • prefers to lie down • is drooling • is having difficulty swallowing • Note: Place the paralyzed side of the body down when placing him/her in the Recovery Position. (The paralyzed side of the body can usually be determined by which side of the face is crooked or drooping.)  Do not give anything by mouth.  Protect him/her from injuries.  Reassure him/her and keep him/her warm.  If breathing stops, start Artificial Respiration (AR).  If there is no pulse, start Cardiopulmonary Respirations (CPR). Note: It is crucial to make notations on when the person first began to experience signs and symptoms of a stroke or the last time he/she was known to be well, as anti-stroke medications must be administered within a certain timeframe to be effective.

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Burns Burns are injuries to the skin and other tissues from heat, radiation and chemicals. Burns that are caused by steam or hot liquid are called scalds. They are the leading cause of injury in the home. Because the Older Adult is particularly at risk, Home Care Assistants need to know the basics of what to do if their client is burned.

Signs & Symptoms of Burns There are three degrees of burns. Each type has unique symptoms:  First Degree Burns: affect the outer layer of the skin (epidermis). Mild pain and swelling may be present; e.g. sunburn.  Second Degree Burns: affect the outer layer and lower layer (dermis) of the skin. Swelling of the skin, blisters, severe pain and peeling of skin. Burns develop a cherry red or bright pink color and are wet and glossy in appearance.  Third Degree Burns: affect the dermis and the underlying tissues. Often the skin is white, blackened or charred and may be numb. There is severe pain. Third-degree burns need immediate emergency medical care. Symptoms that may be present in any type of burn include:       

fever headache dizziness weakness blue tinge to nails and lips difficulty breathing shock

Emergency Care for Burns  Cool the burn immediately by immersing it in cold water. If this can’t be done, pour cold water onto the area or cover it with a clean cloth. Cool it until the pain has lessened.  Loosen or remove anything on the burned area that is tight; e.g. jewelry, clothing, before the area starts to swell. Don’t remove anything that is stuck.  Loosely cover the burn, with a sterile, lint-free dressing (or a clean, lint-free cloth if a dressing is not available). If the area is large, use a sheet. Secure the dressing in place with tape but avoid taping the burned area.  Arrange for medical attention. 194

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 Give first aid for shock What Not to Do When Providing Care for Burns      

Don’t breathe on, cough over or touch the burn. Don’t break blisters. Don’t remove clothing that is stuck to the burn. Don’t use butter, ointments, lotions or oily bandages on the burn. Don’t cover the burn with fluffy material; e.g. wool, flannel material. Don’t cool the individual too much -- once the burn has been cooled, keep individual warm.

Electrocution Electrocution occurs when a low-frequency electric current passes through the body. It usually results in death.

Causes of Electrocution      

touching a faulty or wet electrical outlet coming into contact with a live power line touching a metal object that is in contact with a live power line faulty appliances faulty electrical cords lightning

Signs & Symptoms of Electrocution It is important to recognize the signs and symptoms of electrocution, as the condition can be life-threatening. Signs and symptoms may include:         

abnormal sensations such as tingling, prickling, numbness or burning blisters, burns and wounds slow thinking or talking deliriousness dizziness or fainting difficulty breathing or respiratory arrest seizures, which can cause locking muscles and trembling body skin appears pale or white possible skin color changes under the eyelids or fingernails

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Emergency Care for Electrocution  Look at the electrocuted individual but don’t touch him/her, as he/she may still be in contact with the electrical source. (If you touch the individual, the current may pass through you.). Call 9-1-1 or another emergency service.  Turn off the source of electricity, if possible. If not, move the source away from you and the affected individual using a non-conducting object made of cardboard, plastic or wood.  Once the individual is free from the electrical source, check for breathing and pulse. If either has stopped, begin cardiopulmonary resuscitation (CPR) immediately.  If the individual is faint or pale or shows other signs of shock, lay him/her down with his/her head slightly lower than the body trunk. Elevate the legs.

Fainting Fainting occurs when there is a sudden loss of blood supply to the brain, which results in unconsciousness

Causes of Fainting     

injury standing in one spot too long hunger fatigue fear pain

The warning signs of impending fainting include:  dizziness  perspiration  blackness before the eyes  pale appearance to skin  weak pulse

Emergency Care for Fainting  If the individual is looking or feeling faint: • Have him/her sit down. • If sitting, have the individual lean forward with his/her head between the knees. • If the individual is lying down, elevate the feet and legs. • Loosen tight clothing.  If the individual has already fainted and is lying down: • Keep him/her in a lying position. 196

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• • • •

Elevate the feet and legs. Ensure he/she remains lying down until the symptoms have subsided. Wait at least 5 minutes after symptoms have subsided before getting up. Ensure he/she gets up in stages; i.e. go from a lying position to a sitting position instead of from a lying position directly to a standing position.  Ensure there is a fresh supply of air.  Watch for signs and symptoms of fainting.

Shock Shock is a circulation problem where the body organs and tissues do not get enough blood. It can be caused by injury or illness. It can be life-threatening because the brain and organs cannot function properly. Shock can lead to unconsciousness. While an injury or condition may have caused it, shock can become a medical emergency of its own.

Causes of Shock        

severe blood loss major fractures severe burns crushing injuries heart attack severe allergic reactions spinal cord or nerve injuries. medical emergencies; e.g. diabetes, epilepsy, infection, poisoning and drug overdose.

Signs and Symptoms of Shock      

pale skin, which turns to bluish grey bluish-purple lips, tongue, ear lobes and fingernails cold and clammy skin shallow and irregular breathing, which can be fast and labored changing in levels of consciousness weak, rapid pulse, which may not be palpable near the wrist. If pulse cannot be detected, check carotid artery (on neck)  the individual may be: • restless • anxious • disoriented • confused • dizzy 197

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•

thirsty

Emergency Care for Shock Shock can be minimized by:  giving first aid for the injury or condition that caused the shock  reassuring the individual  minimizing pain by handling the individual gently  loosening tight clothing  keeping individual warm, without overheating  not giving him/her anything to eat or drink but allowing lips to be moistened  placing the individual in the most appropriate position: • If individual is fully conscious and there are no suspected spine or head injuries: • - place him/her on his/her back with feet raised. • If the individual is not fully conscious and there are no suspected spine or head injuries: • - place him/her in the Recovery Position • If the individual has a suspected head or spinal injury: • - steady and support him/her in the position they are already in. • If the individual has a fractured pelvis: • - keep him/her lying flat on his/her back. Where possible, place them on a solid surface such as a backboard and elevate the foot of the backboard.

Diabetic Emergencies Diabetes is a condition wherein the body does not properly process food for use as energy. The body either doesn't make enough insulin or can't use its own insulin effectively, which causes sugar levels to build up in the blood. There are two types of diabetic emergencies:  Insulin Shock: occurs when there is too much insulin and not enough sugar in the blood (hypoglycemia).  Diabetic Coma: occurs when there is too much sugar and not enough insulin in the blood (hyperglycemia).

Signs & Symptoms of Diabetic Emergencies Indicators

Insulin Shock

Onset Speed

 onset is sudden

Possible Cause

 took much insulin was taken  exercised more than usual

Diabetic Coma  onset is slow, often occurring over a period of days  did not take enough insulin  exercised less than normal 198

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Indicators

Insulin Shock  has not eaten enough  has vomited

Skin Condition Pulse/ Breathing State of Consciousness

Other

Note:

 sweaty, pale & cold

Diabetic Coma  ate too much food  illness exists which requires more insulin  flushed, dry & warm

 strong & rapid  strong & shallow  faintness to unconscious

 weak & rapid

      

   

headache confused irritable aggressive trembling staggering difficulty walking

 drowsy, becoming unconscious thirsty nausea & vomiting frequent urination breath smells like acetone; e.g. smell of nail polish remover

It is not as important for Home Care Assistants to know the types of diabetic emergencies, as it is to recognize that the individual’s condition is an emergency and needs medical assistance immediately.

Emergency Care for Diabetic Conditions The goal of emergency care for diabetic conditions is to keep the individual’s condition from worsening while medical assistance is obtained.  If the individual is unconscious: •

Place him/her in the Recovery Position and monitor the ABCs until medical help arrives.

 If the individual is conscious: • Ask: Have you eaten today? An individual who has eaten but has not taken his/her medication may be in a diabetic coma. Action Required: Remind him/her to take his/her medication. • Ask: Have you taken your medication today? An individual, who has not eaten but did take their medication, may be having an insulin reaction. Action Required: Give him/her something sweet to eat or drink.  Send for medical help.

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Note: Don’t assume that the individual is in a state of drunkenness when he/she could be in a diabetic emergency. Check to see if he/she is wearing a medic alert tag and observe him/her for signs & symptoms of diabetic emergencies. Note: When in doubt as to what type of reaction the individual is experiencing, give sugar in any form, since it can be life-saving for an individual who is in insulin shock and won’t cause further harm.

Seizures Seizures, also known as convulsions, are sudden and violent contractions or tremors of the muscles. They are caused by abnormal electrical activity in the brain.

Causes of Seizures        

brain abnormalities head injury trauma high fever tumor poisoning central nervous infection lack of blood flow to the brain

Major Seizures  Partial: only part of the brain is involved, and a body part may jerk. The individual may also experience seeing, hearing and stomach discomfort.  Generalized: the whole part of the brain is involved, and the individual loses consciousness. Signs and Symptoms of Major Seizures        

sudden cry stiffening of the body loss of consciousness falling down noisy breathing frothing saliva at the mouth jerking of the body breathing may stop or be irregular – the individual may turn blue 200

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 loss of bowel and bladder control Emergency Care for Major Seizures The primary goal for emergency care during a major seizure is to protect the individual from injury while the seizure is occurring and to ensure the airway remains open while he/she is unconscious.  During Convulsions • Don’t restrict the individual’s movement. Instead guide him/her away from harm. • Loosen tight clothing, especially around the neck. • Place something soft under his/her head. Note: Do not try to put anything in his/her mouth, between the teeth or try to hold the tongue.  After convulsions: • Assess responsiveness. • Place unconscious individual in the Recovery Position. • Wipe away fluids from the nose and mouth. • Determine if there are any injuries and provide appropriate care if there are injuries. • Keep individual warm and allow him/her to rest. • Monitor breathing.  Obtain medical aid if: • the individual is unconscious for more than five minutes • has a second major seizure within a few minutes • this is the individual’s first seizure • the cause of the seizure is unknown (ask him/her when they regain consciousness)

Minor Seizures Minor Seizures are also known as petite mal seizures. They usually last for only a few seconds and can cause:  loss of consciousness,  twitching eyelids  staring When the individual comes out of a Minor Seizure, he/she is often confused, may have a headache and may fall into a deep sleep. Usually, no emergency measures are needed for petite mal seizures.

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Heat Exposure Heat exposure or hyperthermia refers to a high body temperature due to overexertion or hot temperatures. Home Care Assistants need to know what to do for heat exposure especially if they and their clients live in high temperature areas. Hot weather can be very dangerous for Older Adult people. Heat exposure can cause:  Heat Cramps  Heat Exhaustion  Heat Stroke

Heat Cramps Heat Cramps are painful muscle cramps in the legs and abdomen from too much water and salt loss through sweating. Medical Care for Heat Cramps  Heat cramps are not serious and can be reversed by giving the individual a glass of slightly salted water (1/10 teaspoon per quart).  If after 10 minutes the cramps have not subsided, give him/her a second glass of lightly salted water. (If salted water is not available, give regular water.)  If cramps don’t go away, obtain medical help. Note: Do not give more than 2 glasses of the slightly salted water, as it will worsen the condition.

