Community Chat

[Marp]

@pitdakota, I have a couple of questions if you feel like answering.

1.  In a NH memory care environment how would staff know if a resident with no history of such aspirated?

2.  How long would it take (maximum) between aspiration and onset of pneumonia?

3.  Where does the personal information on a death certificate come from if a family member doesn't know the answers?

[pitdakota]

Hi Marp!  I will try to answer as best I can.

1. Onset of signs/symptoms respiratory distress with no other obvious underlying reason.  Witnessed incidence of mild choking followed by onset of signs/symptoms.  Then they do a chest x-ray to rule out aspriation. 

     a) also have to mention if patient has a feeding tube, there are other factors that might occur that could lead to suspecting aspiration.  Coughing up expectorate that resembles tube feeding, etc.

2. This one is hard to answer because it depends of so many variables:  age & current health status of the person;  current meds (some meds obviously suppress the immune system, so those individuals would be more likely to display signs/symptoms sooner; current pulmonary status & past history of chronic obstructive pulmonary disease (patients are not as adapative and will present with s/s sooner); and certainly the type of substance that was aspirated (some substances are more toxic to pulmonary tissue in addition to causing infection so s/s onset more abruptly & seriously; amount of substance aspirated.  

3.If the patient has been in a nursing home, admission information on the patient's chart when admitted to long term care or previous history & physical documents dictated by phyisicans providing care from previous hospitalizations will sometime be used for death certificates.

I stopped answering 1 & 2, because I remembered an online article I assign for nursing students to supplement their reading for this content.  Heck, why not put the link to that article here??!!  So here is the link:

https://www.americannursetoday.com/jump-into-action-against-aspiration-pneumonia/

[Marp]

@pitdakota,

Thanks Pit. I asked the questions because I lost mom on November 1st. The diagnosis was aspiration pneumonia.

For about 7-10 days prior to her hospitalization she was clearly uncomfortable and irritable while sitting but her discomfort immediately ceased when she was returned to bed with upper body raised. Her wheelchair was changed, she was evaluated for back problems but nothing could be found.

A two days before she was hospitalized I insisted she be checked for UTI, chest x-ray, etc. because she was showing signs of distress and was slightly clammy. Reports all came back negative the day before she was hospitalized due to breathing difficulty.

Without going into procedures and all she was admitted to ICU on 10/30 and passed on 11/01.

I guess what I am trying to determine, without placing any blame, is if her discomfort and symptoms over the last week before admission to hospital were indications that pneumonia should be suspected.

Since she ate very little it is more likely than not she aspirated Boost. She did have COPD but was doing very well on oxygen and her levels were consistently in the 88-92% range.

About the death certificate. Brother handled the information with the funeral director and I know without a scintilla of doubt he did not know the answers to some of the questions and the answers did not come from the NH or other medical records. Mostly a matter of curiosity. The information, whatever the source, is correct.

I'm rambling so will read your linked article and perhaps answer my own questions.

[pitdakota]

Marp,

I am so sorry to hear about your mother.  (((Marp))).  My heart goes out to you.     

If I remember correctly, your Mom did have a diagnosis of dementia.  So this information, to me is very important.  In those patients, restlessness, discomfort, etc......quite a bit of work should be done to rule out aspiration pneumonia first.  If symptoms present after first x-ray, repeat.  Sputum culture (if possible) should be done. 

It is suspect that she was restless and presented those symptoms, but when she was placed back in bed (at rest) with the head of the bed elevated she did better.  Does make me suspect respiratory involvement.  It is hard because a person with dementia can't necessarily tell you that they don't feel like they are getting enough air, or that they feel they are breathing better in this position.  Edited to correct:   This is referred to as orthopnea if you want to read about that topic. 

[Marp]

Thank you Pit.  You know what a mother hen I was with mom and her care at the NH.  I knew something different was wrong but without mom being able to meaningfully communicate figuring things out was often like putting a puzzle together while blindfolded.

