Direct Care Worker Competency Review

Silver Lining Home Health Care, Inc. is licensed as a non-medical registry by the PA Department of Health.  They mandate what the DCWs are allowed and not allowed to do.

The DCWs are permitted to empty a Foley Catheter Bag and they are permitted to change the Foley bag from day to night but they are not permitted to do anything with the catheter itself.  When it comes to a Colostomy Bag, the DCWs are permitted to empty it, change it to a new one but they are not allowed to change the wax wafer.

DCWs are not permitted to give the client any medication directly out of the prescription bottle.  They may remind the client that it is time to take their medication and hand them the bottle but they may not remove the medication directly from the bottle.  If the client has a medication box, the DCWs are not allowed to fill the box.

DCWs are not permitted to administer eye drops of any kind.  They are not permitted to attend to feeding tubes, give fleet enemas, give suppositories and perform wound care.  DCWs are not permitted to do Accucheck finger sticks.  They are not permitted to prepare insulin or give insulin injections. No injections of any kind may be given by a DCW.  Nothing can be done by the DCWs that is invasive to the client. 

DCWs are not permitted to use the client’s credit card or checks for any reason.  They are not allowed to borrow money from the client or the client’s family and they are not allowed to assist the client with his/her finances.  The DCW may be given no more than $50 in cash to make purchases for the client.  The DCW must return with a receipt.

DCWs are not permitted to be the client’s power of attorney and they are not allowed to assume guardianship for the client or witness any client signatures on any forms or documents.

DCWs must contact Silver Lining when a client goes on Hospice as Silver Lining works in conjunction with the Hospice Company and the procedures for giving medication is different.

DCWs who do not keep their credentials that are mandated by the state up-to-date will not receive referrals for work and will not be paid for any assignments until their credentials have been made current.

If you need to speak to a Coordinator, the Payroll Department or the Administrative team Monday to Friday 9 am to 4 pm, you must call 215-885-7701.  This number will be answered by a live person.  If for any reason the staff is working from another location, this number will be answered by our answering service, Holy Redeemer.  They do not just answer the incoming calls for Silver Lining so please have patience.

If you need to submit your timesheet or any other form of documentation, you must email it to time@slhomecare.com.  Your second option is to take a picture of your timesheet and/or documentation and text the picture to 215-806-5190.  Lastly, you can fax your timesheet and/or documentation to 215-886-6985.  When you email or text your timesheet and/or documentation to the sources noted above, your will receive a message acknowledging your submission.  If you do not receive this acknowledgment by the end of the next business day, please contact us at 215-885-7701.  If you choose to fax your timesheet and/or documentation, then you will have to call 215-885-7701 to confirm receipt.  Sending your timesheet and/or documentation by any other method is not recommended.  The other cell numbers that you have for coordinators are work phones and they are not monitored unless the person is on call.

When a client has poor circulation to the legs and feet, elastic stockings are ordered.  These stockings help prevent swelling and blood clots and improve circulation.  These stockings are called “anti-embolic hose” or “elastic stockings”.  They need to be put on before the client gets out of bed. The following is a step by step guide of how to put the elastic stockings on properly.

1. Wash your hands.
2. Explain the procedure to the client, speaking clearly, slowly and directly. Maintain face to face contact whenever possible.
3. Provide privacy for the client.
4. The client should be in the supine position (on his/her back) in bed.  With client lying down, remove his or her socks, shoes or slippers, and expose one leg.
5. Turn stocking inside out at least to heal area.
6. Gently place foot of stocking over toes, foot and heel.  Make sure the heel is in the right place (heel should be in the heel of the stocking).
7. Gently pull top of stocking over foot, heel and leg.
8. Make sure there are no twists or wrinkles in stocking after it is on. It must fit smoothly.
9. Repeat for other leg.
10. Wash your hands.

Alzheimer’s disease causes tangled nerve fibers and protein deposits to form in the brain, eventually causing dementia.  The disease gets worse, causing greater and greater loss of health and abilities.  There is no known cause of Alzheimer’s disease and there is no cure.  Clients with Alzheimer’s disease will never recover.  They will need more care as the disease progresses.