Heat Exhaustion Heat Exhaustion is more serious than heat cramps because the individual has lost a lot of fluid through sweating. Circulation is affected because the blood leaves the vital organs and pools in the vessels, just below the skin. Signs and Symptoms of Heat Exhaustion

     

excessive sweating dilated pupils dizziness blurred vision cramps signs of shock

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Emergency Care for Heat Exhaustion  If individual is conscious: • Lie him/her down in a cool place and elevate the feet and legs. • Remove excessive clothing and loosen tight clothing at the neck and waist. • Give slightly salted water to drink. •  If individual is unconscious: • Place him/her in the Recovery Position. • Get medical help immediately. • Monitor ABCs and give aid as required.

Heat Stroke Heat Stroke, also known as sunstroke, is the most serious heat illness and can be life-threatening. It is caused by prolonged exposure to a hot, humid and possibly poorly-ventilated environment. Heat stroke can cause death or permanent disability if emergency care is not given. Signs and Symptoms of Heat Stroke          

red, hot, and dry skin (no sweating); body temperature may rise above 103 degrees Fahrenheit rapid, strong pulse at first and weakens in the later stages throbbing headache breathing is noisy dizziness nausea and/or vomiting confusion convulsions unconsciousness

Note:

If an individual’s temperature has risen due to heavy physical exertion, the skin will appear flushed, hot and sweaty.

Emergency Care for Heat Stroke  Move individual to a cool and shaded location.  Remove outer clothing.  Cool the individual rapidly by: • immersing him/her in cool water; e.g. bath or shower; or, • spraying or sponging him/her with cool water; or, • wrapping him/her in a cool, wet sheet and fan him/her vigorously (or use an electric fan). 203

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 Monitor body temperature and continue cooling efforts until the body temperature drops to 101-102 degrees Fahrenheit.  When his/her body feels cool to the touch, cover with a dry sheet.  If he/she is conscious, put him/her in the shock position.  If he/she is unconscious, put him/her in the Recovery Position.  If emergency medical personnel do not arrive quickly, call the hospital emergency room for further instructions.

Cold Exposure Exposure to cold or hypothermia is a state of generalized body cooling, in which the body temperature drops more than 2 degrees from its normal 98.6 degrees. Older Adults are susceptible to hypothermia because they:  have poor circulation  have less ability to sense the cold  may be on medications that promote heat loss

Signs & Symptoms of Hypothermia Signs and symptoms of hypothermia vary according to the stage of hypothermia; i.e. mild, moderate or severe: Sign

Mild

Moderate

Hypothermia

Pulse

 normal

Breathing

 normal

Appearance

Mental State

 shivering  slurred speech

 conscious but withdrawn or disinterested

 slow & weak  slow & shallow  shivering has ceased or is violent  clumsiness  stumbling  dilated pupils  bluish skin  confused  sleepy  irrational

Severe Hypothermia  weak, irregular or absent  slow or absent  shivering has stopped

 unconscious

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Emergency Care for Cold Exposure  Prevent further heat loss by: • covering exposed skin • adjusting clothing to keep wind out • moving the individual out of the cold, if possible • loosening or remove tight clothing • if individual has been moved indoors, replacing wet clothing with dry clothing • if individual is outside, placing dry clothing over wet clothing • not letting individual sit or lie on cold surface – have him/her sit/lie on a rolled-up jacket or blanket.  Give him/her something hot and sweet to drink, only if the hypothermia is in the mild state.  Get medical help.  If the individual has frost bite: • Immerse the frost-bitten part in a container of warm water about 104 degrees Fahrenheit. • Keep replacing the water to maintain that constant temperature until the area turns pink or does not improve anymore. (Note: This warming may be painful and could take up to 40 minutes.) • Do not rub the frost-bitten area. • Do not rub snow on the frost-bitten area. • Do not apply direct heat to the frost-bitten area. • Dry the affected area. • Keep the affected area warm and elevated. • Get medical care.

Psychological Emergencies Psychological emergencies can arise when an individual’s state of mind makes it difficult to cope with the situation at hand. The role of Home Care Assistants in psychological emergencies is to help him/her to cope and protect him/her (and others) until medical help arrives. Common psychological emergencies Home Care Assistants could face include:  Suicide Gesture: a person threatens to kill himself/herself.  Anxiety/Panic Attacks: a person acts as if he/she is faced with a life-threatening situation when none exists.  Hysteria: a person has violent fits of laughing and/or crying, imagined illnesses and a general lack of control.

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 Emotional Reaction to Assault: a person, because of physical or sexual attack, goes into severe emotional shock during or after the attack.  Alcohol and Drug Induced Behavior: a person’s behavior can range from quietness to disorientation to aggressiveness.

Signs & Symptoms of Psychological Emergency Indicators that a person may be in a mental health crisis include:     

mood swings, increasing anger or uncharacteristic rage reckless behavior such as using or increasing the use of alcohol and/or drugs foreboding statements such as wanting to die or commit suicide feelings of worthlessness and being a burden to others sleep pattern changes such as over-sleeping or not sleeping enough

Emergency Care for Psychological Conditions          

Note the individual’s pulse and respirations, if possible. Try to find out what has caused the situation either from the individual or other people. Call for medical assistance. Provide quiet, supportive and reassuring care while waiting for medical assistance. If the individual shows signs of aggression or a crime has taken place, contact the police. Be warm, sensitive and compassionate. Control your own emotions. Only become involved to a level you are comfortable with and don’t put yourself at risk. Only make promises you can keep – don’t lie to the individual in any way. Include the individual’s family and friends in the care, as they may be able to reassure and help him/her.  Be careful whenever there is aggressive behavior – don’t restrain the individual unless the protection of others is needed. Note: If the individual is violent or may become violent, keep your distance. Don’t stop him/ her from leaving the area and don’t block his/her exit. Let him/her go and call 9-1-1.

Legalities of Emergency Care Generally, laws protect individuals who act reasonably and prudently when providing emergency care to ill or injured persons.

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Good Samaritan Laws Good Samaritan Laws were developed to encourage people to help others in emergency situations providing they:  Use common sense.  Possess a reasonable level of skill.  Deliver care that is within their level of training. A reasonable and prudent attendant should:      

Call 9-1-1 immediately. Ask a responsive person for permission to provide care. Ask a parent or guardian for permission to help a child or baby before giving care. Check the person's airway, breathing, and circulation before providing further care. Only move injured or ill persons if their lives are in danger. Continue to give care until more highly trained personnel take over.

Good Samaritan Laws may not protect attendants if:  Their actions are grossly negligent or reckless.  They abandon the person needing assistance after starting care.

Implied Consent If an injured or ill person has a mental impairment, is unresponsive or is confused, he/she may not be able to consent to receive care. In this situation, the law assumes the person would give permission if he/she were able to do so. When a child or baby needs emergency medical assistance and his or her parent, guardian, or caregiver is not present, the law also assumes implied consent would be given.

Refusal of Emergency Care Emergency care may be refused by an ill or injured person or by the parent/guardian of a child or baby. Even if care is urgently needed, their wishes must be honored. Should assistance be refused:     

Explain to the injured or ill person why emergency care is indicated. Do not touch or give care to the person. Do not attempt to force care on the person. Remain close by in case the person has a change of mind or becomes unresponsive. Protect your personal safety. 207

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Summary Emergency care provides aide to an injured or suddenly ill individual using whatever materials are available until medical help can be obtained. Its purpose is to preserve life, to prevent the condition or injury from becoming worse and to promote recovery. This is accomplished primarily by maintaining breathing; stopping bleeding, maintaining circulation and preventing shock. Emergency care involves both knowledge and skills, which are attained by taking a formal first aid course from an established organization such as the Red Cross and St. John’s Ambulance. This training requires regular upgrading to keep certification current. Regulatory bodies, Home Care Providers and most clients require Home Care Assistants to be certified in First Aid and CPR, as they often work with Older Adults, who are at greater risk of needing emergency care. Good Samaritan Laws generally protect attendants who provide care reasonably and prudently.

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SECTION 12: INFECTION CONTROL Infection An infection is a diseased state caused by the invasion and growth of pathogens in the body. Pathogens include agents such as a virus, bacterium, protozoa, a fungus, or other microorganism. General infections can be divided into two categories:  Systemic Infections: pathogens and symptoms are spread throughout the body via the bloodstream or lymphatic system. Examples include Tuberculosis, HIV, Mumps and Measles.  Local Infections: pathogens and symptoms are limited to a specific area of the body. Examples include bladder infections and cellulitis. Localized infections can become systemic infections. Examples include pneumonia, urinary tract infections, appendicitis, and cuts/skin infections.

Types of Infection There are five main types of infections:  Bacteria: single celled organisms which multiply rapidly.  Fungi: plants that live on other plants or animals; e.g. molds, yeasts, mushrooms.  Protozoa: one-celled animals, which cause diseases such as malaria and sleeping sickness.  Rickettsia: microscopic forms of life found in insects such as ticks, fleas and lice.  Viruses: very small microscopic organisms that grow in living cells.

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Signs and Symptoms of Infection The signs and symptoms of infection can include one or more of the following:             

fever; foul odor discharge; heat at the site; pain; pus; redness; aches; chills; fever; nausea; vomiting; weakness; and, swelling.

Transmission of Infection Infections can be spread through:  direct contact with an infected person; e.g. hands, body fluids, sex and kissing;  indirect contact with objects used by an infected person; e.g. eating /drinking utensils and personal hygiene items such as razor and toothbrush;  food;  water;  air;  animals;  insects; and,  bandages. Diligence is required to protect clients from becoming contaminated with infection. This is done by removing, blocking or destroying microbes through the application of medical and/or surgical aseptic techniques. Medical asepsis is a clean technique; e.g. hand-washing while surgical asepsis involves the application of sterile techniques. Sterile procedures are not usually the responsibility of Home Care Assistants

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Infectious Diseases Infectious diseases are diseases caused by germs that can be passed to or among humans by several methods. Home Care Assistants need to know how these germs are transmitted and what precautionary measures should be taken to control their spread.

Transmission Mode

Airborne

Droplet

Contact

Transcription Common Examples of Precautionary Description Infectious Disease Measure  Germs are carried in  Tuberculosis  HCAs, who are not airborne or dust particles  Measles immune to these & are inhaled.  Herpes Zoster (shingles) diseases, should not  Varicella (chicken pox) care for infected clients.  HCAs should wear a mask when in the home of someone who has TB.  Germs are transmitted by  Diphtheria  HCAs, who are not coughing or sneezing.  Rubella (German immune to mumps or Measles) rubella, should not care  Influenza (the flu) for infected clients.  Mumps  HCAs should wear a  Meningitis mask if they are within 3  Pneumonia feet of a coughing client.  Scarlet Fever  Pertussis (whooping cough)  Germs are transmitted  Intestinal Diseases; e.g.  HCAs should wear from body surface to Salmonella, E Coli gowns & gloves when body surface.  Hepatitis A & B substantial contact is  Herpes Simplex; e.g. cold expected. sore  Equipment should be  Respiratory Tract cleaned & disinfected Infections; e.g. common before being used by cold someone else.  Sexually Transmitted Diseases  AIDS

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Bloodborne Diseases Blood-borne pathogens are germs (bacteria, virus etc.) that can cause a blood-borne disease. These pathogens are found in infected human blood and certain other body fluids, particularly semen and vaginal secretions. They may be passed from person-to-person with any exposure to infected blood or infected body fluid. Blood-borne pathogens include, but are not limited to:  Hepatitis B Virus (HBV)  Hepatitis C Virus (HCV)  Human Immunodeficiency Virus (HIV) Home Care Assistants can be exposed to bloodborne diseases when working with clients. If proper precautions are not taken, bloodborne pathogens can be transmitted from the client to the Home Care Assistant who, in turn, can transmit them to others.

The Role of HCAs in Infection Control To help control the spread of infectious diseases, Home Care Assistants can:                  

Keep immunizations up to date. Apply universal precautions. Practice safe food handling techniques. Wash hands thoroughly and frequently. Don’t put fingers near eyes, nose or mouth. Cover mouth when coughing, sneezing or blowing nose. Don’t use another person’s dirty drinking or eating utensils. Wash raw fruits and vegetables before eating them. Wear disposable sterile gloves when in contact with blood or body fluids. Wear masks and protective eye wear when there is a risk of being splashed with blood or body fluids. Avoid contact with any sharp objects. Eat a balanced diet every day. Get enough rest each night to feel refreshed. Exercise in moderation every day. Bathe, wash hair and brush teeth regularly. Wash cooking and eating utensils with soap and water after each use. Advise clients and families to have their own personal care items; e.g. face cloth, drinking glass, toothbrush, razor. Teach clients about infection control.

