#11 – Effective Assisting at Nursing Homes

Introduction

By January 2001, there will be over 40 million Americans over the age of 65. Many of our older Americans, due to economics, lack of perceived need, or lack physical access will be forced to live in nursing homes. Today we see many of these seniors as physically limited, sickly, poor, and/or with reduced mental abilities. However, in their time, they were as responsible for the success of their families and communities as we are today in ours.

Part of our vision is to help the disadvantaged to make their lives easier. Where possible, we will offer a comprehensive program to assisted living and nursing homes in our area. This program will be provided with all of the love and respect we would give to our own parents if they were in this situation. Here are our goals.

A. Understanding the residents’ psychological and medical issues
B. Finding an effective plaque removal techniques for disabled residents
C. Using chemical agents (fluoride and artificial saliva)
D. Giving staff in-service presentations on resident oral healthcare
E. Working with residents to maintain good oral health
F. Communicate with other health professionals to improve the overall health of the residents

Providing our level quality in extended care facilities requires a huge effort in coordination/cooperation. Family members, home staff, and our staff, physicians, pharmacists, and social workers must all work together.

We will provide written records, treatment plans, communication with family members, great cleaning, and preventive care appointments, rational treatment recommendations, loving care, reduced fees, training for the facility’s staff, and much more.

Operating in a Nursing Home

A. Who works at a nursing home
1. Administrator
a. Runs the nursing home
b. Establishes policies and procedures
c. Responsible for maintenance of facility, grounds, equipment
d. Hires, fires, manages staff
e. Responsible for all finances

2. Medical Director
a. Required if facility receives Medicare/Medicaid
b. Responsible for all medical/dental policies/outcomes
c. Must be a licensed physician

3. Attending Physician
a. Usually a resident continues seeing the physician that cared for them before they entered the facility. Homes have specific Dr.’s. If patient does not choose one of those, then they are responsible for their own appointments and transportation.
b. Facility will have a physician available for residents who have no preference
c. All treatment is reviewed by director for appropriateness
d. Must review and agree with any medications prescribed by dentist
e. Must see patient once a month.

4. Director of Nursing
a. Plans/supervises all nursing services
b. Responsible to Medical Director
c. Most have an RN available 8 hrs/day, 5 days/week
d. Medical records dept.
e. Done by social services and nursing staff
f. Responsible that all residents oral home care is adequate
g. Orients new staff; responsible for in-service training – done by nurses aide director

5. Nurses’ Aide
a. Not trained/certified nurses, must have high school degree and be state certified
b. Low pay; much turnover
c. Responsible for most day to day care of residents * All daily oral care

6. Social Worker
a. Helps find resources (including financial) for residents
b. Help family members with decisions
c. Help find funding for dental programs
d. Admissions Director
e. Not available at all facilities
f. Help family members with decisions

7. Physical Therapist
a. Employed by home
b. Help residents with physical problems. Find ways to use muscles better. Rehabilitation.

8. Occupational Therapist
a. Find ways to help residents physically be able to do oral hygiene (design grips for brushes, handles for floss, etc.)
b. Improve functional skills of residents.

B. Diagnostic guidelines
1. Standards for HealthPark clients and extended care facility guidelines are very different.

2. Clinical implication of aging.
a. Loss of social roles (family, occupation)
b. Loss of income
c. Reduced physical abilities
1. impaired vision – harder to read, progressive blindness, more light sensitive
2. lack of taste – not age related, caused by xerostomia, medications, diabetis
3. hearing – loss progresses with age

3. Only 1 treatment plan will usually be given
4. Seldom use antibiotics
5. Amount of treatment is determined by lifestyle

C. Signs/symptoms – Tx
1. Xerostomia

a. Signs of Xerostomia
1. Smooth glossy tongue
2. White tissue around teeth
3. Caused by many diseases and medications
4. Rampant decay
5. Burning, sore tongue

b. Treatment
1. Biotene saliva substitute
2. Fluoride paste prescription
3. Chlorhexidrine rinse

2. Decay
a. Look around roots
b. Tx
1. Look for sugar consumption (dietary counseling)
2. Fluoride prescription
3. Mentally disabled – Chlorhexidrine spray (calibrate to 1.2 ml/spray) twice daily (early AM, at bedtime). One spray on front teeth.
a) Mouth rinse or paste would be swallowed or aspirated
b) May not cooperate for brushing
4. Control is directly related to facility staff.
5. Try to control small areas with fluoride.