Alzheimer’s disease generally begins with forgetfulness and confusion.  It progresses to complete loss of all ability to care for oneself.  Each person with Alzheimer’s disease will show different symptoms at different times. For example, one person with Alzheimer’s disease may be able to read, but may not be able to use the phone or remember her own address.  Another person may have lost the ability to read, but may still be able to do simple math.  Skills a person has used constantly over a long lifetime are usually kept longer.

Encourage clients with Alzheimer’s disease to perform Activities of Daily Living (ADLs).   Help them keep their minds and bodies as active as possible.  Working, socializing, reading, problem solving, and exercising should all be encouraged.  Having them do as much as possible for themselves may even help slow the progression of the disease.  Look for tasks that are challenging but not frustrating.  Help your clients succeed in doing them. 

These attitudes will help you give the best possible care to your clients with Alzheimer’s disease:

• Do not take their behavior personally.
• Put yourself in their shoes.
• Treat clients with Alzheimer’s disease with dignity and respect, as you would want to be treated.
• Work with the symptoms and behaviors you see.
• Work as a team.
• Encourage communication.
• Take care of yourself.
• Work with family members.
• Remember the goals of the care plan.

Guidelines: Communicating with Clients Who Have Alzheimer’s disease:

• Always approach from the front.  Do not startle the client.
• Determine how close the client wants you to be.
• Speak in a low, calm voice, in a room with little background noise and distraction.
• Use the client’s name during the conversation.
• Speak slower, using the same words and phrases as often as needed.
• Repeat yourself, using the same words and phrases as often as needed.
• Use signs, pictures, gestures, or written words to help communicate.
• Break complex tasks into smaller, simpler ones.

Guidelines: Use the same procedures for personal care and ADLs for clients with Alzheimer’s disease as you would with other clients.  However, there are some guidelines to keep in mind when helping these clients.  These general principles will help you give the best care:

1. Develop a routine and stick to it.  Being consistent is very important for clients who are confused and easily upset.
2. Promote self-care.  Help your clients to care for themselves as much as possible.  This will help them cope with this difficult disease.
3. Take good care of yourself, both mentally and physically.  This will help you give the best care.

Guidelines: Caring for Clients with Alzheimer’s disease:

• Encourage fluids.  Never withhold or discourage fluids because a person is incontinent.  Follow schedules for toileting.
• Mark the bathroom with a sign as a reminder of where it is and to use the toilet.
• Put lids on trash cans, waste baskets, or other containers if the client has a habit of urinating in them.
• Lay out clothes in the order in which they should be put on. Choose clothes that are simple to put on.
• Schedule bathing when the client is least agitated.  Be organized so the bath can be quick.
• Be flexible about bathing.  Your client may not always be in the mood. Be relaxed.  Allow the client to enjoy the bath. Check the skin regularly when bathing for signs of irritation.
• Ensure safety by using non-slip mats, tubs seats and hand-holds.
• Maintain proper nutrition.  Schedule meals at the same time each day.  Serve familiar foods. Try smaller, more frequent meals if person is restless.  Finger foods can allow eating while moving around.  Keep bite-sized snacks nearby, especially favorites.
• Do not serve steaming or very hot foods or drinks.  Use dishes without a pattern.  White usually works best.  Put only one item of food on the plate at a time.
• Guide the client through meals.  Provide simple instructions.  Offer regular drinks of water, juice and other fluids to avoid dehydration.
• Assist with grooming.  Help the people in your care feel attractive and dignified.
• Prevent infections.  Follow proper procedures for food preparation and storage, household management, and Standard Precautions.
• Maintain a daily exercise routine.
• Maintain self-esteem by encouraging independence in ADLs.
• Share in enjoyable activities, looking at pictures, talking and reminiscing.
• Reward positive and independent behavior with smiles, hugs, warm touches, and thanks.