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Cleansing Methods for Infection Control There are several effective methods employed for preventing the spread of infections. Regardless of which method is used, all processes start with a thorough cleaning. Cleaning is the process of making all objects/surfaces free of organic and inorganic material. Generally, detergents or products containing enzymes will successfully do the job. Objects/surfaces must be cleaned thoroughly before they are processed because organic and inorganic materials influence the efficiency of decontamination, disinfection and sterilization.  Decontamination: the destruction, removal or inactivation of blood-borne pathogens on an object/surface by physical or chemical measures, which render them incapable of spreading infectious particles.  Disinfection: a process for getting rid of most or all pathogenic microorganisms (other than bacterial spores) on inanimate objects/surfaces using chemical sterilizers or disinfectants. In the home environment, items can be disinfected using: •

Dry heat: Clean item and bake in an oven @ 350 degrees F. (180 degrees C.) for 1 hour. Dry Heat is used for dressings.

•

Wet Heat: Clean item and boil for 20 minutes in a covered pot. Wet Heat is used for glass items.

•

Bleach: Clean item and soak in a mixture of 10 cups water and 1 cup of bleach for 20 minutes. Bleach is used for blood, body fluids, feces, vomit, stained clothing, toilet and bathroom/ kitchen surfaces.

•

Vinegar: Clean item and soak in a mixture of 3 cups water and 1 cup white vinegar for 20 minutes. Vinegar is used for kitchens, bath-tubs, showers, toilets, urinals, bedpans and commodes.

•

Household Detergents & Hot Water: Used to clean items, which only require cleaning or items that need to be cleaned prior to being disinfected.

•

Commercial Solutions: Follow individual instructions for usage and safety precautions.

 Sterilization: the total elimination and destruction of all microorganisms through the application of steam under pressure, dry heat, liquid chemicals and/or Ethyl Oxide (ETO), which is a flammable and explosive gas. The sterilization process is not generally done in the home; however, it is used extensively in hospitals and medical clinics/offices.

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Universal Precautions for Infection Control Universal Precautions are measures that can be followed to help prevent the spread of infection through contact with potentially infectious persons or materials. All blood and body fluids are considered potentially infectious materials and every client is handled as if he/she could have an infectious disease. Universal Precautions include processes for:       

hand washing; wearing personal protective equipment; handling sharp objects; handling body specimens; handling blood and body fluid spills; handling household waste; and, handling laundry.

Home Care Assistants must adhere to the standards for Universal Precautions.

Hand-washing Washing Hands with Water           

Turn tap on. Run water until it reaches a warm temperature. Hold hands under water flow. Apply soap so that it totally covers both hands and work soap into a frothy lather, rubbing vigorously, Clean thoroughly under nails, between fingers and on backs of hands. Wash for at least 15–30 seconds. Rinse hands thoroughly under running water starting at the fingertips and flowing towards the wrists, in order that the dirty water runs off the wrists. If a bar of soap is used, it should be rinsed and placed on a drain. Dry hands on a clean cloth towel or on a paper towel. Use a dry section of the towel to turn off the tap. Use a moisturizing cream on hands regularly to prevent skin from drying and cracking.

Demonstration: Hand-Washing  Rub palms of both hands together:

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 Interlace fingers of one hand over palm of other hand; then switch hands:

 Rub palms of both hands together:

 Place back of fingers of one hand to palm of other hand, interlacing hands; then switch hands:

 Rotate thumb of one hand in palm of other hand; then switch hands:

 Rotate fingertips of one hand into palm of other hand; then switch hands:

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Washing Hands Without Water  If hands are not visibly soiled, an alcohol-based hand rub may be used.  When using alcohol-based hand rubs, apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry.  When using an antiseptic hand cleanser or an antiseptic towelette: • use the antiseptic according to its instructions; • dry hands with a clean towel or a paper towel; • clean under the nails and between the fingers carefully; and, • use this method only if soap and water are not available.

Personal Protective Equipment Personal protective equipment (PPE"), is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses.

Disposable Gloves Disposable gloves are worn when:          

providing assistance with toileting; providing assistance with incontinence pads, adult diapers, and child diapers; providing bladder care; providing bowel care; bathing the rectal or groin area; handling items dirtied with blood, body fluids, secretions and excretions; handling dirty dressings, bedding, and clothing; handling feminine hygiene products; cleaning or caring for urinary catheters; coming into contact with draining wounds, broken skin, secretions, excretions blood, body fluids, or mucous membranes;  cleaning up blood or body fluid spills when; • cleaning/disinfecting areas exposed to blood, stool, urine or body fluids; • cleaning toilets, commodes, or soiled equipment; • having open skin lesions on hands; and, • bagging materials soiled with blood or other potentially infectious materials.

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Demonstration: Removing Used Gloves Sterile gloves are not used to provide Personal Care activities and don’t require special procedures to put them on. However, when removing disposable gloves, it is important that hands do not come into contact with blood or body fluids that may be on the gloves. The following demonstration shows how to safely remove used gloves.  Grasp glove cuff with opposite gloved hand and peel off.

 Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist.

 Peel the glove from wrist to fingertips.

 Turn the glove inside out leaving the first glove inside the second.

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 Wash hands thoroughly with soap and water: • as soon as possible after removing gloves; and, • immediately after exposure to infectious material and before touching any noncontaminated objects and surfaces.  Place used gloves, soiled pads, paper towels, rags, and hygiene products directly into a garbage receptacle.  Discard soiled products in a plastic garbage bag and close it tightly.  Place the garbage bag outside for pick-up with the regular garbage.

Gowns & Aprons  Wear gowns/aprons when: • caring for clients with infectious diseases to reduce the possibility of transmission of organisms; • there is a possibility that clothing will become soiled as a result of blood and/or body substances being splashed; and, • it is difficult to properly contain blood and/or body substances.  Wear fluid repellent gowns when: • the skin needs to be protected; and, • there is a possibility that clothing may become heavily soiled from blood, body fluids, secretions and/or excretions. Putting on Gown  Select the proper type and size of gown.  Place the open side of the gown at the back. If the gowns are too small, use two gowns and tie one at the front and the other at the back.  Slip the gown over the hands and arms by holding the arms forward, just above the head.  Adjust the gown at the shoulders.  Fasten the gown at the back of the neck.  Tie the gown firmly at the waist. Removing Gown      

Untie the gown at the waist and neck. Pull the gown over the gloves. Hold the contaminated gown away from the clothing. Discard the gown or place in designated spot for cleaning Remove gloves. Wash hands thoroughly.

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Masks Masks are specialized pieces of equipment worn over the nose and mouth to catch bacteria shed from the wearer’s nose and mouth. They reduce the transmission of bacterial particles from the wearer into the environment and help protect the wearer from blood and body fluid splashes or spatter. Putting on Mask  Place mask so that it covers mouth and nose.  Fasten ties above and below at back of head.  Fit mask snugly on the bridge of nose and under the chin. Removing Mask     

Ensure hands are clean. Undo the ties at the back of the head. Remove the mask by touching the ties only. Discard the mask in a designated waste receptacle. Wash hands.

Protective Goggles Protective goggles are specially designed eyewear worn to protect the wearer’s eyes from splatters or aerosols, which may contain infectious diseases. Putting on Protective Goggles  Place the protective goggles on the face, covering both eyes.  Maneuver them so they fit comfortably and effectively on the face. Removing Protective Goggles    

Ensure hands are clean. Touch the sides or back of the protective goggles only. Place the protective goggles in a designated area for discarding or sanitization. Wash hands.

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Sharp Objects Sharp objects refer to items used for medical purposes and include:     

needles; syringes with needles attached; lancets; razor blades; and, other items that could cause a puncture, cut, or abrasion.

Handling Sharp Objects Handling sharp objects should be kept to a minimum. Some general rules are:  Syringes should always be picked up by their barrel.  Used needles and other sharp objects should: • not be recapped, bent, sheared or broken; • be discarded immediately into an appropriate sharp-object disposal, puncture-proof container; and, • not be carried if they are uncapped.  Used needles should be left attached to the syringes.  If recapping a needle is necessary: • Put the needle on a flat surface. • Scoop cap with end of needle so the cap sits on needle. • Press the cap and needle onto the hard-surface, until cap snaps into place.  Safety devices, for sharp objects, should always be used and must never be circumvented or disabled.  Sharp objects should be discarded in puncture-resistant containers.  If a commercial, sharp object, disposal container is not available, plastic, thick-walled, household containers, such as a bleach or vinegar bottle, could be used.  Transparent plastic/glass containers should not be used for sharp objects.  Sharp objects should not be placed in any container that is going to be recycled or returned to a store.  All containers, with sharp objects, should be kept out of reach of children and pets.  Caution should be taken when sharp objects may be hidden someplace; e.g. Sharp objects are hidden in the laundry or garbage.  Used, sharp objects should be handled with care to prevent accidental cuts or punctures.  Contaminated, broken glassware or dropped sharp objects should be picked up by mechanical means such as with a broom and dustpan, tongs or forceps.  Hands should never be inserted into a container that contains sharp objects.

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Specimens Home Care Assistants may be required to handle specimens in a client’s home; e.g. urine, sputum and feces. Specimens may be needed to send to the laboratory or to test urine. How HCAs Should Handle Specimens           

Put disposable gloves on. Obtain the specimen, following directions provided by the Supervisor/Medical Person. Label the specimen with the client’s name, address, date and time of collection. Place label on the container and not on the lid. Use a clean or sterile container, as directed by Supervisor/Medical Person. The container will vary depending on the type of specimen needed. Put the lid on the container as soon as the specimen is collected. Place container in a plastic bag. Remove gloves and discard. Wash hands. Store the specimen as directed and advise client/family of its location. Follow directions for sending specimen to the lab.

Blood Sugar Tests Clients/families are responsible for testing blood sugar levels. The procedure is not done by Home Care Assistants. Home Care Assistants should not touch the lancets (blades used to prick tissue) or the dipsticks (apparatus used to capture the blood sample), which are used in the process because they are contaminated. (Note: Dipsticks can also be used to test urine.) Home Care Assistants may record test results. They should also ensure that the lancets and dipsticks are disposed of as directed by the Supervisor/Medical Person. Normally, lancets are placed into sharp-object containers. Dipsticks are placed into some type of biohazard container or they are labeled with biohazard stickers.

Blood & Body Fluid Spills Blood and body fluid spills can occur anywhere, even in the home environment. Certain procedures should be followed to prevent contamination.

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How HCAs Can Handle Blood & Body Fluid Spills  Put on protective eyewear and plastic aprons if there is a chance of being splashed with blood or body substances.  Put on disposable gloves.  Confine and contain the spill as soon as possible.  Soak up as much of the spill as possible using absorbent, disposable materials.  Place the absorbent, contaminated materials into doubled-bagged, plastic, garbage bags.  Wash and disinfect contaminated surfaces with disposable sponges/cleaning cloths: • Use a solution of 1-part bleach to 10-parts water for disinfecting. • Use cold water on blood spills. • Use warm to hot water on non-blood spills. • Dry the area, where the spill occurred, to prevent a slippery surface.  Discard disposable sponges/cleaning cloths in double-bagged, plastic, garbage bags.  Clean spillage area with water and detergent.  Wash hands thoroughly with soap and warm water.  If glass items break, sweep the broken pieces into a dust pan. Do not use fingers to pick up broken pieces.  If a spill occurs on a carpet, avoid damaging the area with chlorine. Use a detergent and arrange for an industrial cleaning of the carpet as soon as possible.  If any part of the body has been in contact with blood/body substances, the exposed area(s) should be washed immediately.  Clean contaminated equipment with cold water and detergent; then disinfect it.

