The Respect-Worthy Supervisor:  Receiving and Giving Respect in Home Health Care Supervision. Rita A. Jablonski, Ph.D., RN, ANP Anthony J. DeLellis, Ed.D. - PowerPoint PPT Presentation

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The Respect-Worthy Supervisor:  Receiving and Giving Respect in Home Health Care Supervision. Rita A. Jablonski, Ph.D., RN, ANP Anthony J. DeLellis, Ed.D.

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Title: The Respect-Worthy Supervisor:  Receiving and Giving Respect in Home Health Care Supervision. Rita A. Jablonski, Ph.D., RN, ANP Anthony J. DeLellis, Ed.D.


1
"The Respect-Worthy Supervisor  Receiving and
Giving Respect in Home Health Care
Supervision. Rita A. Jablonski, Ph.D., RN,
ANP Anthony J. DeLellis, Ed.D.
2
Respectful Supervision
  • Begins with respectful communication

3
Give respect to get respect?
?
  • Usually get respect if you give respect, but no
    guarantee
  • Get no respect if you give no respect, guaranteed

4
Giving respect - names are important
  • Call people what they want to be called If her
    name is Mary Jones, do you call her Mary, Ms.
    Mary, Miss Mary, Mrs. Mary, Ms. Jones, Miss
    Jones, Mrs. Jones?

5
Giving respect - names
  • Ask people what you should call them, and then
    just do it

6
Respect is listening
  • Listen actively
  • Look, stop, wait - let them finish
  • Dont interrupt
  • Turn off radio, TV - completely off
  • Let them know you heard and understood
  • Paraphrase

7
Respectful communication -
  • Respect is something we feel, even if we dont
    show it.
  • So show it!

8
Tone and choice of words matter
  • Use respectful tones.
  • Use courteous language, always.

9
Clothes matter
  • How we dress sends a message to the people around
    us about how we feel about them.

10
Assertive vs Aggressive Communication
  • Assertive - say what is on your mind, but keep in
    mind the feelings of others.
  • Aggressive - say what is on your mind, but dont
    care about the feelings of others or deliberate
    try to hurt or offend them.

11
Politeness and Power
  • Powerful people can afford to be polite.
  • Politeness isnt weakness.
  • Politeness isnt being somebody youre not.
  • Politeness to rich and poor alike is - powerful.

12
Addressing Unsatisfactory Performance
  • Opportunity to help the NA to concretely
    understand workplace obligations
  • Cultural differences regarding on time
  • Differences in work ethic among members of
    various age cohorts, e.g. entitlement in
    workers under the age of 30 versus work until
    you drop dead ethic of workers in their 60s

13
Addressing Unsatisfactory Performance
  • May be the first time a worker has had to problem
    solve
  • Instead of telling the worker, Late again, you
    are fired, try asking the worker a series of
    questions to help him or her figure out options
  • Coaching type of management

14
Be assertive when coaching
  • Speak assertively, not aggressively.
  • Stick to the point.
  • Describe the behavior, dont characterize the
    employee as a loser.
  • Dont be afraid to praise someone who is not
    perfect - when praise is due.
  • Dont use praise to avoid conflict.

15
Coaching is shared risk
  • Coaches rise or fall when their teams rise or
    fall.
  • Coaches find inner motivation of team members.
  • Team members eventually have to go it alone.

16
Disagreement
  • Disagreement with an employee is never an excuse
    to switch from assertive communication to
    aggressive communication.
  • Respect, assertiveness, listening, and politeness
    are especially important during disagreement.

17
Effective Supervisors
  • Compassionate
  • Creative
  • Decisive
  • Empathetic
  • Fair
  • Flexible
  • Humble
  • Objective
  • Problem-solver
  • Respectful
  • Self-directed
  • Self-evaluative
  • Understanding
  • Visionary
  • System-thinker (able to see big picture)
  • Hewlett, et al., Minnesota Frontline Supervisor
    Competencies Performance Indicators, U. of
    Minn., 1998.

18
Some Guiding Principles for Supervisors
  • Internal motivation.
  • External motivation.
  • Recognition.
  • Importance of staff development training.
  • 2 important questions
  • What motivates you?
  • How do you want to be recognized?
  • LaLiberte, Hewitt and Larson, Staff Motivation
    and Recognition.