Agitation:  A client who is anxious, uneasy or nervous may display signs of agitation, such as throwing food, yelling or restlessness.  Try to eliminate triggers.  Keep routine constant.  Avoid frustration.  Help client focus on a soothing, familiar activity, such as sorting things or looking at pictures. Remain calm.  Use a low, soothing voice to speak to and reassure the client.  An arm around the shoulder, patting, or stroking may be soothing for some clients.

Sundowning:  When a person becomes restless and agitated in the late afternoon, evening, or night, it is called sundowning.  Remove triggers.  Provide snacks or encourage rest.  Avoid stressful situations during this time.  Limit activities, appointments, trips, and visits.  Play soft music. Set a bedtime routine and keep it.  Recognize when sundowning occurs and plan a calming activity just before.  Remove caffeine from the diet.  Give a soothing back massage.  Distract the client with a simple, calm activity like looking at a magazine.  Maintain a daily exercise routine.

Violent Behavior:  A client who attacks, hits or threatens someone is violent.  Frustration, overstimulation, or a change in routine, environment, or caregivers may trigger violence.  Look for ways to avoid these triggers.  These are appropriate responses to violent clients:

• Block blows, but never hit back.
• Step out of reach.
• Do not leave the client in the home alone.
• Try to eliminate triggers.
• Use techniques to calm the client as you would for agitation or sundowning.

Pacing and Wandering:  A client who walks back and forth in the same area is pacing.  A client who walks aimlessly around the house or neighborhood is wandering.  Pacing and wandering may be caused by restlessness, hunger, disorientation, need for toileting, constipation, pain, forgetting how or where to sit down, too much daytime napping, or the need for exercise.  Remove causes when you can.  For example, give nutritious snacks and maintain a toileting schedule.  Let clients pace and wander in a safe and secure (locked) area where you can watch them.  Suggest another activity, such as going for a walk together.

Hallucinations or Delusions:  A client, who sees, hears, smells, tastes, or feels things that are not there is having hallucinations.  A client who believes things that are not true is having delusions.  Ignore harmless hallucinations and delusions.  Reassure a client who seems agitated or worried.  Do not argue with a client whom is imagining things.  Do not tell the client that you can see or hear his or her hallucinations.  Redirect the client to other activities or thoughts.  Be calm and reassure client that you are there to help.

Depression:  Report signs of depression to the client’s family and to your coordinator immediately.  It is an illness that can be treated with medication. Encourage independence, self-care and activity.  Talk about moods and feelings if the client wishes. Be a good listener.  Encourage social interaction.

Perseveration or Repetitive Phrasing:  A client who repeats a word, phrase, question or activity over and over is perseveration.  Respond to perseveration with patience.  Do not try to silence or stop the client.  Answer questions each time they are asked, using the same words each time.

Disruptiveness:  Disruptive behavior is anything that disturbs others, such as yelling, banging on furniture, slamming doors, etc.  Often this behavior is triggered by a wish for attention, by pain or constipation, or by frustration.  When this behavior happens, gain the client’s attention.  Be calm and friendly.  Try to find out why the behavior is happening.   Try to prevent this behavior, by noticing and praising improvements in the client’s behavior.  Be tactful and sensitive when you do this.  Do not treat the client like a child.  Tell the client about any changes in schedules, routines, or the environment in advance.  Involve the client in developing routine activities and schedules.  Encourage the client to join in independent activities that are safe (for example folding towels).  This can prevent feelings of powerlessness.  Help the client find ways to cope.  Focus on positive activities he or she may still be able to do, such as knitting, crocheting, crafts, etc.

Inappropriate Social Behavior:  Inappropriate social behavior may be cursing, name calling or other behavior.  As with violent or disruptive behavior, there may be many reasons why a client is behaving this way.  Try not to take it personally.  The client may only be reacting to frustration or other stress, not to you.  Stay calm.  Be reassuring.  Try to find out what caused the behavior (for example, too much noise, too many people, too much stress, pain or discomfort).  Respond positively to any appropriate behavior.  It is important to report any physical abuse or serious verbal abuse to the client’s family and to your coordinator.