The linked article was very helpful and the hospital protocols were spot on.  Recognition of onset at the NH would only have been possible if witnessed.  Until the day before she was hospitalized her symptoms as described in the article were subtle and could readily be attributed to a number of things.

Now I will continue my education and learn about orthopnea.

[makeup addict]

@Marp Just wanted to jump in and offer my condolences. 

[hyacinth003]

I am so sorry for the loss of your mother.  It's a loss unlike any other.

Are you asking because you think something was missed?  I lost my mother in 2009 due to complications from multiple sclerosis.  To say she had a LOT going on with her would be an understatement.  She was in the hospital, and I had been with her until about 7pm the night before.  She was saying her lower abdomen was uncomfortable.  I did a full assessment, and couldn't see anything.   She was in the hospital for an intestinal infection, so I thought it was probably that.  By morning, turned out she had lost circulation from her entire leg.  That was probably the source of her pain.  So I beat myself up thinking I SHOULD have found it.  There are other incidents like that as well.

I can't do a ****** thing about any of it.  I have spent a lot of time beating myself up about things since I am an RN and should be BETTER at knowing. 

Aspiration pneumonia can have symptoms quickly or it is more subtle and takes time. 

I am so sorry about your mother.  Hope you don't mind my other comments.

Hyacinth

[Marp]

@hyacinth003,

I'll start by saying thank you for your condolences and telling you no, I do not mind your comments at all.

To answer your question clearly "something was missed" but I can't legitimately fault anyone. I was the one that usually recognized when something wasn't right with mom but only because after taking care of her for 30 years I spotted things that no one else would.

For example, I knew there was a difference between when she was just closing her eyes to "rest" them and when she was closing her eyes because she had a headache. The difference was so subtle that someone that did not intimately know her nuances would not think anything of her having her eyes closed.

In many ways staff was dependent on my input. Mom was raised that you don't complain about things outside the family. There were multiple times when she would tell staff she was fine but tell me she hurt, didn't feel right, etc. They would sometimes have to stand behind mom while I questioned her, guiding me when needed. They could ask her the same questions and she would say she doesn't know or she's okay.

I do feel that if the week before mom was hospitalized a particular nurse had been assigned to mom's unit the results may have been different because he is more proactive in isolating the source of a problem and thinking outside the box of expected findings catching the problem earlier.

I sometimes think I should have figured out that the problem was not musculoskeletal before I did but I also know that is an unreasonable burden I put on myself. I am not a nurse and under the circumstances with mom staff had no reason to suspect she aspirated.

As an aside mom was 94 and had advanced dementia.

P.S.  To anyone reading that has a loved one in a facility that has difficulty communicating I cannot stress enough how important it is that you visit frequently.  Often you will be the first line of defense for your loved one.

[MyShadowLove]

((((((((Marp))))))))

[pitdakota]

Oh Marp, of course you know I am going to say not to blame yourself.  And I say that even after I had a long period of blaming myself about a situation with my father's death.  And I am a nurse!  I couldn't get them to listen to me.  Long story, but when I raised holy heck and then started to take action to move him, it was too late.  He passed away.  My father was 94 too, but that didn't make any difference at the time.  I wanted him to receive the care I knew he should receive and care to keep him comfortable. 

We still have a long way to go with quality care in long term care settings.  We have made strides over the past, but we still have quite a bit of improvement that needs to take place.

It didn't matter how many of my family told me there was no way I should blame myself....I did.  Pure and simple.  It was just something I had to go through I guess.  But in the end, it doesn't change the outcome.  Except I have become much more assertive in communicating the need to improve long term care and educating nursing staff to listen to family.  By the way, the listening to family is something I preach in nursing school.  But it is just as important in long term care where this tends to be overlooked so many times. 

Big hugs to you Marp.  (((Marp))))   It hasn't been that long.  And it is a difficult journey no doubt.  Especially after you have devoted so much time to taking care of a parent.  You were a fabulous daughter.  And your mother was very fortunate to have you.