19
Challenging Issues in Home Care
20
Legal and Ethical Situations that Accompany
Supervision
21
Legal Definitions
  • Assault (criminal act) An attempt to inflict
    physical injury on a person the unwanted
    touching of one individual by another
  • Battery (criminal act) The actual infliction of
    physical injury on a person. Includes every
    willful, angry, and violent or negligent touching
    of anothers person or clothes or anything
    attached to his person or held by him
    (Creighton, 1986).

22
Legal Definitions
  • Unlawful use of restraint Could be considered
    assault and battery
  • Care must be taken to use only with a physicians
    order to monitor the client frequently (minimum,
    every hour) to remove the restraints and
    exercise the limbs (minimum, every 2 hours)

23
Legal Definitions
  • Tort A legal wrong, not a crime (a crime must
    have evil intent and involve a criminal act).
  • A legal right of a person is somehow violated,
    and the violation is called a tort.
  • A legal case involving torts is heard in civil,
    not criminal, court.
  • Example two drivers are involved in an
    automobile accident. No criminal charges are
    filed. One driver sues the other.

24
Legal Definitions
  • Negligence The omission to do something that a
    reasonable person, guided by those considerations
    that ordinarily regulate human affairs, would do,
    or as doing something that a reasonable and
    prudent person would not do (Creighton, 1986, p.
    141)

25
Legal Definitions
  • Malpractice any professional misconduct,
    unreasonable lack of skill or fidelity in
    professional or judiciary duties, evil practice
    or illegal or immoral conduct (Creighton, 1986,
    p. 141)

26
Legal Definitions
  • Defamation The ruining of a persons reputation
    by verbal or printed statements any verbal or
    printed statements that could be considered
    detrimental to a persons personal or
    professional reputation
  • Slander Oral defamation
  • Libel Written/published defamation

27
Legal Definitions
  • Neither slander nor libel refers to a
    conversation or written communication between 2
    persons, unless overheard or witnessed by a third
    person.

28
Legal Definitions
  • Defamation is not an issue when there is a legal
    duty to speak.
  • Confidentiality
  • Be aware of potential HIPAA violations,
    especially when carrying client records and
    information in your car.
  • Be aware of your surroundings when using your
    cell phone in the field. Password protect
    laptops, Palm devices

29
Types Of Legal Issues
30
Types Of Legal Issues
  • Living Wills
  • Also known as Natural Death Acts, Patient
    Self-determination Acts
  • These documents state which specific treatments
    may be rendered if a client is unable to make
    medical decisions for him or herself.

31
Types Of Legal Issues
  • Patient-specific treatment instructions
  • Designation of a proxy to make these decisions
  • Do Not Resuscitate Orders
  • Medicaid regs do not require that DNR orders be
    kept in the client file in the agency, and as a
    practice, agencies do not obtain a copy.
  • The DNR notice is to be posted in the room or on
    the clients door.

32
Types Of Legal Issues
  • The RNs responsibility is to discuss this with
    the family and instruct the aide as to the
    familys wishes regarding who to call should the
    client become unresponsive.
  • That may be the rescue squad, hospice, or a
    family member.
  • If the family wants the rescue squad called, it
    is important that the nurse instruct the family
    to have DNR orders posted in an obvious place.
  • The RN would insure that the aide understands
    what DNR orders are and what the aides
    responsibilities are as a result.
  • Usually, DNRs stipulate that no heroic efforts
    be made in the event of severe illness or
    cardiovascular arrest.
  • Can be modified, e.g., may not administer CPR and
    intubation but may use medications

33
Ethical Issues
34
Ethical Issues
  • Ethics
  • A body of knowledge concerned with the rightness
    or wrongness of an act. In the professional
    arena, ethics refers to the rightness or
    wrongness of professional conduct.
  • Something may be legally right but ethically
    wrong, depending on a persons own code of
    ethics e.g., abortion

35
Ethical Issues
  • Types of ethical views
  • Do no wrong
  • The end justifies the means
  • The individuals choice takes precedence over
    societys views
  • I know what is best for you