Household Wastes Medical Waste  Household medical waste is any waste that is generated from the performance of health care activities in the home. Waste includes paper towels, diapers, incontinence pads, hypodermic needles, bandages, dressing wrappers, old dressings and used intravenous tubing.  Used intravenous tubing is tubing that has been used to administer blood/blood products. Note: Unused intravenous tubing is not considered to be medical waste.  Household medical waste does not include hazardous waste, radioactive waste, or regular household waste.  Usually, medical wastes, produced in the home, do not pose a serious health concern unless the waste is infectious.

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Infectious Waste Infectious waste is medical waste that presents significant health risk, such as the possibility of causing disease in another human being, should that person contact the waste. Infectious waste includes:  wastes that are contaminated with blood or body fluids; or,  sharp objects used on people who have infectious diseases such as needles, syringes and scalpel blades. How HCAs Can Handle Household Wastes  Sort into correct categories at the spot where they are produced.  Place in proper containers.  Keep in separate packaging during collection, storage and transportation to ensure waste material is not released.  Wash hands with soap and hot water for 15 seconds after contact with garbage.  Place soiled bandages, disposable sheets and medical gloves securely into fastened plastic bags before placing them into garbage receptacles.

Laundry All medical and infections wastes on soiled linens, clothing and other items are assumed to be contaminated. They must be handled and collected carefully, in accordance with regulations and guidelines to avoid passing on infection to anyone who may come into contact with them. How HCAs Can Handle Laundry  Separate areas for clean and soiled laundry should be used.  Laundry should be sorted in the laundry room, not in the client’s room.  Clothing and linen, soiled with blood or body fluids, should be put into bags at the spot where the soiling occurred.  Dangerous objects should not be thrown into the laundry bags or hampers.  Plastic aprons should be worn, when indicated.  Clothing and linens that are to be transported should be: • placed loosely into leak-proof bags; e.g. plastic garbage bags; • closed securely; and, • placed into bags labeled as potentially infectious.  Wear protective gloves when bagging clothing and linens that have been soiled with body substances/blood (including menstrual blood).  Wash hands with hot water and soap for 15 seconds after gloves are removed. 223

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 Wear other protective clothing should be worn when indicated.  Use paper towels and/or running water to remove solid materials from clothing and linens prior to laundering.  Flush urine, stool and vomit down the toilet.  Utilize appropriate cleaning methods when washing laundry, e.g.: • separation of items; • suitable water temperature; and, • appropriate machine cycle.  Use a water temperature of at least 140 F. (60 C) to ensure decontamination.  Control the risk of contaminated slime building up in the washing machine by using a water temperature higher than 140F. (60C) at least once a week.  Add bleach or other laundry disinfectant when washing with cooler water.  Follow the instructions on the bleach/disinfectant container.  If clients have suppressed immunity systems or if clothing and linens are heavily soiled: • use higher water temperatures of at least 190 F. (90C); or, • use a water temperature of at least 140 F. (60C) with bleach.  Ensure clothing and linens, which may be contaminated with fecal material, are not washed with items could be used around food.  Dry laundry as soon as it is washed. Don’t leave it sitting for long periods in the washing machine, as dampness can promote the growth of micro-organisms.  Clothing and linens should be stored in a manner that prevents contamination.  Clean linens/clothing should be stored separately from used linen/clothing.  Laundry equipment should be maintained in sanitary condition.  Laundry baskets or other transport items should be cleaned and sanitized after use.  Client’s laundry should not be taken home for laundering due to the increased risk of crossinfection. Note: Bacteria can live in laundry machines, especially if hot water is not used.

Personal Care Items Personal Care Items Personal care items are items used by individuals for grooming and body hygiene such as:    

toothbrush; razor; hair comb & brush; and, manicure and pedicure sets.

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Special Equipment Special equipment refers to items individuals use to assist with their activities of daily living such as:     

bathing; e.g. bath bench; toileting; e.g. raised toilet seat, grab-bars; mobility; e.g. crutches, walking cane; transportation; e.g. wheelchair, scooter; and, sleeping; e.g. adapted or special beds.

How HCAs Can Handle Personal Care Items & Special Equipment  Keep all items and equipment in proper running order.  Do not allow blood, fluid and tissue to dry on any reusable item. Clean them quickly.  Clean all objects and equipment thoroughly to remove blood, tissue, body fluids/ secretions/excretions and other residue before they are disinfected or sterilized.  Clean and disinfect all special equipment used by one individual before it is used by another individual.  Wipe special equipment, which could harbor disease-causing organisms, with a disinfectant at least once a day or whenever visible soiling is evident; e.g. commode, raised toilet seat.  Wipe down items that only come into contact with the skin and not with mucous membranes with a detergent or low-level disinfectant; e.g. crutches, canes, walkers, wheelchair, and blood pressure cuff.  Clean and disinfect reusable objects, which touch mucous membranes, by soaking them in bleach and water.  Wear Personal Protective Equipment when handling contaminated equipment and when using chemical products.  Wear gloves when handling and transporting used special equipment.  Wash hands immediately with soap and hot water for a minimum of 15 seconds after contacting contaminated items.  Clean personal care grooming items with hot water and detergent.  Clean and handle oxygen, as demonstrated by the supplier or a Registered Nurse.

Catheters & Drainage Bags Home Care Assistants often are responsible for cleaning catheters; and emptying and cleaning drainage bags. Only Registered Nurses should insert or remove catheters.

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How HCAs Can Clean a Catheter Unless an RN provides different instructions, catheterization equipment can be cleaned and handled as follows:  Clean catheter once per shift or more frequently, if required.  Wash hands and wear disposable gloves.  Cleanse the catheter using soap, water, and clean cloth. Wipe from the meatus (opening at the end of the urethra) downward about four inches. Repeat as necessary using a new cloth each time.  Rinse well to ensure all soap is removed.  Avoid pulling on catheter.  Ensure catheter is secured properly; i.e.: • tape the catheter to the inner thigh leaving enough slack so it does not cause friction at the urethra; • ensure urine flows freely, that there are no kinks in the tubing, and that the patient is not sitting or lying on the tubing; • coil the tubing and attach securely to bed linens or chair; • keep the drainage bag below the bladder to prevent urine from flowing backward into the bladder; and, • ensure there are no leaks where the catheter connects to the drainage bag. How HCSs Should Empty a Drainage Bag       

  

Empty the drainage bag at the end of each shift or as needed. Wash hands and wear disposable gloves. Place a paper towel on floor and set graduate container on it. Open the clamp on the bottom of the drainage bag. Allow all urine to drain into the graduate container being careful not to let the drain touch the inside of the container. Close the clamp and replace the clamped drain in the holder on the bag. Measure urine. Record amount of output (1 ounce = 30 ml.) and color of urine; e.g. “dilute”; “amber”; “concentrated”; “tea”; “cranberry” or other. Note anything present in urine such as blood, crystals, stones, or particles. Note any foul odors.) Be careful when changing the drainage bag to prevent urine from spilling. Be alert for any leakage, particularly at the point where the catheter and drainage bag connect. Do not place drainage bag directly onto the floor. Attach or place it on an object that prevents contact with the floor.

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How HCAs Can Clean an Emptied Drainage Bag  Wash hands and wear disposable gloves.  Rinse emptied drainage bag with water. (Use syringe, if available, as it enables water to be inserted into bag more easily.) Insert 6 syringes (about 12 ounces) of water.  Discard rinsing water from bag.  Prepare a solution of water and soap (6 syringes of water and 2 squirts of soap) in one bowl. Insert into bag and swish around bag.  Discard soapy solution from bag.  Rinse bag with 6 syringes of water.  Discard rinsing water from bag.  Mix a solution of ½ cup vinegar and 6 syringes of water in second bowl.  Insert vinegar solution into drainage bag.  Gently swirl the vinegar solution around drainage bag to wet the entire inside.  Leave vinegar solution in drainage bag until the bag is to be used.  When drainage bag is needed, empty vinegar solution.  Change urinary bags when necessary and in accordance with the manufacturer’s directions.

Summary Some bacterial, viral, or parasitic infections are contagious even before symptoms appear. Therefore, Home Care Assistants need to recognize the signs of infections, become familiar with common infectious diseases and utilize infection control procedures. Precautions to prevent the spread of germs are the same for all infectious diseases. Protective actions must be taken regularly and applied consistently for every person, in every setting. Universal Precautions need to be applied when handling body fluids, feces, soiled linens and clothing. The single most important precaution is hand-washing. Other Universal Precautions include properly caring for and cleaning special equipment, utensils, personal care items, clothing, and bed linens; wearing protective clothing when necessary and properly disposing of wastes.

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SECTION 13: OBSERVING, REPORTING & DOCUMENTING

Home Care Assistants play an integral role in observing, documenting and reporting accurate and timely information about Older Adults. Since HCAs spend a lot of time with them, they are often the first to notice changes to:  the Older Adult;  their families: and/or,  their home environments. Communicating current information to the Care Team is essential to ensure issues are addressed as early as possible.

Observing The purpose of observing is to quickly detect and report any changes that an individual may be having, even if he/she does not recognize the changes themselves. Early detection can prevent serious problems.

Methods of Observing There are three primary methods HCAs can use for observing:  vital signs;  objective observing; and,  subjective observing. Vital Signs Vital signs are invaluable for HCAs to quickly assess an Older Adult’s condition; e.g.:    

temperature pulse respirations blood pressure

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Note: HCAs require training before taking Vital Signs and need authorization from their Supervisor to perform this function. Objective Observing HCAs can use their own senses to observe an Older Adult’s condition; e.g.: 

Sight: skin color bloody stool bruise  Hearing: • input from Older Adult or family; • wheezing • moaning  Smell: • body odor • breath odor • urine odor  Touch: • skin temperature • tender area • pulse • • •

Subjective Observing HCAs can receive information from other sources; e.g.:  Individual says he/she is dizzy and nauseous.  Family advises Older Adult has been weepy and withdrawn.

Guidelines for Observing    

Get to know what is typical for an individual, so changes can more easily be detected. Ask individual about any symptoms he/she is experiencing. Observe body language. Learn to recognize signs and symptoms of changes.

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Signs & Symptoms of Illness Physical Health: Changes may occur to specific areas of the body. Some are noticeable (signs) while others are expressed by the individual (symptoms); e.g.:

Area of Body Lungs Heart & Circulation Skin Mouth Throat Eyes Ears Nose G.I. Tract Urinary Tract Breath Female Health Male Health

Signs & Symptoms  shortness of breath, wheezing, coughing, chest pain  shortness of breath, chest pain, swelling in legs and ankles, cold feet.  rash, redness, blotches, bruises.  gum swelling or bleeding, toothache, facial swelling.  pain when swallowing, hoarse voice, white patches at back, redness, fever.  swollen eyelid, yellow or green discharge, excessive watering, reported pain  drainage from ear canal, ringing, reduced hearing, redness, pulling ear, fever  rubbing nose, runny discharge (can be colored, cloudy or clear).  pain, bloating, vomiting, diarrhea, constipation, bloody stools, fever.  changes in urine color (cloudy, dark, light, bloody), burning and/or painful urination  fruity smelling odor.  changes in frequency, duration and flow of menses, vaginal discharge, itching, unusual odor.  penis discharge, burning, pain, redness, itching.