Inappropriate Sexual Behavior: Inappropriate sexual behavior, such as removing clothes, touching one’s genitals, or trying to touch others can embarrass those who see it.  Be matter-of-fact when dealing with such behavior. Do not overreact.  This may reinforce the behavior.  Be sensitive to the nature of the problem.  Try to distract the client.  A client may be reacting to a need for physical stimulation or affection.  Consider other ways to provide physical stimulation.  Try backrubs, a soft doll or stuffed animal to cuddle, comforting blankets, or pieces of cloth.

Although Alzheimer’s disease cannot be cured, there are techniques that can improve the quality of life for clients with Alzheimer’s disease, such as the following:

• Reality Orientation involves the use of calendars, clocks, signs, and lists to help clients remember who and where they are.  It is useful in the early stages of Alzheimer’s disease when clients are confused but not totally disoriented.  In later stages, reality orientation may only frustrate clients.

• Validation Therapy is letting clients believe they live in the past or in imaginary circumstances.  Validating means giving value to or approving.  Make no attempt to reorient clients to actual circumstances.  Explore client’s beliefs.  Do not argue with them.  It is useful in cases of moderate to severe disorientation.

• Reminiscence Therapy is encouraging clients to remember and talk about the past.  Explore memories by asking about details.  Focus on a time of life that was more pleasant.  Work through feelings about a difficult time in the past.  It is useful in many stages of Alzheimer’s disease, but especially with moderate to severe confusion.

• Activity Therapy uses activities clients enjoy to prevent boredom and frustration.  These activities also promote self-esteem.  Help clients to take walks, do puzzles, listen to music, cook, read, or do other activities they enjoy.  It is useful throughout most stages of Alzheimer’s disease.

Some clients spend much or all of their time in bed.  Careful bedmaking is essential to their comfort, cleanliness, and health.  Linens should always be changed after personal care procedures such as sponge baths, or any time bedding or sheets are damp or soiled, or in need of straightening.  Bed linens must be changed frequently for these reasons:

• Sheets that are damp, wrinkled, or bunched up under a client are uncomfortable.  They may prevent the client from resting or sleeping well.
• Microorganisms thrive in moist, warm environments.  Bedding that is damp or unclean encourages infection and disease.
• Clients who spend long hours in bed are at risk for pressure sores.  Sheets that do not lie flat under the client’s body increase the risk of pressure sores because they cut off circulation.

If a client cannot get out of bed, you must change the linens with the client in bed.  An occupied bed is made with the client in bed.  When making the bed, use a wide stance.  Bend your knees.  Avoid bending from the waist, especially when tucking sheets or blankets under the mattress.  Mattresses can be heavy, so remember to bend your knees to avoid injury.  It is easier to make an empty bed than one with a client in it.  An unoccupied bed is a bed made while no client is in the bed.  If the client can be moved, your job will be easier.