36
Ethical Issues
  • Clients should be active participants in
    decisions about matters that involve themselves
    or their lifestyles

37
Ethical Issues
  • Decision-making is problematic with cognitively
    impaired individuals

38
Ethical Issues
  • Supervisors must be able to help PCAs realize
    that individuals with cognitive impairment may be
    unable to make decisions is some areas, but may
    be able to make decisions in other areas
  • Mental capacity fluctuates, resulting in periods
    of lucidity and confusion
  • Respect for others as one useful guiding
    principle in remaining ethical

39
Violence in the Clients Home
40
Violence in the Clients Home
  • National Institute of Occupational Health and
    Safety
  • Physical assault, threatening behavior, or
    verbal abuse occurring in the workplace
  • Usually client-caregiver also caregiver-client,
    , caregiver-caregiver, family-caregiver

41
Violence in the Clients Home
  • Violence is not often recognized as a problem in
    the home.

42
Violence in the Clients Home
  • Many administrators and licensed nurses have been
    acculturated to view violence as part of the
    job
  • Many administrators think that physical abuse
    upsets PCAs more than verbal abuse actually,
    PCAs can be just as upset with verbal assaults
    such as racial slurs, cursing, and demeaning
    remarks

43
Impact of verbal and physical abuse on PCAs
  • Feelings of hurt, anger, frustration, resentment,
    sadness, disrespect, being violated, shock, and
    fear
  • Less willing to spend time with offending
    clients, less willing to care for them
  • Absenteeism, negative behavior toward
    supervisors, quitting job

44
Making a difference
  • Put a mechanism in place for PCAs to report
    violent behavior by clients
  • Ask about the existence of physical or verbal
    abuse during supervisory visits, and be prepared
    for more information than you expected make sure
    you document interactions and interventions in
    your notes

45
Making a difference
  • Recognize that the violent or abusive behavior
    may be triggered by a specific event (e.g.,
    bathing) or may be due to feelings that cannot be
    expressed by a cognitively impaired individual.

46
Making a difference
  • Once PCAs alert the nurse supervisor about this
    behavior, the nurse needs to do the following
    speak to the family regarding what they have done
    to successfully handle the abusive and violent
    behavior advise the PCA as to the best approach.

47
Making a difference
  • If the family is also grappling with the same
    issues unsuccessfully, the RN should urge the
    family to discuss possible solutions with the
    health care provider (MD, NP).

48
Making a difference
  • The nurse should advise the family that solutions
    to violent and aggressive behavior must be sought
    if the client is to remain in the home with the
    NA. In fact, this is a common reason for NH
    placement.

49
Making a difference
  • Need to stress that UNDER NO CIRCUMSTANCES IS IT
    ACCEPTABLE FOR CAREGIVERS TO HIT BACK OR
    RESPOND IN KIND TO A CLIENTS ABUSIVE BEHAVIOR.

50
Making a difference
  • Virginia has a mandatory reporting statute and it
    is the nurses obligation to make an APS referral
    for all cases of suspected or actual abuse and
    neglect.

51
Making a difference
  • Sometimes agencies and individuals are reluctant
    to report because it becomes very uncomfortable
    and is sometimes impossible to continue to
    provide services for a client when a family
    member is angry with the agency for reporting
    suspected or actual abuse.

52
Recognizing abuse towards clients
  • Unexplained bruises, cuts
  • Pattern to bruises, cuts fingerprints, cords
  • Sometimes the result of violence against the
    family caregiverpayback
  • Sexual abuse does occur
  • May see vaginal/rectal bleeding, spotting,
    complaints of pain with urination
  • Caregivers who are emotionally and physically
    exhausted are at risk for abuseimportant for
    PCAs to recognize this and report to supervisors,
    so that the agency may help avert future problems

53
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54
Helping Your Staff Care for Clients with Dementia
55
Helping Your Staff Care for Clients with Dementia
  • Explanation of Dementia
  • Dementia is an all-inclusive term that refers to
    global confusion and forgetfulness.
  • It is gradual in onset and proceeds at a slow
    rate.
  • It is irreversible
  • Can be aggravated by depression