3. Periodontal disease
a. Signs – gum inflammation, bone loss, loose teeth
b. Treatment
1. Improve brush/floss
2. Chlorhexidrine rinse twice daily
3. Don’t remove tooth unless painful
4. Loose dentures
a. Even 1 loose tooth helps neuromuscular control of dentures
b. Consider over denture
c. Avoid constructing any new appliance

D. Consideration for providing informed consent
1. Give resident/family time to get all questions answered
2. Discuss risks/benefits of various treatment alternatives and the lack of treatment
3. Write down what was discussed on the treatment sheet
4. No warranties
5. Get written or verbal consent for treatment

Document all treatments

Why do we go to nursing homes? Our nursing home clients, as a group, are low pay, unappreciative, high health risk, hard to manage, heavily medicated, inconvenient problems. Most are on Medicare. Private pay clients complain about our fees. The treatment is limited to avoiding infections, pain, and helping them chew effectively. We work in poor conditions, bent over, with poor visibility. Why bother? Because everyone has the right to feel good and look good even if they are old, poor, or have reduced mental capacity. We have been blessed in many ways – health, careers, friends. This is a chance to give back a little of what we have received.

A few days before our visit, the secretaries will print out a computer list of all the clients we have seen previously at the facility. This list is sent to the head nurse, so added or lost clients can be adjusted on the master sheet.

* Make sure they have orders for their pre-meds.

A. The day before the visit, review the checklist of items to make sure everything is ready. Usually the whole team will meet at the office, clock in, and prepare for the day. Once you’ve rechecked your boxes, place them in the care and head out.

B. Packing up to get ready the day before should include:
Supplies: 2×2’s (2 containers)
Baggies
Bib clips
Bibs
A red Biohazard bag
3 clipboards
Coarse prophy paste (2 dozen)
5 complete and partial dentures brochures
10 copies of Preventive Care brochure
Cotton forceps
Cotton rolls
Cotton tip applicators
Denture adjusting sticks
5 Denture cups
Denture marking kit
Denture marking sticks
Dremel handpiece, acrylic burs
Emisis pans (3)
Exploring points
2 flashlight fingerlights
Floss
Floss Holder
Floss Threaders
Gloves
1 Knife
Lab knives
Masks
Mirrors (6)
Mouth props
2 pencils
2 pens
Plastic chair covers (at least 12 for each hygienist)
3 prong pliers
2 rolls paper towels
Portable Cavitron
Proxi brushes
Reline and repair acrylic
Safety glasses for you, hygienist, and client
Spray bottle of disinfectant
Stain/tartar remover
Toothbrushes
Treatment sheets
The doctor’s signature stamp
5 complete and partial denture brochures
10 copies of preventive care brochures
-small plastic bags for used instruments (1/client to be seen)
-plastic headcovers
1 bottle of amoxicillin
1 bottle of clindamycin

Arrive at the office and load the car.

Your task is to support the dentist/hygienist during the team’s visit to the nursing home. Remember, the residents often get little contact with the outside world. Spend some extra time to enjoy their company and brighten their day. Be prepared for some abuse and some very frank discussions.

Procedure at nursing home
1. Unload the car
2. Take supplies to the room designated for the hygienists. It will be clean and smell like a hospital.
3. Set up all the supplies and equipment.
4. We may not be at our office, but all safety standards still exist. You must be safe.
a. Primary infections: herpes, colds, hepatitis B, and HIV
b. Transmission of infections occurs by
i. Pathogen strong enough to cause infection
ii. A host that is susceptible to the pathogen
iii. A way for pathogen to enter the host
c. Precautions
i. Treat client blood/saliva as infections
ii. Use gloves, mask, eye protection
iii. Ask how to dispose of contaminated waste
5. Clean off the chair and counter with solution and then after each client
6. Place a plastic chair cover over the chair
7. Check the medical history for a client when you seat him/her.
a. If the history indicates the client should be pre-medicated, have one of the nurses provide the antibiotic and wait one hour before treating.
b. Some clients may be confused. Be kind, but be forceful.
c. Be especially careful to note clients on Coumadin or Heparin (bleeders).
d. Any drug groups being used that could cause dry mouth
i. Anti-hypertensives
ii. Anti-cholinergics
iii. Anti depressants
iv. Anti histamines
v. Decongestants
vi. Anti-Parkinson’s
vii. Anti-psychotics
viii. Diuretics
8. The dental assistants duties are to check the medicines that the patients are taking, look over medical history, then brush and floss their teeth or clean the dentures.
9. We will treat the clients in their wheelchair rather than attempt transfers.
10. A portable headrest can be attached to the back of the chair.
11. Make sure the client’s name is in the denture
12. Lubricate client’s lips.