Signs & Symptoms of Injury Signs Evident to Observer        

bleeding swelling bruises abnormal shape of bone or joint sunken eyes dilated pupils decreased range of motion of a limb or joint numbness or tingling

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Symptoms Reported by Injured Person    

feeling sick feeling dizzy pain or tenderness in a certain area feeling hot or cold

Note: Refer to Section 11- Basics of Emergency Care Signs & Symptoms of Mental or Emotional Changes  mood changes from outgoing and happy to withdrawn and sullen.  behavior changes from calm and cooperative to aggressive and uncooperative.  appearance changes from being neatly dressed and groomed to wearing wrinkled clothing and having disheveled hair.  communication changes from conversationalist to untalkative or unclear speech.  social/family relationships change from being participatory to being withdrawn and/or apprehensive when others are around. Signs & Symptoms of Changes in Home Environment    

loss of spouse or partner; e.g. grumpiness, sorrow, unhappiness insufficient income to meet rising costs; e.g.: less food supply. changes in housekeeping standards; e.g. clean and neat home is now dirty and untidy. changes to home structure, which display a need for repair; e.g.: broken entrance steps.

Reporting Reporting is an oral update given to the Supervisor, Co-workers and/or Care Team for continuity of care. It can be done on a one-on-one basis, in a group setting, or at a client care session. Usually a report is given after the completion of a Home Care Assistant’s shift. However, reports are also given as often as an individual’s condition requires or as often as the Care Plan stipulates. Any changes from an individual’s normal or changes in his/her condition should be reported immediately.

Reporting Channels Channels used to deliver verbal reports include:  person-to-person  phone 231

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 tape recorder  voice mail

Guidelines for Reporting       

Make notes during shift. Deliver reports in a professional manner. Provide individual’s name, location and age. Summarize individual’s health conditions. Make reports thorough and accurate. Report only things personally observed or done. Report observations and actions taken while on duty; e.g.: • observations useful to co-workers; • time of observation or action; • type of observation or action; • individual’s response to observation or action; • individual’s input, which could affect treatment or care; • changes from individual’s norm; • changes in individual’s condition; • changes in the environment.  Decide to report things instead of choosing not to report them to: • avoid risk to individual; • avoid risk to self; and, • assist Supervisor.

Documenting Documenting or charting is the act of recording pertinent information in the records of individuals to whom services or care is being provided.

Benefits of Documenting It is important to keep records on care and services delivered because records:      

provide a history and status if another service provider takes over; provide a communication tool for members of the Care Team; enhance the quality of service delivered; serve as a guide for the care provider to plan and implement effective interventions; may be a requirement of federal, state or municipal legislation; may provide service confirmation for payment by a Third-Party; e.g. Insurance Company is paying for the home care services; 232

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 help protect the client and service provider in the event of legal and/or ethical proceedings.  can demonstrate HCAs are competent and safe service providers; and,  assist in the evaluation of service quality and identify areas for improvement.

Information to be Documented When proving care to individuals, certain information needs to be documented, including (where applicable):         

observations; e.g. physical, emotional and safety complaints; e.g. service is not meeting needs statements; e.g. headache safety issues; e.g. loose stairway railings vital signs; e.g. Temperature, Pulse, Respirations & Blood Pressure intake and output; e.g. amount of fluids consumed & amount of urine voided blood sugar levels; (HCAs document results only --they do not perform the test.) medication management; e.g. medication was taken as prescribed unusual incidents; e.g. fall or wrong medication taken

Guidelines for Documenting  Ensure notations are constructed, maintained and used, in accordance with statutory requirements.  Follow the employer’s system for recording information for consistency purposes.  Identify the individual on each page of the document. Record the following: • Individual’s name; • current date; and, • page number.  Make entries factual, consistent and accurate.  Ensure entries are legible and neat.  Print comments instead of writing them.  Ensure spelling, grammar and punctuation are correct.  Avoid jargon, meaningless phrases, assumptions and offensive or biased comments.  Keep abbreviations to a minimum. Use only those abbreviations recognized by all members of the Care Team.  Ensure notations are readable when photocopied or scanned.  Avoid using words with more than one meaning.  Include client’s/family’s input, whenever possible. Place their exact words in quotation marks.  Provide all details about problems and subsequent actions taken.  Make notations after care is performed or an event has occurred.  Make notations as soon as possible after an unusual incident has occurred. 233

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Only document details of care personally provided. Do not document observations made or care provided by others.  Record notations in the order they occurred. If an entry is documented out of sequence, place an arrow extending from the notation to the spot where it should be inserted.  Use short and concise words to avoid misinterpretation.  Be sure to record routine services.  Make record permanent; e.g. use ink or other durable means for all entries.  Include essential data with every notation. i.e.: • date. • time. • legible signature. and, • professional designation; e.g. HCA, RN  Do not erase original notations. To make corrections: • use a single line to rule out incorrect information; • write “error” and initial beside “error”; and, • insert the correct information right after the error notation.  If an entire page needs to be done over: • draw a diagonal line through the page and initial it. • write “original” across the deleted information. • don’t leave any blank lines. • label the new page as “correct copy”  Consider notations made by any Care Team member to be equally important.  Use better judgment to decide what is relevant and should be recorded.  Assume that entries made will be scrutinized at some point.  Respect and protect records: • protect confidentiality of electronic and hardcopy records; • keep them secure and protect from theft, fire and/or water; • ensure they are accessible only by authorized persons; • keep documents in good condition. • maintain and protect records in accordance with regulations; and, • consider records to be legal documents.

Standard Medical Abbreviations & Acronyms Abbreviations are shortened forms for written words or phrases. e.g. I&O is short for “Intake and Output”. Acronyms are words formed using the first letter of each of the major parts of a compound term; e.g.: TLC is short for “Tender Loving Care”.

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Purpose of Abbreviations & Acronyms Abbreviations & Acronyms are primarily used in written communication although they can be issued orally; e.g. STAT (Do immediately!) They:  help members of the Care Team to communicate quickly and effectively;  reduce time needed for documenting; and,  conserve record space. Note:

Abbreviations and Acronyms must be used consistently and correctly to avoid misinterpretation by another party.

Home Care Assistants must know common abbreviations and acronyms not only to document their own notations correctly but also to interpret the notations made by other people. It is important for HCAs to use the abbreviations and acronyms accepted by the agency that employs them. The following table shows some common abbreviations and acronyms HCAs may write, read and/or hear.

List of Common Abbreviations & Acronyms Abbreviation abd a.c. AD ADL Ad lib AM (am) Amb Amt Ap ASAP ASHD As Tol Bid BM (bm) BP BRP ć BS C CA CAD Cal Cap

Meaning Abdomen Before Meals Right Ear Activities of Daily Living As Desired Between Midnight & Noon Ambulatory Amount Apical As Soon As Possible Arteriosclerotic Heart Disease As Tolerated Twice A Day Bowel Movement Blood Pressure Bathroom Privilege With Bowel Sounds Centigrade Cancer Coronary Artery Disease Calories Capsule

Abbreviation min ml MOM MS NA Na Neg NEURO No (#) NPO NS Nsg N&V NWB O2 OB OD OOB OR ORTHO os OS OT

Meaning Minute Milliliter Milk of Magnesia Multiple Sclerosis Nursing Assistant Sodium Negative Neurology Number Nothing by Mouth Normal Saline Nursing Nausea & Vomiting No Weight Bearing Oxygen Obstetrics Right Eye Out of Bed Operating Room Orthopedics Oral Left Eye Occupational Therapy 235

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Abbreviation Cath CBC CBR cc C & DB CHF Chol CNS COPD

Meaning

Abbreviation

Meaning

OU Oz (OZ) p.c. peds per peri PM (pm) Po (per os) pre op

Both Eyes Ounce After Meals Pediatrics By or Through Perineal After Noon By Mouth Preoperative

CPR CVA dc (d/c) dias DM DOA DON drsg Dx ECG (EKG) EEG EENT EMG ER F FBS Fe fib

Catheter Complete Blood Count Complete Bed Rest Cubic Centimeter Cough & Deep Breath Congestive Heart Failure Cholesterol Central Nervous System Chronic Obstructive Pulmonary Disease Cardiopulmonary Resuscitation Cerebral Vascular Accident Discontinue Diastolic Diabetes Mellitus Dead on Arrival Director of Nursing Dressing Diagnosis Electrocardiogram Electroencephalogram Eyes, Ears, Nose & Throat Electromyogram Emergency Room Fahrenheit Fasting Blood Sugar Iron Fibrillation

PROM PT PVD Postop prep prn Pt (pt) q qd qh q2h, q3h, qhs qid qod qt quad R RBC

Fl (fld) Ft FWB Fx gal GB GI gm gr gtts GU GYN H (hr) H2O H2O2 Hgb

Fluid Feet Full Weight Bearing Fracture Gallon Gallbladder Gastrointestinal Gram Grain Drops Genitourinary Gynecology Hour Water Hydrogen Peroxide Hemoglobin

reg RLQ RN ROM RUQ Rx ś SO SOB Spec (spec) SSE ST stat SQ (subq) syst sx

Passive Range of Motion Physical Therapy Peripheral Vascular Disease Postoperative Preparation When Necessary Patient Every Every Day Every Hour Every 2 Hours; Every 3 Hours Every Night at Bedtime 4 Times A Day Every Other Day Quart Quadriplegic Rectal Temp; Respiration; Right Red Blood Cells; Red Blood Count Regular Right Lower Quadrant Registered Nurse Range of Motion Right Upper Quadrant Prescription Without Significant Other Shortness of Breath Specimen Soapsuds Enema Speech Therapy Immediately; At Once Subcutaneous Systolic Symptoms 236

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Abbreviation

Meaning

Abbreviation

HS (hs) ht Hx ICU in I&O I/S

Hour of Sleep Height History Intensive Care Unit Inch Intake & Output Instruct & Supervise

TB tbsp temp TIA tid TLC TPR

IV K L lab lb liq LLQ LPN lt LUQ MD meds mid noc

Intravenous Potassium Left or Liter Laboratory Pound Liquid Left Lower Quadrant Licensed Practical Nurse Left Left Upper Quadrant Medical Doctor Medications Midnight

tsp Tx U/a (U/A, u/a) URI UTI via VS WBC W/C wk WNL wt yr

Meaning Tuberculosis Tablespoon Temperature Transient Ischemic Attack 3 Times A Day Tender Loving Care Temperature, Pulse & Respirations Teaspoon Treatment Urinalysis Upper Respiratory Infection Urinary Tract Infection By Way of Vital Signs White Blood Count Wheelchair Week Within Normal Limits Weight Year

The 24-Hour Clock The 24-hour clock is a system of telling the time. Its period runs from midnight to midnight and is divided into 24 hours, numbered from 0 to 24. It does not use a.m. or p.m. A time in the 24hour clock is written in the form hours:minutes (for example, 02:30), or hours:minutes:seconds (02:30:15). Numbers under 10 usually have a zero in front e.g. 06:15. Under the 24-hour clock system, the day begins at midnight, 00:00, and the last minute of the day begins at 23:59 and ends at 24:00, Advantages of the 24-Hour Clock over the 12-Hour Clock

 There is less confusion between morning and evening times; e.g. 6 o'clock can be indicated by stating or documenting: • 18:00 for evening time; or, • 06:00 for morning time.  It is easier to calculate duration of time.

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Comparison of the 24-Hour Clock & the 12-Hour Clock 24-HOUR CLOCK

12-HOUR CLOCK

0000 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400

12:00 midnight 1:00 a.m. 2:00 a.m. 3:00 a.m. 4:00 a.m. 5:00 a.m. 6:00 a.m. 7:00 a.m. 8:00 a.m. 9:00 a.m. 10:00 a.m. 11:00 a.m. 12:00 noon 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m. 5:00 p.m. 6:00 p.m. 7:00 p.m. 8:00 p.m. 9:00 p.m. 10:00 p.m. 11:00 p.m. 12:00 midnight

Client Care Records Client Care Records are a compilation of notations made by all members of the Care Team into one record. Separate files are set up for each person receiving care and all notations and documents for that client are kept in that person’s file.

Purpose of Client Care Records  Record a history of care and treatments given to individual.  Determine and guide interventions.  Establish a Communication Tool for members of the Care Team to keep each other updated on what has been done.

