SOLVING A MYSTERY – Nursing Talk

Nursing Talk

Dear Cassandra:

Two years ago I got my nursing license at Joliet Junior College. I have been working in a home for the visually impaired, and I have experience with trachs, g-tubes, and vents. I am interested in pediatric private duty.

I am tatted out and have a tramp stamp. I have rings in my pierced eyebrow, nose, and navel, and a stud in my tongue. My hair is orange, red, green, and purple. I think I have a great body and badonkadonk. I like to wear tight clothes and show lots of cleavage. My jewelry box is filled with bling. I spend hours each day on my BlackBerry during breaks at work, while driving, while eating. I have to keep in touch with my peeps.

I have orientated on several cases. However, the parents seem reluctant to let me work with the children. They have told the scheduler that they do not feel comfortable with me. Do you think my appearance can be affecting the way the parents are reacting to me? What can I do?

Tatted Out in Tinley Park

*******************************************************************

Dear Tatted Out,

First, let me try to decode your letter and get a mental picture of you. Your body is covered with tattoos, and you have a special tattoo on your lower back.

When you are wearing low-riding jeans and a short t-shirt, that tattoo can be seen. You like to wear sparkly, gaudy jewelry, and you have multiple piercings.

You wear low cut blouses showing lots of cleavage, and you think you have an attractive derriere. You are constantly sending e-mails, tweets, and text messages on your digital device such as a BlackBerry or phone. You feel you must stay in constant contact with your people, your closest friends or family.

Do I think your appearance can be affecting the way client’s parents react to you? Fo’shizzle (certainly). The parents are entrusting the care of their child to the nurse. Right or wrong, they are not comfortable with you based on what they see. They interpret it as rebellion, not professionalism. You are defying or resisting the established convention and tradition.

Rebellion has been a pattern in the youth of every generation. In the 1950’s, the most outrageous thing a teenage boy could do was to go to school with his shirt hanging out. In the l960’s, college students drove their parents crazy by wearing dirty white tennis shoes with holes in them. In the late l960’s, straight young men started wearing blue, green, orange, even pink dress shirts with their suits. IBM demanded that its male employees continue to wear traditional white dress shirts. In the 1970’s, rebellious young men had long hair, especially dirty, stringy, long hair. In the 1990’s, teenage girls had six or seven piercings going from their ear lobes to the top of their ears. Today’s teens pay good money for new jeans with holes in them.

Image still plays an important role in adult society. Bankers wear dark suits and have conservative hair styles. Lawyers wear suits to court to show respect to the court and judge. Would you trust your money or your life to a dirty, unshaven, unkempt man with greasy hair? What can you do? You have a choice.

You can continue to dress and act the way you do and continue to be rejected, or you can dress and act in a professional way. Wear clothing that covers your tattoos on your arms and back. Take out the rings from the piercings on your eyebrow and nose, and take out the stud from the piercing in your tongue. Wear less revealing clothing. Save the outrageous hair color for the weekend. Leave your BlackBerry/phone at home or in your purse. Focus on the care of the child.

If you think this is unfair, get used to it. If you want to play in the games of the adult world, you have to follow the rules of the game.

—Cassandra

Note: First published on American Home Health's news, November 2010.

End of Life –A Primer on Death and Dying–

End of Life

Legalities
Federal legislation (Patient Self-Determination Act, requires providers participating in the Medicare and Medicaid programs to furnish patients with information on advance directives. The information is to be given to patients upon admission to a facility or when provision of care begins. Providers covered by this requirement include the following entities: hospitals, nursing facilities, providers of home health or personal care services, hospice programs and health maintenance organizations.

Advance Directives
Advance directives are legal forms that allow an individual to document his medical care preferences should he lose his medical decision-making capacity. Illinois law allows for the following three types of advance directives: (1) health care power of attorney; (2) living will; and (3) mental health treatment preference declaration. If you make one or more advance directives and/or a DNR order, tell your doctor and other health care providers and provide them with a copy.

