This is really gross, but I need help!

[TerryJ2]

The nurse from my cousin's nursing home just called. She said that P was using her finger to dig up her rear, and had smeared fecal material all over the bed and bathroom was she walked. (She is very unsteady on her feet, even after the kyphoplasty Mon.)
She wanted to know if this was something new.
I told her no, she feels constipated, and with-the broken coccyx, the nerves are always firing and she feels constant pressure.
Why she thinks it's okay to do something so unsanitary and ineffective, I have no idea. I suggested that it was becoming more of a habit, it may be turning into an Obsessive Compulsive Disorder (OCD) thing, and I wanted a therapist to interview her. (We've been waiting for 5 wks now.)
I also said it would work best to inform her of the sanitation facts, rather than just chastise her for doing something bad, as that would simply hurt her feelings and she wouldn't "get it."

Any ideas?

 

[hearts and roses]

You're right, Terry, this is really gross -

I think your approach to tackle it from a sanitary point of view as opposed to simply shaming her and embarrassing her is the best. I think perhaps they should monitor her BM movements for a while to see when she truly needs to 'go'; possibly have an aide 'shadow' her to prevent her from doing this again...i.e., gentle reminders about remaining clean and sanitary.

That said, I do think it's one thing for her to be trying to alleviate the pressure and another thing to be spreading it on the walls, etc. To me, that sounds like more than an Obsessive Compulsive Disorder (OCD) thing of feeling pressure and trying to alleviate it. That behavior is different and she should probably be seen by a phsychiatrist/therapist to figure out what's going on with that. There is a name for it, but I can't think of it now. There are many on the board who have dealt with it and I'm hoping one will come by soon.

Hugs - that had to be a difficult call.

 

[slsh]

Terry - as delicately as I can put it, digital stimulation actually is one method of dealing with- bowel hygiene. Obviously, a glove or finger cot would be appropriate.

My recommendation to the nursing home would be to help your cousin with monitoring her bowel movements and if she is constipated, to put her on a protocol. Lots of (less invasive) choices out there.

Has she been checked for a physiologic cause beyond the coccyx issue? If her pelvic floor is weakened, that could be contributing.

 

[mstang67chic]

Definately look into medical issues with this but I'm with the sanitary line of thinking. Also, if she'll buy into them, little white lies in this case, in my opinion, would be acceptable. "P, the more you do that, the more you risk tearing the wall and getting a very virulent or nasty infection that would result in surgery" or something....do you think she'd buy it?

 

[DDD]

If it were a chld I would suggest a pin worm check. I suppose it is possible for an adult to have the infestation but most often it is passed via toilet seats from kids. It wouldn't explain the smearing but from family experience I know that it is enough to drive anyone crazy. Sorry I can't be of help. DDD

 

[susiestar]

What a difficult call. I am sorry you have to deal with this. It seems there are physical and psychiatric/emotional reasons behind the behavior. She should be evaluated by a gastro doctor and a therapist/psychiatrist.

They need to get her on a routine to get rid of the constipation. Miralax, dulcolax, and a diet higher in fiber will help greatly. If the BM is not hard it may not trigger the nerves.

Checking for pinworms is not a bad idea. I know that they went around the nursing home my great aunt was in at one point. She should also be checked for fissures and sores - fingernails can cause these and an infection there would be horrible.

Why not provide some gloves and special towels or baby wipes to handle the problem while she is still doing this? Would it have a chance of working, esp if combined with the sanitation reminders? Shaming or chastising her probably will not work. Just like it doesn't with kids.

Staff will need to pay a lot of attention to her for a while. They should get her on a routine - trying to go every few hours at first.

The doctor should have more ideas. She is NOT the first elder to develop this issue. Just be sure you know if they use restraints - and for how long she would be left in them, would she be alone or have someone with her.

A friend's Gma was in a nursing home and found that her Gma was being restrained almost 20 hours a day because she was smearing feces. The staff didn't bother to find out why, and it caused a LOT of problems and fears in her Gma. Sstaff also wanted to put in a feeding tube because she was losing too much weight. She was not free when the food was there. Kitchen staff brought food and removed trays but were not allowed to remove restraints. Nursing staff didn't often go in and let her loose so she could eat. Poor lady was left to watch and smell food she couldn't eat - and she was hungry! Staff told doctors she was refusing to eat.

Just be aware. Not all facilities are like this, but it is something you should ask about and drop in at random times to check on.

 

[Hound dog]

Experience speaking here.

First, this nurse that called....Just what she said and how she put it makes me think that 1. she's a new nurse or 2. she doesn't have much experience in the nursing home setting.

Like I said, experience. I worked in nursing homes since I was 16 until about 23, as well as the hospital.

This is behavior that is not abnormal with elderly women, most especially those who have mobility issues with the bowel or like your aunt, always feel as if something is "stuck" there and that she needs to go. I mean, c'mon....it's uncomfortable and if the pressure gets to a certain point, well let's be honest...you just want it out of there no matter what it takes.

The behavior shows itself in elderly women who have issues with constipation and who may have at home used stool softeners, laxatives and Fleets to resolve the issue. The problem is that with chronic long term use of such products they tend to make it worse as the body tends to become dependent on them. And that's when the digging out behavior starts.

What the nurse should have asked is if your aunt has had long term issues with constipation. Has she used products such as Metamucil, Fleets, or laxatives on a fairly regular basis in an attempt to keep her bowels regular?

Definitely unsanitary. No so ineffective necessarily. At least with some of the patients I had.