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 Organize all documentation in one file for quicker access to all information about one individual.  Provide accountability to evaluate the effectiveness of care being delivered.  To maintain confidentiality.  Ensure record accessibility is restricted to only those involved in an individual’s care.  Meet legal requirements for permanent records.  Confirm service delivery to Third-Party Payors.  Prevent or respond to liability suits.

HCA Responsibilities for Client Care Records Home Care Assistants are responsible for recording and maintaining client care documents, in accordance with legal requirements. HCAs are expected to:           

Adhere strictly to the Care Plan. Assist with problem identification. Consult with Supervisor directly. Observe and report individual’s response to treatments and activities. Attend care conferences. Create records routinely as part of their duties. File documents using their employer’s Recordkeeping System. Follow their employer’s policies and procedures for managing records. Handle records with care. Avoid destroying records without authority. Protect records from unauthorized access.

Details HCAs Should Record As part of the Care Team, Home Care Assistants have a duty to document relative information. Attention to detail is essential, particularly when personal care is provided. HCAs notations should include:  changes in individual’s health status or supports;  time spent with individual;  changes in the assigned schedule; e.g.: • HCA is substituting for another HCA. • Client was not at home when service was to be delivered. • Family is staying with the individual and help is not required. Or, • Another provision has been made for the individual’s care.  unusual incidents or occurrences. These events should be verbally reported to the Supervisor as soon as possible and then followed-up with a written report.

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 information on individual’s condition in real time and measures taken to address his/her needs;  medication supervision; e.g.: monitoring to ensure medications have been taken as prescribed.  steps taken to ensure quality care is provided; e.g. expertise applied, and safety measures taken;  reason that care was not provided; e.g. individual was too ill to have a scheduled bath;  expenditures made on individual’s behalf.  travel costs incurred performing errands/shopping/outings for individual;  activities performed to assist in transfer of individuals to other care provider when needs can no longer be met where they are.  signatures of individual/individual’s representative and HCA on documentation for validation purposes. Notes: Sometimes determining what to record and what not to record becomes a “judgment call”. Note: Courts-of-Law generally consider what has not been documented has not been done. Recordkeeping Benefits for HCAs Home Care Assistants benefit from maintaining client records as doing so enables them to:    

perform their duties more efficiently; adhere to work-related legal obligations; protect clients and employers; and, protect their employee rights.

Case Management Records For Case Management purposes, the Care Team uses a variety of documents for recording information. The type(s) utilized are determined on a case-by-case basis, depending on the needs of the individual. Common Case Management documents include:  Needs Assessments including: • General Needs • Personal Care Needs • Nursing Assessment • Home Safety  Care Plan (Service Plan)  Monitoring and Follow-up Evaluations  Progress Report  Status Notes 240

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 Medication Tracking  Flow Chart for Activities of Daily Living Needs Assessments Instrumental Activities of Daily Living Instrumental Activities of Daily Living refer to daily tasks, which enable individuals to live independently in their homes and communities. Individuals are assessed on their ability to perform these tasks; e.g.:      

do light housework; prepare meals; take medications as prescribed; go shopping and run errands; manage finances; and, use telephone.

Activities of Daily Living Activities of Daily Living refer to personal care activities necessary for everyday living. Individuals are assessed on their capacity to perform their own self-care; e.g.:        

bathing; grooming; dressing, oral care; toileting; walking; transferring; and, eating.

Nursing Assessments Nursing Assessments are conducted to identify the actual or potential health needs of individuals/families, which include:    

the physical, medical, social and emotional aspects of the individual’s condition(s); the level of care indicated; the need for referrals; and, coordination of care with other health professionals, as indicated.

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Home Safety Assessments Home Safety Assessments are undertaken to identify obvious and possible hazards present in the home environment; e.g.:       

physical dangers in the home environment; structural problems indicating need for repairs. presence of handrails and other safety devices; presence of throw rugs, cords which could cause tripping sufficient and adequate lighting; existence of smoke detectors; and, proper storage of hazardous materials.

Care Plan A Care Plan (Service Plan) is a written proposal to identify and meet an individual’s unmet needs and to provide consistent, well-planned care. It is usually developed during an in-home assessment by a designated Agency representative such as the Supervisor or RN. Whenever possible, Care Plans are created in conjunction with the individual and/or his/her family/representative. Changes are made to the Care Plan by the Supervisor or RN in consultation with the individual and/or his/her family/representative and other professionals (as indicated); e.g. Occupational Therapist. Purpose of Care Plan  Identify an individual’s functional limitations and determine unmet needs he/she may have with:  Activities of Daily Living;  Instrumental activities of Daily Living;  Establish short-term and long-term goals;  Establish interventions, actions and/or referrals to address the individual’s unmet needs;  Establish monitoring and follow-up schedules to determine the effectiveness of the Care Plan;  Outline the duties that Home Care Assistants are to perform in each client’s home; and,  Establish boundaries as to what activities Home Care Assistants may or may not do when providing care to the individual.

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Monitoring & Follow-up Evaluations Regular monitoring and follow-ups are conducted on the Care Plan to:  ensure that the interventions in place are working as intended; and,  anticipate or respond to additional problems, which may develop. Revisions may be made to the Care Plan if Follow-up Evaluations indicate the:  interventions in place are not achieving their intended goal;  individual has developed additional problems; and/or,  individual no longer needs the intervention(s). Note: Home Care Assistants never change the Care Plan. Changes are made by the Supervisor or RN in consultation with the individual/individual’s family and/or other Professionals, Progress Reports A Progress Report summarizes and updates the status of individuals receiving care. They can be given orally or in writing. Progress Reports generally provide information including:

           

physical issues; emotional outlook; medications; treatments; medical appointments; hospitalizations; bladder and bowel habits; diet and eating; mobility; transferring capabilities; exercise regimes; and, social activities.

Status Notes Status notations are made, during each shift by Home Care Assistants and/or other individuals, who provide services to clients. These notes serve as a communication tool for team members, especially when ongoing and multi-intervention care is being provided by several people. Status notations are made to:  describe care provided; 243

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    

monitor client’s progress, behavior, activities and other pertinent data. provide information where there is more than one service provider involved; keep a record, when a client’s memory is not keen; document details required by Third-Party payors (e.g. insurance companies); and, maintain a written record for cases wherein legal actions are pending.

Medication Records When Home Care Assistants are tasked with monitoring an individual’s medication regime, they must document the following:     

name of the medication, the dosage of medication; the date the medication was taken; the time the medication was taken; and, their name and position; e.g. HCA

Note: HCAs must make their notations in accordance with the format established by their employers. Flow Charts Individuals, who receive personal care, often need to have their conditions, physical functions and care monitored; e.g.:       

bowel and bladder habits; intake (how much they drink) and output (how much they urinate); vital signs (temperature, pulse, and respirations); blood pressure; weight; baths/shower and shampoos; and, foot-care.

These activities must be documented. While notations are often made in the Progress Notes, a Flow Chart is a helpful tool, as it provides a quick reference in one location; i.e. it offsets the need to review Progress Notes page by page to access the same information.

Summary Observing, reporting and documenting are essential components of Care Services because they provide a communication tool for the Care Team, which enhances the quality of service delivered; makes early detection of problems easier; and meets legal requirements. 244

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Different forms of observing are utilized: vital signs; objective observing; and, subjective observing. When relevant, what is observed, must be documented. Reporting is the verbal method of providing an update while documenting is the written method of recording an update. Client Care Records are a compilation of notations made by all members of the Care Team into one record. Separate files are set up for everyone receiving care and all notations and documents for that client are kept in his/her file. Client Care Records are maintained to provide a history and status on clients; determine and guide interventions; adhere to legislation; confirm service delivery to Third-Party Payors; and, prevent or respond to liability suits. Home Care Assistants play an integral role in observing, documenting and reporting accurate and timely information, as they spend a lot of time with their clients. Often, they are the first to notice any changes. Client Records can also benefit HCAs, as they enable HCAs to perform their duties more efficiently; adhere to work-related, legal obligations; protect their clients and employers; and, protect their own employee rights.

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SECTION 14: ETHICAL & LEGAL ISSUES Difference Between Ethics and Laws Ethics guide what a person should do, whereas laws determine what a person must do. Ethics are ideal human conduct while laws regulate human behavior. Ethics and laws are made in alignment to avoid contradicting each other. They provide requirements and guidelines on how individuals should act. The primary differences between the two are:  Ethics are standards of human conduct that govern the actions of: • the whole society; and, • its individual members.  Laws consist of rules and regulations, whereas ethics are guidelines and principles that inform people how to live or how to behave in a situation.  Laws are created by governments; i.e.: local, regional, national or international. Ethics are governed by individual, legal or professional norms; e.g. workplace ethics, environmental ethics.  Laws are expressed in written form in the constitution, whereas, ethics, are not found in written form.  Breaches of law may result in punishment, penalty or both whereas ethics are no subject to the same consequences.  Laws are made to maintain social order and peace and protect all the citizens. Ethics are the code of conduct that helps a person decide what is right or wrong and how to act.  Law are legally binding, whereas ethics are not.

Ethics Ethics are the principles that guide a person or society in determining what is good or bad and what is right or wrong, in a given situation. They are commonly used as a moral code by members of a profession to conduct their duties and obligations properly. Ethics involve applying judgment and making choices about what to do and what not to do.

Ethical Principles  Beneficence: do good for clients; e.g. helping or encouraging them to do their Range of Motion exercises will benefit them.

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 Nonmaleficence: do no harm, either intentionally or unintentionally to clients; e.g. don’t abandon them when help is needed.  Respect their autonomy. Respect clients’ rights of self-determination; independence and freedom to make their own decisions; e.g. respect their wishes, even if you don’t agree with them.  Truthfulness: tell the truth to someone who has the right to know the truth; e.g.: client needs a higher level of care than the Service Provider can provide.  Confidentiality: don’t pass on information that clients have a right to conceal; e.g.: don’t reveal confidential details about clients to their families even when pressured to do so.  Justice: entails fairness, equality and impartiality. There is an obligation to be fair to all people regardless of their individual characteristics: e.g.: age, gender, religion, ethnicity, culture, economic status or political view

Work Ethics Good work ethics in the workplace are a requirement for Home Care Assistants. Great technical skills alone cannot make up for productivity losses due to poor work ethics. Employers expect HCAs to conduct themselves in a professional and acceptable manner. Therefore, a good HCA displays qualities and characteristics, which are both innate behavior (done instinctively) and learned behavior (acquired knowledge). It is advantageous for HCAs to have good work ethics because:  positive work ethics will increase their worth as employees; and,  employers hire people who have desirable work practices. How HCAs Can Practice Good Work Ethics  Act in a professional manner and be a role model for good ethical practices.  Know your personal strengths, weaknesses and feelings so you can better understand your clients, thereby enhancing their care.  Have a positive attitude. Avoid complaining, negativity and displays of bad temper, moodiness and unhappiness.  Be reliable. Report to work on time, begin delegated duties immediately and work continuously except for scheduled breaks.  Complete tasks in the expected timeframe, combine tasks for greatest effectiveness and avoid idle time.  Strive to exceed work quality standards. Expect nothing but the best from yourself and take pride in what you do.  Be considerate and courteous to clients, families, friends, colleagues and professionals.  Cooperative with Care Team by: • helping achieve its goals; • being willing and supportive; 247

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• going the “extra mile” during stressful or difficult times; • displaying leadership skills; and, • maintaining appropriate relationships with all members.  Be loyal, honest, trustworthy reliable and responsible to co-workers and clients.  Be disciplined in using proper ethical behavior.  Keep all obligations and promises.  Respect the rights of others.  Look at things from others’ perspectives and be empathetic towards their thoughts and feelings.  Conform to all safety regulations for the protection of all.  Keep private information confidential and don’t gossip about the affairs of others.  Avoid criticizing or denouncing others because their beliefs and values differ. Respect their individuality.  Follow instructions carefully and utilize all your knowledge and skills. Always, give your best efforts.  Realize and admit to errors. Learn from the experience and avoid making the same mistake again.  Demonstrate good organizational skills, time management, prioritizing, flexibility, stress management and dealing with change.  Be truthful and accurate about care given, clients’ progress, and events that occurred or did not occur.  Only perform functions that are within the legal scope for HCAs.  Follow the Care Plan exactly. Do not perform additional activities unless instructed to do so by the Supervisor.  Protect privacy of clients, especially when providing personal care.  Refer questions regarding a client’s condition to Supervisor.  Dress appropriately and be well-groomed.  Do not accept tips or gratuities. Be tactful and courteous when declining.