Power of Attorney
A durable power of attorney for healthcare is a more comprehensive document that allows individuals to appoint a person to make healthcare decisions for them should they lose decision-making capacity. Anything written on this document can be rescinded at any time. The health care power of attorney lets you choose someone to make health care decisions for you in the future, if you are no longer able to make these decisions for yourself.

Living Will
A living will is a document that allows an individual to indicate the interventions he or she would want performed if terminally ill, in a coma with no reasonable hope of regaining consciousness, or in a persistent vegetative state with no reasonable hope of regaining significant cognitive function.

A living will tells your doctor whether you want death-delaying procedures used if you have a terminal condition and are unable to state your wishes. A living will, unlike a health care power of attorney, only applies if you have a terminal condition.

Do Not Resuscitate
A DNR, Do Not Resuscitate, order can be given by the client or the family. This order can be rescinded at any time. You may also ask your doctor about a do-not-resuscitate order (DNR order). A DNR order is a medical order stating that cardiopulmonary resuscitation (CPR) will not be started if your heart or breathing stops. You may sign a document directing that should your heart or breathing stop, efforts to resuscitate you will not be started. Your attending physician may also sign a DNR order.

Before a DNR order may be entered into your medical record, either you or another person (your legal guardian, health care power of attorney or surrogate decision maker) must consent to the DNR order. This consent must be witnessed by two people who are 18 years or older. If a DNR order is entered into your medical record, appropriate medical treatment other than CPR will be given to you.

Bereavement and Children
Healthcare providers should reassure their dying young patients that their feelings are accepted. They should offer love, physical closeness, and physical comfort. Providers should be sensitive to nuances in the child-s behavior regarding when and how much to communicate about their prognosis. Providers need to talk with children about death in an honest, specific way and give children an opportunity to make decisions about care whenever possible. These strategies are particularly important when the patient is an adolescent.

Ethnicity and Cultural differences and Considerations

  • Ethnicity: Need to identify the ethnicity or ethnicities the family identifies with.
  • Communication: Is an interpreter needed for communication?
  • Literacy level: Literacy levels may vary within the family. Different family members may be literate in different languages.
  • Acceptability of expression of emotions: While wailing/keening may be acceptable and expected at the time of death and at the funeral, stoic acceptance may be required by the culture subsequently.
  • Body language: Cultural expectations for posture, eye contact to denote respect as well as emotional affect.
  • Orally based vs. literacy based cultures: In orally based cultures, story telling and group learning are especially valued, i.e. Story Circles.
  • Power of Words: It may be unacceptable to directly approach feelings and issues. Again story telling is helpful. “In my experience…”
  • Cultural conflict can be a source of complicated grief. It is important to determine what the family and cultural community believes was the cause of the child-s illness. Did the family feel they had input or control in the treatment process? Is there belief that “Western” treatments were in conflict with traditional healing practices?
  • What do families and cultural groups believe about death and afterlife? This can be a source of trauma or comfort. Spiritual belief in reincarnation may involve belief that trauma to the body (such as surgical interventions) in this life could cause birth defects in a future life. This may have been a course of conflict between the family and the medical community during the course of the child-s illness and provide distress during the grief process. Was the family able to fulfill requirements for spiritual rest of the deceased? Did they have time and finances necessary for prayers, rituals and funeral requirements?
  • We as caregivers need to understand our own cultural orientation and how that affects our approach to others as well as understanding how a family-s cultural background impacts their understanding of life, health, illness, and death. As we walk with families through this most difficult time, use of a transcultural framework for the bereavement risk-assessment and care-plan will give the caregiver tools to guide the journey.
  • Spirituality – Religious/spiritual belief system.
    Keeping an awareness of cultural implications helps us provide support to all clients. An approach of reserved yet warm demeanor shows respect, and allows the provider to watch for cues. Reflecting back the degree of closeness, touch, vocal inflection and eye contact honors the bereaved individual-s sense of self. In my experience, sharing love for the child and sharing in the loss crosses many cultural barriers.
  • Communication
    Honest, compassionate communication between the patient/family unit and caregivers is essential at the end of life. Frank, open communication about resuscitation orders, artificial nutrition, hydration (giving fluids), and life support, as well as arranging personal affairs, help the patient prepare psychologically for dying. The patient should participate actively in treatment decisions as long as possible to maintain control over how and where he/she dies.
  • Reflection about the meaning of the patient-s life helps to establish a legacy of his/her contribution to family, friends, and society. Regrets about the past, guilt for risky behaviors, and sadness about the future are also normal feelings for the dying patient. Working to resolve these issues gives the patient a sense of completion and fulfillment necessary to deal with the impending sense of loss and separation.
  • For some patients, religious beliefs or a close relationship with God can be a source of support. If the dying person finds meaning and comfort in his/her faith, members of the clergy are available to address the patient-s spiritual needs.
  • Depression is a common symptom in the dying patient, arising from physical deterioration, loss of function, and a sense of impending loss and separation. Depression can be alleviated by counseling and medication.
  • Psychological, social, and legal support is available to deal with difficult questions that may arise near the end of life. A patient may need help expressing his/her wishes about death and addressing final tasks, such as making a will and getting documents in order.