13. Ask the client these questions:
a. Do you have any problems chewing or eating your food?
b. Do you have dentures? How much do you wear them?
c. When was your last dental visit?

14. Adjust the goose neck light so the hygienists can see as they remove the calculus.
15. Be very careful to maintain good infection control procedures in our area. When everything is arranged, make sure all the patients’ dental and medical records are organized in groups.
a. Those by room numbers who will be examined or treated in their room
b. Those who will have their teeth cleaned and examined at our area or in their room
c. Those who have special needs determined by the staff

16. As the hygienist begins her exam, read out loud the resident’s medical history, any highlights of past dental treatment, and nursing staff comments. Look for:
a. Alzheimer’s stroke (CVA), Parkinson’s, MS – poor home care
b. Poor nutrition
c. Diabetes – slow healing

Be sure to utilize universal precautions:
i. Wear gloves, mask, eye protection
ii. Wash hands before re-gloving for the next resident
iii. Residents should wear eye protection
iv. All dental team members should wear scrubs
v. Use a container for sharps disposal
vi. Have a container for infectious waste disposal
vii. Any exposure incident must be reported to the dentist
viii. Use surface disinfectant on all possible surfaces between residents
ix. Use nitrile gloves to clean used instruments
x. Bring enough mirrors, exploring points, in bags for all residents without needing to re-sterilize them
17. While hygienist uses portable Cavitron, place emisis basin under client’s chin
18. Fill out the treatment sheet. Record in detail all procedures performed. Make a list of all clients that need to be brought to HealthPark for further treatment. (See example sheet.)
19. Pull the nursing home charts. Find the dental treatment page. Have Dr. (see sample sheet) review your entry. Stamp it.
20. While wearing gloves; disinfect all surfaces, replace chair cover, throw away disposables, and set up for the next client – including disposables and instrument pack. Use red waste bag for infectious waste.
21. When finished with client, fill out “Oral Hygiene Care Plan” to place in resident’s charts (See page)
22. When finished with the last client, clean all the instruments, pack everything up, isolating contaminated instruments and put it back into the car.
23. When you return to the office, review the treatment sheets. Give a list to the secretaries of the clients that received treatment
a. Prophy
b. Denture repair
c. Exams
d. Denture construction

Also, make a list of clients that will require further treatment at our office.
i. Extractions
ii. Fillings
iii. Mobile enough to come here for cleanings

24. Organize all treatment sheets alphabetically so the secretaries can enter the treatment information and fees into the computer.

If only 1 chair is available
Switching chairs can be very time consuming. Follow these steps to speed the process
1. Have the next patient sit in a chair near the hygiene chair
2. Make sure all paperwork is updated
3. Ask if any new concerns
4. Brush the teeth
5. Enjoy the patient

Have fun with the clients. You may be the only non-staff human contact your client has all day. Even though your role will seem very casual, be careful what you say. Here are some examples:

Mr. Smith is 80 years old. “Mary,” the assistant says, “this is Mr. Smith. Isn’t he something? He’s 80 years old and still going strong.”
Sound harmless? Not to Mr. Smith. He has just been introduced as a museum piece rather than a person.

Mrs. Johnson is 75 years old and is watching the assistant prepare for the doctor. Her questions seem endless. “What is that over there? How do you use that thing? Is this going to take a long time? Is this going to be expensive? Does the doctor use that often?
After responding to several questions, the assistant finally says, “Mrs. Johnson, why don’t you just relax? The hygienist will be with you in a minute.”
Think if what is going through Mrs. Johnson’s mind. Why won’t she talk to me? I really want to know what’s going on. And who said I wasn’t relaxed? Shouldn’t I be? Is there something to worry about?

Mrs. Allen has brought her 78 year old mother in for treatment. The assistant greets them and says to the daughter, “Your mother looks so nice today. That color is really flattering on her. Could you please have her fill out this form?”
And there stands mother, wondering if she is invisible and thinking “does she think I’m incoherent?”
How easy this is to do. For some reason we don’t address them because we think they won’t understand. Unfortunately, they end up feeling they are not accepted.

Mr. Wilson, who is 76, is seated in the treatment room carrying on a conversation with the assistant when the assistant says, “It must be nice to have so much free time. What do you do to keep yourself busy?”
The assistant has assumed that Mr. Wilson has a lot of free time, and even if it is true, her remark could prove embarrassing to him. He may feel unproductive or even guilty and he may not know how to reply.