Laws Laws are accepted rules and regulation created by the government, which may be municipal, regional, national or international. They are used to govern the actions and behaviors of individuals and are enforced through the imposition of penalties.

Legal Terms There are certain legal terms Home Care Assistants should know to understand their responsibilities under the law.

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Legal Term Abandonment Abuse

Assault

Battery

Defamation of Character

False Imprisonment

Fraud

Invasion of Privacy

Libel

Malpractice

Meaning

Example

Abandonment occurs when a support system or family leaves an individual without care or support. Abuse is the improper usage or treatment of a person or entity. It can occur in many forms; e.g.: physical, emotional, sexual, financial, neglect & discrimination. Assault is an attempt or threat to harm someone else, which causes the victim to fear harm. It does not involve touching the body. Battery is touching someone else’s body without consent.

Don’t leave an individual with severe dementia home alone before the family or a replacement worker arrives. Become familiar with the signs and symptoms of abuse and report it, as soon as possible after it is observed. Don’t threaten the client to get the results you want; e.g.: don’t threaten to withhold food if client does not cooperate.

Don’t touch anyone without verbal or implied consent, which can be achieved by gesturing or by obtaining permission from them or a responsible party. Defamation of Character occurs when one Don’t falsely tell a Third-Party that a client person hurts another person’s character, has dementia when he/she may only be a fame, or reputation by making false and little forgetful. malicious statements to a Third-Party. Defamation can be accomplished as libel or slander. False Imprisonment is restraining or Don’t restrain a client to his room by locking restricting a person to a bounded area, him/her in; or, restricting his/her ability to without any jurisdiction or consent open the door. Fraud is saying or doing something to trick, Be upfront and honest with clients and cofool, cheat or deceive another person. It professionals. Don’t claim to be something can involve the usage of sneakiness, you are not; e.g. don’t represent yourself deception, collusion or ploys. As a result, as being a Nurse, if you are not. the targeted person suffers losses to his/her property or suffers legal injury. Invasion of privacy is the intrusion into the Don’t reveal an individual’s private or personal life of another. personal information without his/her consent. Libel is a false & malicious defamation of Do not make false statements or another, which can be expressed in print, accusations about a client; e.g. don’t write drawings, sign, writing & pictures. It is a letter to a newspaper editor stating the carried out with the intent of harming the client is breaking the law, when there is no reputation of the recipient & exposing proof that he/she is. him/her to public hatred, contempt or ridicule. Malpractice occurs when a member of any Don’t provide care that you are not profession acts with negligence or authorized or trained to do; e.g.: change incompetence in dealing with a patient or sterile dressings. client.

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Legal Term

Negligence Slander

Meaning

Example

Negligence is a person’s act or omission of performing his/her responsibilities when providing expected care to another, which results in injury or death to the individual. Slander is false and defamatory, spoken words intended to harm another's reputation, business, or means of livelihood.

Don’t try to lift an individual with a Hoyer lift alone. Mechanical lifts require 2 people to safely transfer people. Do not make false statements about an individual; e.g. don’t tell others that he/she is a thief just because you suspect he/she is.

Parameters of HCA Duties There are some functions that a Home Care Assistant must never do:  Don’t administer medications in any form, unless: • you have undergone specialized training and been certified in medication administration; • your state has authorized HCAs, who are certified in medication administration, to perform this activity; • you have written instructions to assist with medications from your Supervisor or the Registered Nurse, involved with the case; and, • you know which medications you can give and which ones you cannot give.  Don’t conduct sterile procedures.  Don’t insert tubes or objects in a person’s body openings or remove them from their body.  Don’t take verbal or telephone orders from Physicians.  Don’t perform procedures that require sterile technique.  Don’t give information about the diagnosis or treatment plans to clients or their families.  Don’t diagnose or prescribe treatments or medications for clients. Only Physicians can prescribe and determine treatment.  Don’t supervise the work of other HCAs.  Don’t do anything that is beyond HCAs established duties.  Don’t perform any function that is beyond your capability and/or training.

How HCAs Can Avoid Legal Action The main legal responsibility of Home Care Assistants is to avoid legal action against themselves and their employer. To help achieve this goal, HCAs should:  Complete all tasks assigned in the Care Plan. Failure to complete them all could make you liable for neglect.  Deliver competent care to avoid being liable for damages or injuries resulting from careless work.

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 Perform assigned and authorized duties only: • maintain confidentiality of personal information; and, • do not abuse anyone and report any abuse observed.

Client Rights Clients have the right to:      

receive courteous, respectful and dignified treatment and care; give informed consent or refusal of service; be cared for by qualified, competent and trained personnel; have full access to their care records, in accordance with HIPAA regulations; be spoken to or communicated with in a manner or language they can understand; request special communications; e.g.: contact them via an alternative phone number or address;  expect that their personal information will not be released to others unless: • they have given authorization; and/or, • it is a requirement of law;  receive privacy and confidentiality regarding their: • health; • social circumstances; • financial situation; and, • what takes place in their homes;  be free from involuntary confinement, and from physical or chemical restraints;  be free from any actions that would be interpreted as being abusive. e.g. intimidation, physical/sexual/verbal/mental/emotional/material or financial abuse;  report all instances of potential abuse, neglect, exploitation;  receive service and interactions without bias to race, color, age, sex, sexual orientation, creed, religion, disability and familial/cultural factors;  express complaints verbally or in writing about: • having their person and property respected; • resolving conflict, without fear of reprisal or retaliation;  participate in the development of their Care Plans & receive explanations about: • services proposed; • changes in service; and; • alternative services available;  receive a written copy of the Care Plan, which includes the name and telephone number of the Service Agency and the Supervisor;  be informed of the cost of services and notification procedures for fee increases;  receive statements or receipts for fee-based services;  be notified, within a reasonable amount of time, of plans to: 251

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• terminate services; and/or, • transfer their care to another agency;  have their family or legal representative exercise their rights when they are legally authorized to do so; and,  die with dignity.

HCA Rights Home Care Assistants have the right to:         

work in a safe environment; be treated without discrimination; be free from harassment, abuse, attack, verbal and mental abuse; not be abused by any means; e.g.: verbal, emotional, physical, sexual or financial; considerate and respectful behavior from clients; protect themselves from physical attack; not put their lives, their physical health, or the health of their families at risk; have reasonable access to the tools needed to perform the duties of their position; be given sufficient personal time during the work shift to keep hydrated and nourished as needed;  receive timely payment for services provided including: • wages; • expenditures made on behalf of clients; and, • expenditures ensued by using their own vehicles;  receive protection for: • whistleblowing to expose fraud and corruption actions • disclosure of information relating to conduct of employer or another employee for: - illegal actions; - criminal offences; - discrimination; - environmental dangers; and, - health or safety dangers;  file complaints and grievances without fear of retaliation;  be notified if complaints are registered against them; and, the right to: • address registered complaints: • have investigations conducted confidentially; • have fair and unbiased hearings; and, • be given the results of the investigations; and,  give input to the Care Team.

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Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act of 1996 (HIPAA), protects the privacy and security of health information and provides individuals certain rights to their health information. The Act regulates:    

requirements to maintain confidentiality; procedures for protecting privacy; regulations on who can receive and review information; and, penalties for not adhering to the law.

Privacy Rule HIPAA’s Privacy Rule protects individually-identifiable health information (PHI) held or transmitted in any form (e.g. electronic, paper, verbal) by covered entities such as health care providers and health plans or their business associates who have access to PHI. Personal Health Information includes:  an individual’s past, present or future physical or mental health/condition;  the provision of health care to the individual; or,  the past, present or future payment for the provision of health care to the individual. HIPAA deems the following personal information to be Protected Health Information:         

Name Telephone number Address/zip code E-mail address Fax number Social security number Full face photo Finger or voice print Internet Protocol (IP) address

        

Uniform Resource Locator (URL) Medical record number Insurance number Account number All elements of dates Vehicle identifier Certificate/license Device ID or serial number Any unique identifying number, code or characteristics.

Security Rule HIPAA’s Security Rule establishes national standards to protect individuals’ electronic personal health information, which is created, received, used, or maintained by a covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of electronic Protected Health Information.

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Breach Notification Rule Generally, a breach is to disclose or use, without permission, Protected Health Information in a way that can compromise the privacy or security of the PHI. When breaches occur, HIPAA’s Breach Notification Rule requires that the Department of Health & Human Services (HHS), affected individuals, and in some cases the media be notified. Most notifications must be provided within 60 days following the discovery of a breach.

HIPAA Rights Protected Health Information cannot be released without an individual’s written authorization unless it is for treatment, payment or health care operations. Neither can PHI be provided to an individual’s family without obtaining his/her written or verbal consent to do so. When consent is given to release information, the authorization must be documented in the individual’s file. Under HIPAA, individual’s also have the right to:  review and make copies of their medical record;  make amendments, if they feel there are errors;  be informed about who has received access or copies of their files, except those files necessary for health care operations, treatment or payment;  limit use or access by others to their medical information;  receive confidential communication in their channel of choice.  receive a copy of the Service Provider’s privacy notice or policy. How HCAs Can Safeguard Older Adults’ PHI  Handle Protected Health Information (PHI) in the same confidential manner whether it is in written, electronic or verbal form.  Ensure PHI is not disclosed to unauthorized persons.  Don’t leave their records lying around unattended or in a place that others can see them.  Don’t look at their files unless you have a "need-to-know"; e.g.: don’t look at them out of curiosity.  Take precautions to ensure their printed information is not abused or used without authorization.  Ensure all emails containing PHI are encrypted.  Double check names and phone numbers before sending PHI by fax or email.  Don’t discuss confidential matters where others might overhear the conversation.  Be careful about what is said, where it is said and to whom it is said.  Store all active and inactive records in a secure location.

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 Don’t leave PHI on their voice mail unless they have given permission to do so. If permission is not given, leave a message asking for a return call.  Discard confidential information appropriately; e.g.: use locked trash bins or shredders.  Don’t remove or discard computer equipment without Supervisor’s permission: e.g. software, flash-drives. CDs.  Log off your computer if you must leave your workstation.  Never tell anyone your password including Supervisor and co-workers.  Follow guidelines for strong passwords: • use eight characters; • use mixed upper and lower-case letters; • incorporate at least one number; • don’t use repeating or consecutive letters or numbers; and, • don’t use common words or phrases.  Don’t write down passwords or include passwords in emails.  Report suspected or actual breaches of client confidentiality to the Supervisor. Failure to do so can result in disciplinary action or termination of employment.

Older Adult Abuse Older Adult Abuse can be a single, or repeated act or a lack of appropriate action, which causes harm or distress to the Older Adult. Typically, the abuse occurs in situations wherein there is an expectation of trust. Often abusers are people the Older Adult has a relationship with or knows; e.g.: spouse, partner, family member, friend, neighbor, or person caring for them. Many forms of Older Adult Abuse are recognized as types of domestic violence or family violence since they are committed by family members. Paid caregivers have also been known to prey on their Older Adult clients.

Forms of Older Adult Abuse Criminal activity such as street muggings, home break-ins and distraction burglaries are not considered to be Older Adult Abuse. However, many activities do fall into this abuse category including:  Emotional Battering: causes pain, anguish or distress through harassment, threat, intimidation or other verbal or non-verbal actions.  Financial Exploitation: is the improper or illegal use of their funds, assets or property for personal advantage.