56
Helping Your Staff Care for Clients with Dementia
  • Associated with many diseases
  • Alzheimers Disease
  • Cardiovascular disease
  • Atherosclerosis
  • Cerebrovascular accidents (CVA or stroke)
  • AIDS
  • Is not a normal part of aging

57
Helping Your Staff Care for Clients with Dementia
  • Common behaviors in dementia
  • Non-aggressive
  • Moaning, repetitious words or sentences
  • Wandering, rocking
  • Aggressive
  • Yelling, cursing, screaming
  • Hitting, spitting, biting

58
Helping Your Staff Care for Clients with Dementia
  • Paranoia is not uncommon, especially when the
    person with dementia is trying to make sense out
    of the environment or situation.
  • In early stages of dementia, the person knows
    that something is wrong. In later stages, the
    person does not know that something is wrong, and
    blames other people for missing items, changes in
    the routine, etc.

59
Helping Your Staff Care for Clients with Dementia
  • Sexual behavior, such as masturbating in public
    is also not uncommon.
  • Sexuality is present in aging and disabled
    persons, and the confused person is often seeking
    sexual solace.
  • Persons with dementia may confuse another client
    for a spouse or may forget they were ever
    married.
  • Inhibitions are removed, which explains why
    sexually inappropriate behavior may occur in
    public.

60
Helping staff work with clients with dementia
  • Several researchers have developed a model to
    explain the disruptive behaviors associated with
    dementia

61
Helping staff work with clients with dementia
  • Need-driven, Dementia-compromised Behavior Model
  • All behaviors, no matter how distasteful, are the
    result of the clients response to some emotion
    or fear. Clients with dementia have difficulty
    interpreting stimuli and may react with violence
    if they believe that they are being harmed.
  • It is important to realize that the person with
    dementia does not exhibit disruptive behavior
    because they choose to, but the behavior is the
    result of the dementiacommunication patterns are
    altered by the disease causing the dementia

62
Helping staff work with clients with dementia
  • Assessing reasons for disruptive behavior
  • Misinterpretation of surroundings

63
Helping staff work with clients with dementia
  • Persons with dementia have limited capacity for
    learning new information. Even though they are
    told several times, this is the bathroom, they
    may still misinterpret the surroundings and may
    react with fear
  • Vision and hearing impairment may further create
    problems with correct interpretation

64
Helping staff work with clients with dementia
  • Pain and painful procedures
  • May be aggravated by clients who are resistant to
    taking medication and may not receive their pain
    medications
  • Stress
  • Sensory overload

65
Helping staff work with clients with dementia
  • Meaningless noise
  • Desire for immediate attention
  • Loss of control/autonomy
  • Fatigue

66
Helping staff work with clients with dementia
  • Desire for sexual intimacy
  • Change in routine
  • Psychiatric co-morbidities
  • Failure of staff to acknowledge communication
    attempts and failure to anticipate and meet
    residents needs. This can only happen when they
    know the resident. KNOW THY RESIDENT should be
    the gospel of disruptive behavior management

67
Helping staff work with clients with dementia
  • Strategies for helping PCAs to cope with
    disruptive behavior
  • Determine antecedents to the disruptive behavior
  • This may be challenging because the cause may not
    be immediately apparent, and the cause may not
    always be consistent (i.e., whatever caused the
    disruptive behavior yesterday may not cause
    disruptive behavior today). A pattern needs to be
    determined. Important for staff to discuss what
    they believe precipitated the disruptive behavior.

68
Helping staff work with clients with dementia
  • Bathing is a usual antecedent. If water is near
    the face or head of a confused person, he or she
    may react in an aggressive manner
  • Let the client get into the tub slowly
  • Approach client in a relaxed manner
  • Less likely to provoke agitation. If one
    approaches a confused person in an authoritarian
    or bossy manner, the client may react in an
    unfavorable way.

69
Helping staff work with clients with dementia
  • Avoid being focused solely on the task
  • Hello Mrs. Jones, how are you? Here, let me help
    you get this dress on. Hows that?
  • Hello, Mrs. Jones. Im going to help you get
    dressed.
  • The second approach will more likely result in
    agitation than the first approach.