1. Wash your hands.
2. Explain the procedure to the client, speaking clearly, slowly, and directly.  Maintain face-to-face contact whenever possible.
3. Provide privacy if the client desires it.
4. Place clean linen on clean surface within reach (e.g., bedside stand or chair).
5. If the bed is adjustable, adjust bed to a safe working level, usually waist high.  Lower the head of the bed.  If the bed is movable, lock bed wheels.
6. Put on gloves
7. Loosen top linen from the end of the bed on the working side.  Unfold the bath blanket over the top sheet to cover the client, and remove the top sheet.
8. You will make the bed one side at a time.  If the bed has side rails, raise side rail on far side of the bed.  This protects the client from falling out of the bed while you are making it.  After raising the side rail, go to the other side.  Assist the client to turn onto his or her side, moving away from you toward the raised side rail.
9. Loosen the bottom soiled linen, mattress pad, and protector, if present, on the working side.
10. Roll the dirty linens from head to the foot of the bed tucking it snugly against the client’s back.
11. Place and tuck in clean bottom linens, finishing with bottom sheet free of wrinkles. If you are using a flat bottom sheet, leave enough overlap on each end to tuck under the mattress.  If the sheet is only long enough to tuck in at one end, tuck it in securely at the top of the bed.  Make hospital corners to keep bottom sheet wrinkle-free.
12. Smooth the bottom sheet out toward the client.  Be sure there are no wrinkles in the mattress pad.  Roll the extra material toward the client and tuck it under the client’s body.
13. If using a waterproof pad, unfold it and center it on the bed.  Tuck the side near you under the mattress.  Smooth it out toward the client, and tuck as you did with the sheet.
14. If using a draw sheet, place it on the bed.  Tuck in on your side, smooth, and tuck as you did with the bedding.
15. Raise side rail nearest you.  Go to the other side of the bed and lower the side rail on that side.  Assist client to turn onto clean bottom sheet.  Protect the client from any soiled matter on the old linens.
16. Loosen the soiled linen.  Check for any personal items.  Roll linen from head to the foot of the bed.  Avoid contact with your skin or clothes.  Place it in a hamper or basket.  Never put it on the floor or furniture.  Never shake it.  Soiled bed linens are full of microorganisms that should not be spread to other parts of the room.
17. Pull and tuck in clean bottom linen just like the other side, finishing with bottom sheet free of wrinkles.
18. Ask client to turn onto her back.  Keep client covered and comfortable, with a pillow under the head.  Raise the side rail.
19. Unfold the top sheet and place it over the client.  Ask the client to hold the top sheet.  Slip the blanket or old sheet out from underneath.  Put it in the laundry hamper.
20. Place a blanket over the top sheet, matching the top edges.  Tuck the bottom edges of top sheet and blanket under the bottom of the mattress.  Make hospital corners on each side.  Loosen the top of the linens over the client’s feet.  At the top of the bed, fold the top sheet over the blanket about six inches.
21. Remove the pillow.  Do not hold it near your face.  Remove the soiled pillowcase by turning it inside out.  Place it in the laundry hamper.
22. Put a clean pillowcase on each pillow and place under the client’s head or as the client desires.
23. Remove and discard gloves.  Wash your hands.

Because one-half to two-thirds of our body weight is water, we need 64 ounces, or eight 8-ounce glasses of water or other fluids a day.  Water is the most essential nutrient for life.  Without it, a person can only live a few days.  Water assists in the digestion and absorption of food.  It helps with waste elimination.   Through perspiration, water helps maintain normal body temperature.  Maintaining fluid balance in our bodies is necessary for good health.  Do not limit fluids if a client is incontinent unless his/her doctor has given written instructions to do so for another medical reason.

The fluids we drink – water, juice, soda, coffee, tea, and milk provide most of the water our bodies use.  Some foods are also sources of water, including soup, celery, lettuce, apples, watermelon and peaches.

Difficulty swallowing is clinically known as dysphagia and occurs when one’s esophagus does not function properly. When a person with dysphagia eats or drinks, they cannot swallow correctly. This swallowing disorder causes discomfort, coughing, choking and even aspiration of food particles and saliva into the lungs, which can lead to a serious, potentially life-threatening infection.

Doctors explain that difficulty swallowing can occur for a variety of reasons, including multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Parkinson’s disease (PD), stroke, and various forms of dementia. These conditions can affect the muscles and/or nerves involved in the process of swallowing. Other conditions can contribute to swallowing difficulties, such as gastroesophageal reflux disease (GERD) and growths in and around the esophagus.

There are recognizable, yet often subtle, signs and symptoms that indicate dysphagia. When these signs occur, it is important for caregivers to address them as soon as possible, doctors urge.  Treatment and management will depend on an official assessment called a ‘swallowing study,’ which is commonly performed by a speech-language pathologist (SLP).”

• Additional time and effort spent at meals
• Food, liquid or saliva leaking out of the mouth at any time
• “Cheeking” foods instead of swallowing them
• Gurgling sounds or voice during and after meals
• Frequent coughing, gagging or choking while eating
• Weight loss
• Dehydration
• Chest congestion
• Aspiration pneumonia

In Alzheimer’s and dementia patients, some degree of difficulty swallowing will occur during the disease trajectory, and it is a common indicator of disease progression. “In this case, the cause is a loss of gag reflex and/or decrease in level of consciousness, which requires increased care and supervision,” explain doctors.