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 Neglect: can be either physical or emotional, including confinement, isolation or denial of essential services.  Abandonment: occurs when a caregiver, who is responsible for providing support, deserts the Older Adult.  Self-Neglect: occurs when an individual does not take care of his/her own health and safety needs and thus is at risk for illness or injury.  Physical Assault: includes any type of physical force or violence that results in injury, impairment or physical pain to the body.  Sexual Abuse: consists of non-consensual, sexual contact and includes situations wherein the Older Adult is not capable of giving consent.  Healthcare Abuse: includes activities such as: • not providing health care but charging for it; • getting kickbacks for referrals; and, • double billing for services.

Signs & Symptoms of Older Adult Abuse Indicators that Older Adults may be victims of abuse:              

Living conditions are inadequate, unsafe or unclean. Old and new bruises are obvious. Lack of personal hygiene. Clothing is dirty and/or in disrepair. Loss of weight. Signs of dehydration and poor nutrition. Frequent injuries, which cannot be sensibly explained. No access to food, water and/or toilet. Medications are not purchased or taken, as prescribed. Frequent visits to Emergency Room. Reluctance to talk or answer questions. Long periods of being restrained or locked up. Appears anxious, fearful or agitated. Appears quiet or withdrawn. Appears anxious to please the caregiver, who is always present.

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How HCAs Can Report Suspicions of Older Adult Abuse  Report all abuse concerns to the Supervisor including: • suspicions of abuse; • suspicions of self-abuse; • alleged acts of abuse; • personally-observed abuse.  Obtain their written consent to report the alleged abuse, if possible. Should he/she not be willing to cooperate, the suspected abuse should still be reported.  Report details of suspected or alleged abuse including: • name and address of Older Adult being abused; • your name and contact information • whether the Older Adult is in immediate danger; • what you observed and how long it may have been going on; • when you last saw the Older Adult; and, • who the alleged perpetrator is.  If client is in immediate danger, call: • 9-1-1 or other Emergency Response System; • the local police emergency number; or, • the local hospital emergency room.  If client is not in immediate danger, notify the Supervisor who will assume responsibility for reporting.  If there is no Supervisor, report alleged abuse situations to the: • local law enforcement, if the abuse is sexual, physical, and/or involve theft or fraud, as these types of abuse are criminal offences; • appropriate client abuse authority(ies) in the local area; and/or, • Department of Aging.

Abusive Professional Caregivers Professional Caregivers do abuse Older Adults under certain circumstances. When they do, their behavior is often precipitated by over-work, stress, exhaustion and lack of sleep. Regardless, of the reason, Older Adults must never be abused. Consequences for Caregivers Who Abuse Older Adults If a Service Provider is advised that one of their caregivers is suspected of Older Adult abuse, it will typically:  immediately remove the accused caregiver from direct contact with all clients;  investigate the alleged allegations. If allegations prove to be true, the caregiver responsible is: 257

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• disciplined; and/or, • terminated from employment  refer the alleged abuse to local law enforcement if the abuse was sexual, physical and/or involves theft or fraud, as they are criminal offences. If allegations are proven to be true, the caregiver responsible faces penalties, which could include: • probation; • fine; and/or, • imprisonment;

Coping Mechanisms for Abusive Caregivers Various coping mechanisms are available to stop or prevent caregivers from abusing Older Adults. These strategies will help caregivers take better take care of themselves and the Older Adults under their care; e.g.:     

Support Groups Stress reducing activities; e.g.: exercise and yoga Personal Breaks; e.g.: Older Adults receive Respite Care or attend Adult Day Care Counseling Rehabilitation Services for substance abuse, if applicable

Child Abuse Child Abuse is any form of physical, emotional and/or sexual mistreatment or lack of care that causes injury or emotional damage to a child or youth. The misuse of power and/or a breach of trust are part of all child abuse.

Forms of Child Abuse The following are considered Child Abuse:  causing the death of a child;  causing physical injury to a child through action or failing to act;  creating a strong possibility of physical injury through a recent act or failure to act;  causing serious physical neglect of a child;  creating danger for a child by cutting, kicking, stabbing, throwing, burning or biting;  restraining or confining a child, in an unreasonable manner because of its method, location and/or duration;  forcefully shaking, slapping or striking a child under one year of age;  inhibiting the ability of a child to breathe;  fabricating, or intentionally causing or inflating a medical symptom or disease, which could contribute to a harmful medical evaluation or treatment; 258

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 causing or contributing substantially to serious mental injury to a child by: • one action; • failure to act; or. • a number of actions or failures to act;  generating a possibility for sexual abuse or exploitation of a child through: • any recent act; or, • failure to act;  causing sexual abuse or exploitation of a child through: • any act; or, • failure to act;  leaving a child unsupervised with a person (other than the child's parents) while knowing or should have know that this person: • is required to register as a sexual offender and the child/victim was under the age of 18 when the crime was committed; • has been determined to be a sexually-violent predator; or, • has been determined to be a sexually-violent, delinquent person under the age of 18.

Signs & Symptoms of Child Abuse Physical  welts on face, buttocks, abdomen, chest and inner thighs; shape of welt may indicate what item was used to abuse; i.e.: belt, wooden spoon.  burns and scalds on hands, feet, back or buttocks: • intentional burns leave a pattern from the item causing the burn; e.g.: cigarette, stove burner; • scalds create a clearly marked area where the body part was immersed in a hot liquid; e.g.: a scalded hand looks like a glove  Fractures to the arms, legs, nose, skull and/or ribs  Bruises on the face, mouth lips, cheeks, back, buttocks, arms, chest and/or thighs  Bite marks on skin Sexual       

blood stains on underclothing bleeding, cuts and bruising of genitalia, anus or mouth vaginal discharge genital odor painful urination difficulty sitting or walking pregnancy

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Child Neglect Child neglect is a form of child abuse, wherein a child’s basic needs are not being met by his/her caregivers. Children may be neglected because of parenting problems including mental disorders, substance abuse, domestic violence, unemployment, unplanned pregnancy, and/ or poverty.

Child’s Basic Life Necessities A child’s necessities of life include:      

clothing shelter healthy diet education good hygiene supervision

     

medical & dental care adequate rest safe environment moral guidance & discipline exercise fresh air

A neglected child is a child who is:  deprived of his/her basic life necessities;  left alone when by an adult without adequate supervision;  left alone with an individual who is not able to supervise efficiently. Exceptions: A child is not considered to be abused/neglected solely if:  he/she does not attend school; and/or,  his/her parents (or persons responsible for providing care) believe that spiritual means and prayers are all that are required to treat disease.

Reporting Suspected Child Abuse/Neglect Child Protective Services (CPS) are located within local communities. They are responsible for receiving and investigating reports of suspected child abuse and neglect. Reports are received by CPS are assessed to determine:  if the report meets the legal definition of abuse or neglect; and,  how dangerous the situation is.

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Contact Information

 If the child is in immediate danger, the individual observing the actual or suspected child abuse/neglect should immediately call “9-1-1 or other Emergency Response System.  If the child is not in immediate danger, the individual observing or becoming aware of actual or suspected child abuse/neglect, should immediately make a direct report by: • •

phoning Childhelp National Child Abuse Hotline @ 1-800-4-A-CHILD (1-800-4224453). This hotline is available “24-7” to U.S. & Canadian Territories; or, contacting Child Welfare Information Gateway, which provides state toll-free numbers for reporting child abuse/neglect: https://www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspLis t&rolType=custom&rs_id=5

Report Details The responsibility of the individual reporting cases of suspected or actual child abuse/neglect is to report what is known and not to investigate the situation. The report should include all known information including:          

name and address of child believed to be a victim of abuse/neglect; name and address of parents/individuals responsible for child's custody/care; child's sex, age and date of birth; nature and extent of the suspected abuse including any evidence of previous injuries or disabilities; explanation for the suspected abuse; where the suspected/actual abuse occurred; identity of the individual(s) suspected of causing the abuse/neglect; family composition; name, telephone number and e-mail address of the person making the report; and. any actions taken by the individual making the report

Mandated Reporters Mandated Reporters are persons who, because of their profession are legally required to report any suspicion of child abuse or neglect to the relevant authorities. In most cases, they work with vulnerable people such as children and Older Adults. Typically, Mandated Reports include:  Health Care Workers (includes Home Care Assistants)  Social Workers 261

Section 14 Ethical & Legal Issues

     

Teachers Child Care Providers Law Enforcement Individuals Mental Health Professionals Educators Medical Professionals

Note: Some states consider all citizens to be Mandated Reporters.

Confidentiality & Immunity Rights of Abuse Reporters  Unless reporters make a malicious report, reporters are immune to civil or criminal liability if they: • report suspected abuse; • take part in any follow-up activity; or, • testify in any administrative or judicial proceeding.  The name of the reporter or any person mentioned in the report will not be disclosed without the reporter’s written permission or through court order.  Employers are prohibited from imposing penalties on an employee for making a report or cooperating with an investigation.

Consequences of Not Reporting Child Abuse/Neglect  Legal penalties, often in the form of a fine or imprisonment, may be levied against: • Mandatory Reporters who fail to report suspected child abuse or neglect; and, • Any person who files a report known to be false.  Disciplinary action and/or termination of employment may be taken against an employee who retaliates against an individual who, in good faith, reported suspected or actual child abuser/neglect.

Advance Directives Advance Directives are written, legally-recognized instructions, relating to the provision of health care when an individual becomes incapacitated.

Types of Advance Directives  Living will  Durable Power of Attorney for Health Care  Surrogate Decision Maker 262

Section 14 Ethical & Legal Issues

 Do Not Resuscitate Order Living Will A Living Will tells how a person feels about medical care intended to sustain life. He/she can accept or refuse care. There are many issues to address, including resuscitation, dialysis, tube feeding, organ donation and respirators. Durable Power of Attorney for Health Care A Durable Power of Attorney for Health Care enables people to name a client advocate to carry out their wishes and act on their behalf should they become incompetent. An advocate can be a family member, friend or any person they trust providing the advocate:  meets state minimum age requirements; and,  is competent. Surrogate Decision Maker A Surrogate Decision Maker, also known as a health care proxy or an advocate for an incompetent person, speaks for that person about the desires for his/her life. The role of the surrogate decision maker is to:  ensure, if possible, that any decisions made about that person’s care are consistent with what is known of that that person’s own values and wishes; and,  adhere to documented Advance Directives. Do-Not-Resuscitate Order A Do-Not Resuscitate” (DNR) order is a request a person gives to not provide him/her with Cardiopulmonary Resuscitation (CPR) if their heart stops or he/she quits breathing. DNR orders are accepted by doctors and hospitals in all states.

Summary Ethics are the principles that guide a person in what is good or bad or right or wrong They are commonly used as a moral code to conduct work duties and obligations properly. A good HCA displays qualities and characteristics, which are both innate and learned behavior. Since good work ethics increase HCAs’ value as employees, their chances of being hired increase. Laws are accepted rules and regulation created by the government. They are used to govern the actions and behaviors of individuals and are enforced through the imposition of penalties. The 263

Section 14 Ethical & Legal Issues

main legal responsibility of HCAs is to avoid legal action against themselves and their employer. HCAs must know and adhere to the legal parameters of their position duties. HIPAA protects the privacy and security of Protected Health Information and provides individuals certain rights to their health information. HIPAA regulations stipulate how health care providers and health insurance companies may handle PHI. HCAs must continually protect the Older Adults’ PHI and follow HIPAA’s privacy, security and breach rules. Abuse is a form of mistreatment by one or more individuals that causes harm to another person. The most vulnerable groups are Older Adults and children. HCAs must familiarize themselves with the signs of abuse for both groups and understand their obligations to report signs of suspected abuse. HCAs should also know how to react in situations wherein they are being verbally abused and actions they might take if they are physically threatened and/or attacked. Advance Directives are written instructions, which are recognized by law, relating to the provision of health care when an individual becomes incapacitated. HCAs should be familiar with the common types of Advance Directives and understand any responsibilities they may have, especially if a Do Not Resuscitate Order is in place.

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