70
Helping staff work with clients with dementia
  • Have the client control the flow of water (e.g.,
    using a hand-held shower head to direct the flow
    of water)
  • Sometimes, the client does not understand what is
    expected of him or her with a specific task, and
    may become frustrated and act out.

71
Helping staff work with clients with dementia
  • It is a good idea to talk to the client about
    personal things of interest to him or her during
    tasks (e.g., grandchildren, previous occupation,
    favorite activities)
  • Be flexible in approach with client
  • The use of gestures and pantomime to show the
    client what you want him or her is helpful

72
Helping staff work with clients with dementia
  • Do not limit your conversation to the client
    because of the confusion. Chatting away with
    the client has been shown to improve agitated
    behavior. The client may respond to the verbal
    stimulation.
  • However, when asking the client to do something,
    use short, one-step REQUESTS, not commands. Do
    not keep repeating the same request, otherwise
    the client may become agitated

73
Helping staff work with clients with dementia
  • Show interest in the client, both verbally and
    nonverbally
  • Avoid interruptions

74
Helping staff work with clients with dementia
  • Studies have shown that interruptions resulted in
    increased agitation and tension on the part of
    the client and decreased flexibility and personal
    contact on the part of the nursing assistant.
  • Remember not to take aggression personally,
    unless you have deliberately done something to
    provoke the client, it is not your fault!
  • Praise the client in an adult-like manner.

75
Helping staff work with clients with dementia
  • Have manipulatives in the environment
  • In the home environment, encourage families to
    have items available that are associated with
    activities that the client previously enjoyed.
    One family kept jumbo blunt knitting needles and
    bits of yarn in a basket for their grandmother,
    who was an avid knitter prior to the dementia.
    She derived comfort from sitting and holding the
    items in her lap.

76
Helping staff work with clients with dementia
  • Use touch judiciously
  • Some clients respond well to touch others may
    react negatively. Find what works with your
    clients.

77
Helping staff work with clients with dementia
  • If the client is already agitated, touching in a
    forceful manner may escalate the agitation
  • Remove client from the disruptive area, if
    possible
  • If the client is engaging in sexually
    inappropriate behavior (e.g., masturbating in
    public), will need redirection. Depending on the
    severity of the clients dementia, you may be
    able to encourage him or her to refrain from this
    behavior in public and to engage in it in a
    private area.

78
Helping staff work with clients with dementia
  • Distraction
  • Humor or playful responses may divert the
    clients attention from the discomforting
    situation and may stop the aggressive behavior

79
Helping staff work with clients with dementia
  • Keep clients busy
  • In one study, disruptive behaviors rarely
    occurred during organized activity or when
    clients were proceeding to an activity. However,
    72 occurred during periods of inactivity

80
Supervisory Meetings and Plans of Care
  • Encourage participation from PCAs
  • By alerting the agency if disruptive behaviors
    become unmanageable
  • By identifying triggers to disruptive behavior
  • By sharing proven intervention that work in
    preventing disruptive behavior

81
Supervisory Meetings and Plans of Care
  • Communicate these interventions to the scheduling
    coordinators, and asking that those interventions
    be passed on to any new aides assigned to the
    case. May want to document this information in
    the nurses notes as well

82
Supporting Your Staff When a Client Dies
83
Supporting Your Staff When a Client Dies
  • Help PCAs recognize that loss is a part of life
  • Can be sudden (death of a young person) or
    expected (death of a terminally ill person)
  • Can be bittersweet
  • Transition of a child from infant, to toddler, to
    preschool, to school age
  • Loss of a child leaving home, but going to
    college and growing up
  • Some losses seem bad initially, but then turn out
    to be a blessing (a man is laid off from one job,
    only to find a better one)

84
Supporting Your Staff When a Client Dies
  • When losses are bunched together, as in older
    years, multiple effects can be devastating

85
Supporting Your Staff When a Client Dies
  • Reactions to Loss
  • Because losses are personal, reactions to loss
    are individualized
  • What may be a small loss to me may be a larger
    loss to someone else
  • The process of grieving is called bereavement

86
Supporting Your Staff When a Client Dies
  • Although the process is individualized, there are
    some general components
  • Sadness
  • The person is unhappy with the loss. He or she
    expresses sadness, cries.
  • Denial
  • This isnt happening. If I ignore it, I wont
    have to deal with it.