End of life signs and symptoms, clinically

  • Restlessness can be treated by managing other symptoms, such as pain. Familiar faces and objects also can have a calming effect. Medication may be used when necessary.
  • Problems with incontinence (lack of normal control) of urine or stool can be managed using drugs, catheters, or disposable products.
  • Dry mouth is a common complication relieved by simple means, such as drinking fluids, breathing humidified air, sucking on ice or Vitamin C tablets, or chewing sugarless gum. Medication is also available.
  • Fatigue (tiredness) is a common symptom as death approaches. A patient may need to sleep and rest a large part of the day and rely on a caregiver for day-to-day needs.
  • At the end of life, weight loss is common. There may be some concern about loss of appetite or difficulty swallowing as the patient-s death approaches, but these conditions are not necessarily a cause of suffering for the patient. Despite concerns about weight loss and dehydration, a dying patient is usually most comfortable when allowed to eat and drink as much — or as little — as he or she would like. This helps the patient avoid digestive discomfort and fluid retention.
  • The dying patient has to cope with a declining physical condition, as well as relevant issues about existence, spirituality, and separation. The patient may need help to make up for loss of function and maintain quality of life for the time he/she has remaining.
  • The goals of care for the dying patient now change from curative to palliative, helping patients live comfortably, as well as supporting them and their families emotionally and spiritually.

Pain, symptom management and care at the time of death

  • Comfort is the primary goal of therapy for dying patients.
  • Drugs can also be helpful to relieve shortness of breath. Morphine is the most commonly used for this problem.
  • Oxygen therapy may also help breathing problems. Often other simple measures can make breathing more comfortable: a familiar voice to reduce anxiety, a change in position, relaxation techniques, or an open window or fan. If the patient is unable to cough and secretions collect in the airway, the doctor may recommend suctioning (using a tube to remove fluids) through the nose or mouth.
  • Medication for pain can be given around-the- clock so that it does not wear off between doses. The medication schedule is tailored to each patient-s perception of pain to ensure relief.

Conclusions

Grief is a global experience. Death is a great loss in any culture. Families experience this loss within the context of personal beliefs, values, and experiences. We, as health caregivers, assume a position to assist the family in helping them to prepare to make future health care decisions now.

Cultural Consideration

Cultural Considerations

Caring for patients at home requires much more than knowledge of disease processes. When home health care workers enter the home of a patient, they are stepping into an entire social world; and when that patient is from a culture that has customs that vary from those of the visiting caregiver, the potential for problems increases dramatically. Caring for culturally diverse patients is challenging because the rules of appropriate behavior vary tremendously in and among cultures, based on education, social class, length of time spent in the country, the degree to which an individual interacts with members of his or her own culture versus that of other cultures, and personality factors.

Many issues may arise when treating culturally diverse patients in their homes. The following examples are generalizations; they do not apply to everyone. It is hoped, however, that the information below will increase awareness of what may be encountered when providing home health care to members of different cultural and ethnic groups.

