Challenge of Diaper Change Timeliness

[George Acenas]

If CNA ratio to total care resident is 1:8, Is responding to SAR/LTC resident’s call to be changed within 30 minutes realistic? On weekends the ratio increases to 1:12 and more due to call outs? Should visiting families be asked to help toilet their family because of an overwhelmed team? Should the General public be educated that this eventual incontinence is our natural destiny? The advance directive exists here in America.

[LovingLife123]

The problem becomes that skin breakdown and infection occur if the resident is allowed to sit in soiled briefs.  

Of course families should be allowed to help toilet their family member, but many don’t want to.  We see pee and stool all day long, but most people don’t.  

I know you are short staffed and overwhelmed but people can’t lay around in soiled briefs.  It can become a life or death issue if skin breakdown and infection occur.  

[MunoRN, RN]

Having the entire staff for a an LTC wing with 36 patients constantly in one patient's room is also a life or death issue.

Unfortunately part of our job is to prioritize care, which is a nice way of saying deciding who isn't going to get otherwise needed care and for how long so that other patients don't suffer excessively.  

Even in an ICU during Covid the standard rule became q 4 hour diarrhea cleanups, this was for diarrhea that occurred literally continuously, so that means close to 4 hours of sitting in your own stool.

We don't have a healthcare system that is set up to provide continuous stool removal and cleaning.

[K. Everly, BSN, RN]

There is reality and then there are best practice and policy. 

Sometimes the two don’t meet. Doesn’t make it right, but makes it a fact of life. 

Too many poops for the number of hands on the floor - what can ya do…

If my family member were in a SNF or SAR, I would do everything in my power to be there to provide assistance so my loved one got what they needed without assuming it’s simply because the staff doesn’t care. 

[JBMmom, MSN, NP]

Are most people horrified to think of their loved one sitting soiled for extended periods of time? Yes, of course. And most staff would prefer to get people changed and cleaned immediately as well. However, the demands of a job sometimes (often) conflict with what we like the real world to be. If there's anyone sitting around at a desk or chair leaving someone in a soiled brief, then even 5 minutes is too long. However, in an environment where everyone is doing their best to care for people, sometimes these things are just going to happen. 

[hppygr8ful, ASN, RN, EMT-I]

21 hours ago, George Acenas said:

if CNA ratio to total care resident is 1:8, Is responding to SAR/LTC resident’s call to be changed within 30 minutes realistic? On weekends the ratio increases to 1:12 and more due to call outs? Should visiting families be asked to help toilet their family because of an overwhelmed team? Should the General public be educated that this eventual incontinence is our natural destiny? The advance directive exists here in America.

When I worked with cognatively impaired elders it was considered very poor care to refer to disposable briefs as diapers. State inspectors determined this was infantalizing and demeaning. I was told the correct term was "Adult Protective Undergarment." try saying that 5 times realy fast. By the same note anything used to keep food or drink from spilling during meal time was called a shirt protecter, never a bib.

I am sure that when you are 1:8 ratio (actually pretty decent distribution for elder care) not every single resident will be wet/soiled at the same time. and if that is the case then of course someone will have to wait but every effort should be made to change the brief before it is completely saturated. 

I'm not sure why you reference the advance directive as I have never seen one that lists the option of staying in a soaked or feces filled brief. Advance directives exist to provide dignity and comfort not to allow staff to neglect this very necessary aspect of care. 

In my experience many family members do not mind helping with toileting or brief changes but some facilities don't want them too as it places the facility at risk for lawsuits if the resident should fall. @JBMmom said it best in that if anyone nurses,CNAs etc is just sitting around then a resident should not be made to wait. 

Hppy

[LovingLife123]

19 hours ago, MunoRN said:

Having the entire staff for a an LTC wing with 36 patients constantly in one patient's room is also a life or death issue.

Unfortunately part of our job is to prioritize care, which is a nice way of saying deciding who isn't going to get otherwise needed care and for how long so that other patients don't suffer excessively.  

Even in an ICU during Covid the standard rule became q 4 hour diarrhea cleanups, this was for diarrhea that occurred literally continuously, so that means close to 4 hours of sitting in your own stool.

We don't have a healthcare system that is set up to provide continuous stool removal and cleaning.

So, for diarrhea in the ICU you didn’t use a flexiseal?  

[Hoosier_RN, MSN]

36 minutes ago, LovingLife123 said:

So, for diarrhea in the ICU you didn’t use a flexiseal?  

Not every ICU utilizes those. Not everyone is trained for their use

[MunoRN, RN]

53 minutes ago, LovingLife123 said:

So, for diarrhea in the ICU you didn’t use a flexiseal?  

They took them away a couple of years ago, the GI docs demanded we get rid of them.

I've noticed on Physician discussion boards that the opposition to them among Docs is surprisingly common.

[mtmkjr, BSN]

The underlying assumption is that the staff is immediately responsive to every need as much as is physically possible. In my experience I do not find that to be consistently true. It is for some CNAs (and nurses), but there is also a lot of feet dragging and mis-prioritizing of care. I have extreme high regard for those who do the best they can, but while I agree that staffing ratios are very often poor, and working short staffed on top of that is a major problem, there is the additional fact that not everyone who works in healthcare is dedicated to providing optimal care. 

[kbrn2002, ADN, RN]

The SNF I worked in for many years had a normal ratio of 12:1 for CNA's to residents. The expectation was that all residents who were incontinent and/or mobility impaired were repositioned and checked every two hours. In reality was this always done? Of course not. 

[vintagegal, BSN, DNP, RN, NP]

Am I the only one cringing at the phrase “diaper change”? How about incontinence care, brief change, or perineal care ?