87
Supporting Your Staff When a Client Dies
  • Anger
  • Can be at self or others
  • May belittle others, may become a difficult or
    demanding client
  • Sometimes, PCAs are targets because they are
    safe a client may be angry at a son or
    daughter, but can ill afford to antagonize that
    person, so he or she takes out the anger on a PCA
    May express anger by trying to exert control over
    those items that the person still has control
    over.
  • Example a quadriplegic client who calls the PCA
    every five minutes for a minor, trivial requests,
    and/or verbally abuses the PCA

88
Supporting Your Staff When a Client Dies
  • Blaming
  • May seek to make someone else the culprit for the
    loss. This is an attempt to make meaning out of a
    lossThis bad thing happened to me because
  • May blame self or others If only I had taken my
    medicine, I wouldnt have had this stroke.

89
Supporting Your Staff When a Client Dies
  • Bargaining
  • If I can learn to walk with this walker, you
    will let me go back to my apartment, right?
  • Can be with family, health care providers, even
    God
  • Depression
  • The person may lose interest in food, enjoyable
    activities
  • May sleep all of the time or most of the day

90
Supporting Your Staff When a Client Dies
  • Acceptance
  • Reconciles the loss with overall picture of self
  • Adjusts self-concept to fill up hole left by
    loss
  • This process may take days to years, depending on
    the extent and importance of the loss
  • Some people move out of one stage, only to return
    to it later
  • Some stay stuck in stages

91
Supporting Your Staff When a Client Dies
  • Role of the Supervisor
  • Anticipate the loss and prepare PCAs

92
Supporting Your Staff When a Client Dies
  • Know the persons most at risk
  • Start of care
  • Holidays
  • Holidays hold memories of family gatherings and
    rituals. Losses may be felt most acutely the day
    of the holiday or immediately after, when family
    members or friends leave.
  • May cry easily and all of the time
  • Anniversaries
  • Birthdays, wedding anniversaries, and death
    anniversaries may trigger memories and feelings
    of loss

93
Supporting Your Staff When a Client Dies
  • Persons with previous histories of depression
  • Persons who are rigid or negative
  • Persons who are flexible and resilient cope
    better with loss than those who are not.
    Example Mrs. S. was a morose individual who was
    rigid and negative her entire life. She was
    very demanding during each visit when the PCA was
    with her. She would also complain during the
    entire visit about the care she had received from
    other caregivers and agencies. The PCA began to
    dread her visits and asked to be reassigned to a
    different case. How can the aide be helped to
    deal with her frustration in order to remain on
    the case with Mrs. S.?

94
Supporting Your Staff When a Client Dies
  • Determine at what stage the individual is in
  • Communicate this information to the family
    member.
  • The person may benefit from psychiatric and
    spiritual counseling
  • Work with the individual

95
Supporting Your Staff When a Client Dies
  • Avoid even more losses
  • Give the client as much independence as possible
  • Give clients choices regarding meal ideas, daily
    activities make choice options realistic.
  • Listen to clients ideas about the care
  • Sometimes care revolves around agency schedules.
    Allowing the client to voice his or her opinion,
    and listening, empower the client.
  • Help the PCA to not take things personally

96
Supporting Your Staff When a Client Dies
  • The best response of the PCA to the client is to
    personalize their actions based on the clients
    needs and history. While this strategy is ideal,
    the realities of staffing and workload may make
    this approach very challenging.
  • This is also extremely difficult
  • No one likes to be the scapegoat, but realize
    that the client is not striking out at you, the
    person.
  • Tell the client, gently but firmly, I dont like
    it when you (fill in blank). I understand that
    you are upset and hurting, and I would like to
    help you.