Dementia progresses differently in each person, so it can be difficult to know what to expect and when. However, dysphagia often presents in late-stage dementia patients who tend to have difficulty communicating and may even be nonverbal. For this reason, dementia caregivers should watch carefully for any signs of swallowing issues. Doctors say aspiration pneumonia is one of the most common causes of death in Alzheimer’s patients.

If swallowing issues present in the early or middle stages of dementia, a family member may misconstrue the subtle signs and assume that their loved one is acting out or does not enjoy the food they are being served. However, perseverance and encouragement can’t solve this dilemma. Undiagnosed and untreated dysphagia could jeopardize a dementia patient’s well-being.

The first thing to do is make a doctor’s appointment and see if a referral to a speech-language pathologist may be necessary. An SLP will run tests (such as a swallow study, if necessary) to assess the type and severity of a senior’s dysphagia and determine next steps for minimizing choking and preventing aspiration. Swallowing disorders are often managed through diet modification with a focus on texture and moisture levels.

The type of dysphagia diet an SLP prescribes will depend on the cause and extent of a senior’s swallowing difficulties. For some, a normal diet with emphasis on softer foods and smaller bites may be effective, while others may need their foods pureed and their liquids thickened to a certain consistency. Finding the right dysphagia diet requires the expertise of a speech-language pathologist, otherwise incorrect diet modifications can make eating and drinking with dysphagia more dangerous.

Caregivers may grow impatient during meals as we sit and wait for each bite or sip to be swallowed. Handfeeding is one of the best approaches for those with more advanced dysphagia, but it can be especially trying. Doctors offer the following suggestions for facilitating mealtimes and promoting safe eating habits.

1. Carefully plan and serve meals, snacks and beverages that conform to an SLP’s prescribed dysphagia diet. Try thickening liquids with a commercial thickener (like Thick-It) or pureed fruit, such as apricots and prunes. Thickened liquids won’t trickle down the throat as readily as thin liquids and are less likely to cause coughing, choking and aspiration. Note that certain thicknesses are recommended depending on one’s ability to chew and swallow. Part of undergoing a professional assessment is determining what food texture is safest for your client.
2. Serve foods with thicker gravies, sauces or other condiments to add moisture that assists with swallowing.
3. Make ample time for meals to allow adequate chewing and complete swallowing.
4. Remove distractions at mealtimes to allow for full concentration on eating.
5. Use eye contact and encouragement with visual cues, such as opening/closing your mouth when the person is supposed to sip or bite.
6. Be cognizant of and alert to cues that indicate distraction, choking or food retained in the mouth.
7. Ensure your client is sitting as upright as possible while eating, not slumped forward or reclining.
8. Schedule meals for times of the day when your client is most alert and cooperative.
9. Try serving smaller, less intimidating portions. Some Alzheimer’s clients do better with finger foods than those that require utensils. Finger foods are less challenging to maneuver and allow dementia clients to tap into the automatic rhythms and movements they have used all their lives when eating.
10. Regardless of whether a client is still feeding him/herself or you are helping them, mealtimes require lots of patience. Give them as much autonomy as possible and all the time they need to finish their meal. Let your client make choices and honor those choices—don’t be forceful. Let care and respect show on your face rather than fleeting irritation at their slowness.

In many instances, such as temporary difficulties that result from a stroke or prolonged intubation, working with an SLP who specializes in dysphagia can maintain or restore a person’s ability to eat and drink safely. Each client is different, which is why a professional assessment is crucial for devising customized care and nutrition plans.

In other cases where dysphagia is related to a progressive neurodegenerative disease like Parkinson’s or Alzheimer’s, swallowing exercises, thickening agents and eating techniques recommended by speech-language pathologists will eventually lose their effectiveness. Sadly, as these conditions progress, so does the severity of swallowing difficulties. Put simply, seniors with late-stage dementia “forget” how to swallow, lose weight and become increasingly frail.