LANGUAGE

A common source of problems is language, the most significant being lack of a common tongue. In such cases, interpreters are often used. However, this can also create cultural problems.
For example, most Asian cultures are extremely hierarchical, and it is viewed as inappropriate for a young person to tell an older person what to do. This may be particularly problematic when the home health care nurse or worker tries to communicate with the patient. Because the eldest male is at the top of the social hierarchy, instructions to the patient may have to be conveyed via that family member.

EYE CONTACT

Another aspect of communication which is a potential source of misunderstanding is eye contact. In Anglo American culture, eye contact is seen as an important component of direct and honest communication. Avoidance of eye contact is often interpreted as anything from a psychiatric symptom to evidence of dissembling, or at least, of withholding information. Such interpretations, however, are likely to be incorrect, if the person who is avoiding eye contact is Asian, Middle Eastern, Native American, or possibly Hispanic.

In Asian cultures, to look someone directly in the eye implies equality. The lack of eye contact is used to imply inequality in some situations. For example, a physician or a nurse would be considered superior to a patient, as would a male to a female. Thus, direct eye contact with a superior shows a lack of respect. Many Hispanics will also avoid direct eye contact as a way of demonstrating respect, although Latin cultures lack the rigid hierarchy common to most Asian cultures.

Among many Middle Eastern cultures, eye contact is avoided between men and women out of propriety. Direct eye contact may be interpreted as sexually suggestive, and thus care is taken to avoid such implications. In many Native American cultures, the eyes are believed to be the window to the soul. If you look someone directly in the eye, you could steal their soul. Or they could steal yours. In order to avoid inadvertent soul loss/theft, eye contact may be avoided. Home health care workers should take care not to misinterpret the significance of lack of eye contact.

GENDER

Gender issues can be another source of conflict. In the Muslim Arab culture it is forbidden for a man to look at the body of a woman to whom he is not married. The wise home health agency, recognizing the importance of sexual segregation in many Middle Eastern cultures, will try to send same-sex providers to patients’ homes.

In many Middle Eastern cultures, it is the role of the husband to protect his wife; to act as a buffer and intermediary between her and the rest of the world. Most Middle Eastern women do not see this as sexist or oppressive; rather, they value the protection and care.

If a female home care worker senses that there is essential information that is being withheld due to the presence of the husband, she should insist on examining her privately. Otherwise, it is best to respect the patient’s culture.

TOUCHING

The issue of touching goes beyond gender. Although there is tremendous individual variation regarding people’s comfort level with being touched, there are some cultural patterns. In Middle Eastern cultures, touching between members of the opposite sex is to be avoided, especially touching of females by males. This is also true in the orthodox Jewish religion . In general, Asians may not be like being touched, and physical contact is relatively infrequent in most Asian countries. Although nursing care emphasizes the importance of touch, health care workers must realize that this practice was developed in the context of Western nursing culture, and may not be appropriate for all ethnic groups. Most Hispanic patients, on the other hand, will probably feel quite comfortable with hands-on care.

FOOD

Another issue that frequently arises concerns food. In general, accepting offered food in a patient’s home avoids insult. The rules regarding how quickly you should accept it vary; however, in an African American home, it should be accepted immediately, especially if the visitor is Anglo American. Given the long history of racial discrimination in this country, a white person’s refusal of food from an African American may be interpreted as evidence of racism.

Iranians will expect food to be accepted on the second offer. The first time it is offered is out of politeness; the second offer demonstrates sincerity. Such a rule allows the maintenance of social propriety, even when one has no extra food to share.

If the person offering food is Chinese, it is appropriate to accept on the third offer. To accept sooner is seen as rude, although as with all cultures, allowances may be made for outsiders who are not always expected to know the rules. A group of nurses from mainland China once said that one of the biggest problems they had in the U.S. was that when they politely turned down offers of food, a second offer never came Many reported that until they learned the American custom for accepting food, they were constantly hungry.

PSYCHOSOCIAL CARE

Often, issues that arise are more complicated than cultural gestures. An Anglo-American female patient, for example, insisted that her agency not send her Filipino caregivers. After the second experience with a Filipino caregiver, the patient complained to her agency that Filipinos are too cold and reserved. This case actually raises two issues. Filipino nurses are often perceived to be cold and unfriendly because, in the Philippines, nurses are trained only for technical nursing care. The psychosocial aspects of nursing that are important in American culture, are seen as inappropriate and intrusive in the Philippines.