97
Supporting Your Staff When a Client Dies
  • Keep yourself aware of the resources of your
    agency, and use them

98
Dying Trajectory
99
Various Shapes Of Dying Trajectory
  • prolonged or rapid
  • characterized by uncertainty

100
Response To Trajectory
  • closed awareness
  • the client is not told that he or she is dying,
    but the family and caregiver know
  • mutual pretense
  • everybody knows the person is dying, but everyone
    pretends it is not happening
  • open awareness
  • the dying process is openly discussed by all

101
Physiological Changes
  • peripheral circulation decreases
  • first in feet, later in hands, ears, and nose
  • mottled cyanotic skin, esp. in extremities
  • internal temperature may remain high, so keep
    patient's room cool

102
Physiological Changes
  • changes in vital signs
  • respirations rapid shallow, irregular or
    abnormally slow
  • cheyne stokes or agonal
  • decreased and weaker pulse
  • decreased blood pressure

103
Physiological Changes
  • loss of sensation, power of motion, reflexes in
    legs and gradually in arms
  • diminished touch sensations
  • pain and pressure remain intact
  • loss of muscle tone
  • cool, clammy

104
Physiological Changes
  • relaxation of facial muscles jaw may sag
  • difficulty swallowing gradual loss of gag reflex

105
Physiological Changes
  • muscles in back of throat and tongue leading to
    snoring sounds or death rattle
  • GI system shuts down
  • May not require or tolerate food or fluids. Do
    not force food. Offer sips of water for comfort
    only.
  • Nausea, flatus, abdominal distention,
    constipation
  • Decreased sphincter control leads to incontinence

106
Physiological Changes
  • Physical Signs of Actual Death
  • cessation of heart activity respiration
  • pupil dilation absence of reaction to light
  • body changes
  • algor mortis
  • gradual decrease of temperature with cessation of
    circulation (falls about 1.8F per hour) until
    reaches room temperature
  • livor mortis
  • discoloration that appears in dependent areas of
    the body caused by breakdown of RBCs with
    release of hemoglobin

107
Physiological Changes
  • Psychosocial Signs of Impending Death
  • Detachment
  • life reflection
  • speaks of death with increasing frequency
  • puts affairs in order
  • speaks of seeing loved ones who have already died

108
Physiological Changes
  • There is a difference between death and the dying
    process
  • Most aged persons are at peace with the idea of
    death
  • There may be apprehension about the dying
    process fear of inadequate pain management,
    heroic measures, life support machinery,
    impending transfer to a hospital, etc.
  • Important for the PCA to know who is in charge
    when a client is actively dying when to call
    family member, nursing supervisor, or 911
  • IMPORTANT cultural differences in attitudes and
    customs concerning the dying process, death, and
    burial

109
Physiological Changes
  • Help the PCA to support of family/significant
    others
  • research has shown most important thing is to
    know that loved one receiving compassionate,
    competent care
  • reassure the family that their loved one is
    comfortable
  • It was important for me how they cared for my
    husband. They called him by name and told him
    what they were going to do before they did it.
    (Wilson Daley, 1999, p. 24)
  • OK to cry with family after relative has died
  • In waivered services, after care is not a covered
    service. The NA is instructed to leave once a
    family member ahs arrived in the home.

110
Physiological Changes
  • Support the PCA with his or her own emotions and
    reactions
  • Both the family of the deceased, , and staff
    caring for the deceased have similar emotions
  • IT IS OK FOR PCAs TO ACKNOWLEDGE THAT THEY CARED
    FOR THE PERSON AND WILL MISS THEM
  • Some PCAs believe it is better to not get
    attached.
  • These individuals may avoid caring for a dying
    person or will be aloof, so as not to become
    emotionally involved.

111
Physiological Changes
  • As people come to grips with their own sense of
    loss, they may avoid the dying person and the
    family. This negatively impacts the care of the
    family and the client.
  • Let yourself grieve. Give yourself permission to
    feel your feelings. Accept sadness as a
    consequence of having a rich relationship with
    the client.
  • Find your own support system through co workers
    or your family.

112
Physiological Changes
  • Best for persons who are struggling with their
    own emotions and feelings of loss to work with a
    chaplain or social worker, so that the care they
    give is not affected.
  • The role that the PCA may play during a death can
    be frightening for some, especially those new to
    the role.

113
Putting It All Together
  • What are the things I can do?
  • What are the most important principles for me to
    follow and instill in others?
  • What are the five most important principles
    related to this workshop for me to follow?
  • What are the five most important lessons for me
    to pass along to others?
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