“Once dysphagia becomes so severe that swallowing is no longer possible, the disease may have progressed to the point of considering an evaluation for hospice care,” Doctor’s advise. “For example, weight loss and the inability to feed oneself and swallow are fundamental hospice criteria. An evaluation by a hospice professional would be appropriate to determine if end-of-life care is appropriate.”

Feeding tubes are often presented as an option for preventing dehydration and malnutrition in seniors with severe dysphagia, but this treatment option is an invasive one with limited success. For this reason, many seniors specify their preferences for life-prolonging treatments like tube feeding using written advance directives to guide their caregivers.

• Bedsores are ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, and/or wearing a cast for a prolonged period.
• Bedsores can happen when a person is bedridden, unconscious, unable to sense pain, or immobile.
• Bedsores can be prevented by inspecting the skin for areas of redness (the first sign of skin breakdown) every day with particular attention to bony areas.

A bedsore develops when blood supply to the skin is cut off for more than 2 to 3 hours. As the skin dies, the bedsore first starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and the area can become infected.

A bedsore can become deep. It can extend into the muscle and bone. Once a bedsore develops, it is often very slow to heal. Depending on the severity of the bedsore, the person’s physical condition, and the presence of other diseases (such as diabetes), bedsores can take days, months, or even years to heal. They may need surgery to help the healing process.

Bedsores often happen on the:

• Buttocks area (on the tailbone or hips)
• Heels of the feet
• Shoulder blades
• Back of the head
• Backs and sides of the knees

Bedsores are divided into 4 stages, from least severe to most severe. These are:

• Stage 1. The area looks red and feels warm to the touch. With darker skin, the area may have a blue or purple tint. The person may also complain that it burns, hurts, or itches.
• Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. The person complains of significant pain and the skin around the wound may be discolored.
• Stage 3. The area has a crater-like appearance due to damage below the skin’s surface.
• Stage 4. The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage. 

A wound is not assigned a stage when there is full-thickness tissue loss and the base of the ulcer is covered by slough or eschar is found in the wound bed. Slough may be tan, grey, green, brown, or yellow in color. Eschar is usually tan, brown or black. 

Healthcare providers diagnose bedsores by inspecting the skin of those at risk for them. They are staged according to their appearance.

Specific treatment of a bedsore is discussed with the client and/or the client’s family by their healthcare provider and wound care team and based on the severity of the condition. Treatment may be more difficult once the skin is broken, and may include the following:

• Removing pressure on the affected area
• Protecting the wound with medicated gauze or other special dressings
• Keeping the wound clean
• Ensuring good nutrition
• Removing the damaged, infected, or dead tissue (debridement)
• Transplanting healthy skin to the wound area (skin grafts)
• Negative pressure wound therapy
• Medicine (such as antibiotics to treat infections)

Healthcare professionals will watch the bedsore closely. They will document size, depth, and response to treatment.

Bedsores can be prevented by inspecting the skin for areas of redness (the first sign of skin breakdown) every day with particular attention to bony areas.  Other methods of preventing bedsores and preventing existing sores from getting worse include:

• Turning and repositioning every 2 hours
• Sitting upright and straight in a wheelchair, changing position every 15 minutes
• Providing soft padding in wheelchairs and beds to reduce pressure
• Providing good skin care by keeping the skin clean and dry
• Encourage an ambulatory client to get up every eight hours and move around.
• Providing good nutrition because without enough calories, vitamins, minerals, fluids, and protein, bed sores can’t heal, no matter how well you care for the sore

A Transient Ischemic Attack (TIA) is often called a mini-stroke, but it is really a major warning.

TIA is a temporary blockage of blood flow to the brain. Because most TIA symptoms last from only a few minutes up to 24 hours, they are often dismissed and not taken seriously. But this is a big mistake. TIAs may signal a full-blown stroke ahead.

When you first notice symptoms, get help immediately.

Anyone can have a TIA but the risk increases with age. If you’ve previously had a stroke, pay careful attention to the signs of TIA, because they could signal a second stroke in your future.

Some common warning signals include sudden onset of the following:

• Weakness, numbness or paralysis on one side of your body
• Slurred speech or difficulty understanding others
• Blindness in one or both eyes
• Dizziness
• Severe headache with no apparent cause

The risk factors are smoking, cardiovascular disease, diabetes and blood clots called embolisms.