In the United States, there is often no one but the nurse to take care of the patient’s psychosocial needs. The American patient who expects the health care worker to show personal interest may perceive a Filipino nurse — who is trying to behave appropriately — as cold and uncaring. Ideally, health care workers trained in other cultures should be given guidance and training as to what is expected of someone in their position here. Too often, it is assumed that the foreign worker will somehow, “just know what to do.”

The broader, complex issue raised by this example is that of racism. It must be decided whether patient satisfaction is more important than attitudes that promote racism. Generally, the solution is to tell patients that the home health care agency has sent the best person available for the job.

Cold Germs

Cold Germs
Photo Credit: James Gathany

Doorknobs, TV remotes, refrigerator handles and other commonly touched household surfaces are hotbeds of cold germs, which can survive on those surfaces for two days or longer, says a University of Virginia study.

The study included adults with cold symptoms who were asked to name 10 places in their homes they had touched in the preceding 18 hours. The researchers then went to the participants’ homes to hunt for cold germs, the Associated Press reported.

“We found that commonly touched areas … were positive (for cold germs) about 40% of the time,” said ear, nose and throat specialist Dr.Birgit Winther. Cold germs were found on six of 10 doorknobs, eight of 14 refrigerator handles, three of 13 light switches, six of 10 TV remote controls, eight of 10 bathroom faucets, four of seven phones, three of four dishwasher handles, and three of three salt and pepper shakers.

The study was presented in October, 2008 at the National Conference on Infectious Diseases in Washington, D.C., the AP reported.

Safety Measures During Extreme Weather Conditions – Winter Storms

Bad Winter Weather

Safety Measures

  • Heavy snowfall and extreme cold can immobilize an entire region.
  • Gather emergency supplies: A battery powered radio, flash light, food that does not require cooking, your medication, extra blankets, and extra drinking water
  • Keep your home well heated. Stay indoors during the storm. Avoid drinking alcohol.
  • Dress warmly even if you do not feel cold. Wear several layers of loose-fitting, lightweight, warm clothing.
  • Wear mittens or gloves and a hat.
  • Seek immediate medical attention if you have any following signs:
    • Drop in body temperature below 96 degree F, sleeplessness, confusion, slurred speech, stiffness in legs or arms, shivering.
Source: American Home Health's Client Handbook, section Safety Instructions and Guidelines.

Why Home Health?

Home Health

Home health care has emerged as one solution to the complex problems in health care delivery. Technological advances allow sophisticated medical treatment to be performed in the home. Home health care is a safe and less costly alternative to hospitals and nursing homes. A changing health care focus towards self-care, independence and cost containment has once again made the home a place to be born, a place to recover and heal, and a place to die.

For more information, please visit American Home Health @ www.ahhc-1.com

SENIOR CITIZEN ASSESSMENT FREEZE HOMESTEAD EXEMPTION

Senior Celebration

HERE’S ANOTHER WAY TO SAVE MONEY IF YOU ARE SIXTY-FIVE OR OLDER.  THE INFORMATION BELOW IS FOR RESIDENTS OF KANE COUNTY. INCOME MAXIMUMS AND DEADLINE DATES VARY FROM COUNTY TO COUNTY.  CONTACT YOUR COUNTY ASSESSMENT OFFICE FOR INSTRUCTIONS AND THE APPROPRIATE FORM.  INFORMATION AND FORMS ARE ALSO AVAILABLE ON THE INTERNET. 

 IF YOU ARE NOT ELIGIBLE, THINK ABOUT YOUR PARENTS OR OLDER FRIENDS.  TELL THEM ABOUT THE PROGRAM.  HAVE THEM CONTACT THEIR COUNTY ASSESSMENT OFFICE.  REMEMBER THAT INCOME MAXIMUMS AND DEADLINE DATES VARY FROM COUNTY TO COUNTY.