And you might want to inform her that it is a common behavior to hyper focus on the bowels for woman of your aunts generation. When they were young a spoonful of castor oil was believed to cure a lot of what ails you. And doctors preached that good regular bowel movements were critical to good health.

mother in law has the same issue. Although to my knowledge has not yet resorted to digging. Because I was adamant with staff that when she says she needs something......she is not kidding and to get her a stool softener and something stronger as needed. Now they're standing orders from her fam doctor.

Is aunt aware enough that you and or staff can explain that some of the pressure she is feeling can be due to the broken tail bone and that as long as she is going regularly there is no need for her to worry? Because I know that keeping track of that sort of thing is a big deal to staff.......just so she won't have issues with it.

I don't recall aunt's level of functioning. So the spreading it could be anything from trying to clean her hands to an attempt to get her self up to go the the bathroom. Hard to tell.

For my patients with this issue we paid special attention to whether or not they were staying regular (at least 2-3 times a week or their own "normal") and if it had been longer then we took action either by standing orders or by contacting the dr to get something to relieve the problem. Usually that was enough to stop the behavior. Only time I recall that it didn't was when the patient had taken it to the Obsessive Compulsive Disorder (OCD) type of behavior and then medications were ordered for her, but they really didn't help much. Staff just made sure we were around when she was using the bathroom to prevent it from happening. Often she was very vexed with us. lol

 

[TerryJ2]

Thank you all.

She is on laxatives, both liquid and pill form.

She goes to the bathroom (on her own! Yaay!) about every 45 min.

She was on laxatives at home b4 she came down here.

Yes, I have to wonder about the head nurse. She's so into doing her routine, that she has no curiosity or desire to look into things further. She's been there for yrs.

I will call the dr myself. I called her the other day but will call again to detail the issue.

 

[TerryJ2]

Oh, and it's against the law to use restraints in this kind of a facility.

 

[timer lady]

Terry, I worked nursing homes for about 8 years; I saw this a lot. Seniors are very concerned about their bowels.

I'm sorry the nurse is so "goofy" .

 

[TerryJ2]

Thank you!

 

[Hound dog]

Goofy? Linda you're being so kind.

If she is not a new nurse and has been at this facility for years......then she does not pay much attention to her patients, or isn't very bright. mother in law has a few where she is and I usually just work around them, it's easier. lol

Terry call the doctor, explain the problemm, and get the necessary standing orders in place.

by the way, it is against the law to restrain anyone without written orders from the doctor and darn good reason to do so. This behavior would not, I'd don't believe, be considered enough to warrent restraints of any sort.

 

[Abbey]

Speaking from someone that currently has a broken tail bone...it is VERY difficult to regulate bowel movements and urination. I went 9 days before I could go and then, it was not pleasant. You just don't have the sensation to go. doctor said it was nerve damage and could be 6-8 weeks before I feel any relief. I swear I was about to the digging out point (ewww...) but Dukolax helped a small bit.

Hope she gets the help she needs.

Abbey

 

[GoingNorth]

I also had this problem when I broke my tailbone. I was simply not able to pick up on cues to "go" due to swelling and nerve inflammation.

I had to use laxatives for a few weeks until the swelling and stuff went down. Not very pleasant at all.

Has she been checked for displaced fragments from the tailbone fracture? The rectum runs right under the tailbone and fragments can press on it and cause a constant sensation of "fullness".

 

[TerryJ2]

Good idea, GoingNorth. I'll ask the surgeon who did the kyphoplasty, because he's seen the MRI.

 

[Marguerite]

On the pin worm issue, I want to point out just how contagious these things are. They can transfer so easily, from person to person. The beasties live in the GI tract (lower end) and don't really do much at all you. But they can be very annoying, and you can lose sleep form the maddening itch.

The itch is caused by the female worms emerging usually at night when you're trying to sleep, to lay their eggs just outside the anus. It tickles. So you scratch, and get eggs under your fingernails. You also get eggs on your pyjamas, on bedding, on underwear, on other clothing. The eggs are tiny, they dry out and can blow around in the dust. If you have them on your fingers then anything you touch is possibly loaded with eggs. I remember an ad for threadworm treatment (we call them threadworms here, but it's the same thing) that showed a kid passing a pencil to another kid in school. The caption read, "Annie has just given John a case of threadworms."

Thankfully they are easy to treat. It does help to diagnose for sure, and with kids, you diagnose by examining the anus after bedtime with a torch and magnifying glass. Not sure you could do then en masse in a nursing home... But simply dosing everyone at the same time with the one shot pill would work. As long as staff dose themselves too.

When we treated any of our kids, we dosed everyone in the family at the same time. Otherwise parents could have it and reinfect the kids.

Our kids got very good at diagnosing themselves.
"Mu-u-um! I've got itchy bottom again!"

Marg

 

[susiestar]

Restraints are against the law here with-o doctor orders and good reason also. It still happens, esp if staff gets overwhelmed or annoyed. It is one reason it is so important to stop by at different times when a loved one is in a nursing home. It was not always illegal to use restraints and the risk is there is you are not aware of it. ESP with staff who has been there "forever".

I am SO glad they are illegal in most cases.

In addition to the medical treatment/checking, would giving her something like knitting to keep her hands busy be helpful?

Sorry she is having this problem. You too Abbey!

 

[Marguerite]

In addition to the medical treatment/checking, would giving her something like knitting to keep her hands busy be helpful?

Considering what else she has been doing with those hands, I'm not sure if that is a sweater I'd feel comfortable wearing...

Marg

 

[Abbey]

GN said it correctly. You don't pick up on the cues of when to go. You just feel full all the time and can't do anything about it. They might consider an old fashioned enema. They're not fun and quite embarrassing, but it gets the job done.

Abbey