Get help immediately if you think you could be having a TIA. Trained medical staff will need to evaluate your condition. Some signs are only visible with hospital equipment.

When a TIA occurs in a young person with no clear risk factors, the patient might be sent to a neurologist for testing to rule out vasculitis, carotid artery dissection and other types of injury or infection.

TIAs are often called “mini-strokes” because their immediate consequences are fairly benign. But the term “warning stroke” is a better label, because a TIA usually foreshadows a full-blown stroke.

TIAs are caused by a clot or blockage in the brain. The blockage is short term. The clot will usually dissolve on its own or it gets dislodged, and the symptoms usually last less than five minutes.

The statistics tell the story:

1. Approximately 15% of all strokes are foretold by a TIA.
2. Among patients treated for a blockage-related stroke (ischemic), between 7 – 40% report experiencing a TIA first.
3. About 1/3 of people who have a TIA go on to have a more severe stroke within one year.

Each year, millions of older people—those 65 and older—fall. In fact, more than one out of four older people fall each year but less than half tell their doctor. Falling once doubles your chances of falling again.

Falls Are Serious and Costly:

• One out of five falls causes a serious injury such as broken bones or a head injury.
• Each year, 3 million older people are treated in emergency departments for fall injuries.
• Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.
• Each year at least 300,000 older people are hospitalized for hip fractures.
• More than 95% of hip fractures are caused by falling, usually by falling sideways.
• Falls are the most common cause of traumatic brain injuries (TBI).
• In 2015, the total medical costs for falls totaled more than $50 billion.  Medicare and Medicaid shouldered 75% of these costs.

Many falls do not cause injuries. But one out of five falls does cause a serious injury such as a broken bone or a head injury.  These injuries can make it hard for a person to get around, do everyday activities, or live on their own.

• Falls can cause broken bones, like wrist, arm, ankle, and hip fractures.
• Falls can cause head injuries. These can be very serious, especially if the person is taking certain medicines (like blood thinners). An older person who falls and hits their head should see their doctor right away to make sure they don’t have a brain injury.
• Many individuals who fall, even if they’re not injured, become afraid of falling. This fear may cause a person to cut down on their everyday activities. When a person is less active, they become weaker and this increases their chances of falling.

Research has identified many conditions that contribute to falling. These are called risk factors. Many risk factors can be changed or modified to help prevent falls. They include:

• Lower body weakness
• Vitamin D deficiency (that is, not enough vitamin D in your system)
• Difficulties with walking and balance
• Use of medicines, such as tranquilizers, sedatives, or antidepressants. Even some over-the-counter medicines can affect balance and how steady you are on your feet.
• Vision problems
• Foot pain or poor footwear
• Home hazards or dangers such as: broken or uneven steps, throw rugs or clutter that can be tripped over.

Most falls are caused by a combination of risk factors. The more risk factors a person has the greater their chances of falling.

Falls can be prevented. These are some simple things you can do to keep yourself from falling.

• Ask your doctor or healthcare provider to evaluate your risk for falling and talk with them about specific things you can do.
• Ask your doctor or pharmacist to review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines and over-the counter medicines.
• Ask your doctor or healthcare provider about taking vitamin D supplements.

Do exercises that make your legs stronger and improve your balance. Tai Chi is a good example of this kind of exercise.

Have your eyes checked by an eye doctor at least once a year, and be sure to update your eyeglasses if needed.

If you have bifocal or progressive lenses, you may want to get a pair of glasses with only your distance prescription for outdoor activities, such as walking. Sometimes these types of lenses can make things seem closer or farther away than they really are.

• Get rid of things you could trip over.
• Add grab bars inside and outside your tub or shower and next to the toilet.
• Put railings on both sides of stairs.
• Make sure your home has lots of light by adding more or brighter light bulbs.
• Keep items you use often in cabinets you can reach easily without using a step stool.
• Use non-slip mats in the bathtub and on shower floors.