IF YOU OR YOUR PARENTS OR OLDER FRIENDS WERE NOT AWARE OF THE PROGRAM AND FAILED TO APPLY, HAVE THEM CONTACT THEIR ASSESSOR’S OFFICE.  IT MAY BE POSSIBLE FOR THEM TO SEEK THE BENEFITS RETROACTIVELY FOR AT LEAST A FEW YEARS. 

SENIOR CITIZEN ASSESSMENT FREEZE HOMESTEAD EXEMPTION

 Are you upset that your real estate tax bill keeps increasing each year?  Are you sure that you are getting all the exemptions for which you qualify?  Are you aware of the Senior Citizen Assessment Freeze Homestead Exemption for property owners over 65?

What is the “Senior Freeze” exemption?

The Senior Citizen Assessment Freeze Homestead Exemption reduces the Equalized Assessed Valuation (EAV) of a home by the difference of a home between the 2016 Equalized Assessed Value and the Equalized Assessed Value of the “Base Year.”  The base year generally is the year prior to the year the taxpayer first receives the exemption.  This exemption does not freeze the amount of a property tax bill, which could change if the tax rate changes.  The assessment and tax bill may increase if improvements are added to the home.  oswHowever, if the Equalized Assessed Value of the home decreases in the future, the taxpayer will benefit from any reduction.

Who is eligible?

At least one of the owners of the property must

  • Be sixty-five or older by December 31, 2015.
  • Own the property or have an equitable interest in it by written instrument or had a leasehold interest in the single family home.
  • Use the property as his principal residence on both January 1, 2015 and January 1, 2016.
  • Have a total household income of $55,000 or less in 2015.

What is a household?   

A household means the applicant, the applicant’s spouse, and all persons who use the residence of the applicant as their principal dwelling place on January 1, 2016, whether they pay rent or not.

What is included in household income?

Household income includes your income, your spouse’s income, and the income of all persons living in the house.  Examples of income are listed below:

  • Alimony or maintenance received
  • Annuity benefits
  • Black Lung benefits
  • Business income, including capital gains
  • Cash assistance from the Illinois Department of Human Services and/or any other governmental cash assistance
  • Cash winnings from other such sources as raffles, lotteries, and gambling
  • Civil Service benefits
  • Damages awarded in a lawsuit for nonphysical injury or sickness (for example, age discrimination or injury to reputation)
  • Dividends
  • Farm income
  • Illinois Income Tax Refund
  • Interest, including interest received on life insurance policies
  • Long term care insurance (federally taxable portion only)
  • Lump sum Social Security payments
  • Miscellaneous income from rummage sales, recycling aluminum, baby sitting, etc.
  • Military retirement pay based on age or length of service
  • Monthly insurance benefits
  • Pension and IRA benefits (federally taxable portion only)
  • Railroad Retirement benefits
  • Rental income
  • Social Security income
  • Supplemental Security Income (SSI) benefits
  • Unemployment compensation (all)
  • Wages, salaries and tips
  • Workers’ Compensation Act Income
  • Workers’ Occupational Disease Act income

What is not included in household income?

Examples of income that are not included in household income are listed below.

  • Cash gifts and loans
  • Child support payments
  • Circuit Breaker grants
  • COBRA Subsidy Payments
  • Damages paid from a lawsuit for a physical injury or sickness
  • Energy Assistance payments
  • Federal income tax refunds
  • IRAs “rolled over” into other retirement accounts, unless “rolled over” into a Roth IRA
  • Lump sums from inheritances or insurance policies
  • Money borrowed against a life insurance policy or from any financial institution
  • Reverse mortgage payments
  • Spousal impoverishment payments
  • Stipends from Foster Parents and Foster Grandparent programs
  • Veterans’ benefits

When must I file?

If you are eligible for the Senior Citizen Assessment Freeze Homestead Exemption, you should file the appropriate form with the County Assessment Office by July 1, 2016.  You must file an application every year to continue to receive an exemption.  The eligibility requirements under “Who is eligible?” must be met each year.  Additional documentation (i.e., birth certificates, tax returns, etc.) may be required by the County Assessment Office to verify the information on this application.

What if I need additional assistance?

If you have questions, please contact the Kane County Assessment Office at (630) 208-3818.

 by Karen Centowski