How would you have responded to the above situations? It is very easy for communication with elderly patients to be misunderstood, but there are effective ways to guard against this.

–Don’t fail to pay attention because you are busy with other things. Show concern for what they say and think before responding.
–Don’t say something won’t hurt if it will or that the doctor will be there in a minute if he won’t.
–Don’t change the subject. The patient has something to say that is important to him.
–Don’t make assumptions based on age.
–Look at patients when speaking or listening.

An effort to understand the needs of the elderly and to communicate sensitively with them can make their visits more enjoyable for staff and patients.

IN SERVICE TRAINING

You will also be responsible for short in-service training sessions with the staff. Dr. can provide your handouts on various topics to improve the level of care at the facility.

To present on in-service, follow these steps:
1. When you arrive, tell the director when you would like to present
2. The director will tell you where and “pass the word” to the staff
3. Have the director make enough copies of your handout
4. Presentation
a. Introduce yourself and your role at HealthPark
b. Announce your topic and distribute the handout
c. Affirm that you may know dentistry, but they know how they can best implement your ideas into their care routine
d. Make the presentation
e. Take questions and lead a discussion of how the staff will work your ideas into their daily routine

RESIDENT DENTAL STATUS – FIRST EXAM

Resident’s Name  / Room Number  / Date:

A. Medical History
1. Current diseases

2. Current medications Purposes

3. Drug allergies

B. Mental Status
1. Cognitive 1 5 (best)
a. Eye contact, self-respect
b. Respond appropriately
c. Answer questions accurately

2. Personality (angry) 1 5 (fun)
a. Easy to anger
b. Block dental care?

C. Dental History
1. Has a regular dentist no __ yes __ (name of dentist _______________)
2. How long since last dental exam? ____________________________

D. Client’s interests ______________________________________________________________________________________________________________________________________________________

Can resident perform self-care? Yes ___ No ___
With some assistance Yes ___ No ___

Is oral hygiene currently administered entirely by nursing staff? Yes ___ No ___

Is a change in oral hygiene care required? Yes ___ No ___

Does resident have xerostomia? Yes ___ No ___

Has a fluoride dentifrice or other (toothpaste) been prescribed? Yes ___ No ___

What brand? _________________________________

Listerine/Chlorhexidrine Yes ___ No ___
Fluoride gel prescribed Yes ___ No ___
Artificial saliva prescribed Yes ___ No ___

Wears dentures? Yes ___ No ___ Wears partial dentures? Yes ___ No ___

Has a denture adhesive been prescribed? Yes ___ No ___

____________________________________________________

Are dentures or partial dentures cleaned daily? Yes ___ No ___

Are dentures labeled? Yes ___ No ___

Does resident sleep in dentures? Yes ___ No ___

Does resident remove dentures at other times each day? Yes ___ No ___

For how long? ________

PROGRESS REPORT

NAME __________________________________________________________________

DENTIST’S ORDERS – TREATMENT SHEET

 UNABLE TO EXAMINE
 EXAM
 PROPHYLAXIS
 HEALTH OF MOUTH GOOD FAIR POOR
 NO TREATMENT NECESSARY
 FINDINGS: __________ GUM DISEASE
__________ DECAY
__________APPLIANCES LABELED, STORED SAFELY
 OTHER TREATMENT
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
INSTRUCTIONS FOR NURSING STAFF
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 NEEDS HELP CLEANING TEETH ONCE DAILY – Brush, floss, gauze wipes
 USE PRESCRIPTION FLUORIDE TOOTH PASTE
 USE CHLORHEXIDRINE MOUTHWASH AT BEDTIME
 ARTIFICIAL SALIVA _____ TIMES PER DAY
 ELECTRIC TOOTHBRUSH
o NEEDS TO BE SEEN IN TIPP CITY DENTAL OFFICE FOR ________________________________
Instructions: _____________________________________________________________________
____________________________________________________________________

SIGNATURE ____________________________ DATE _______________

AUTHORIZATION AND CONSENT TO DENTAL TREATMENT

Patient _________________________________ Date ________________

This authorization and consent for treatment is given by Dr. ________________, hereinafter referred to as Doctor.

1. Doctor has advised that in his/her own opinion the following treatment is indicated: ____________________________________________________________________requiring a fee of ____________
2. Doctor has advised be that in his/her own opinion the consequences of not treating this condition include, but are not necessarily limited to: ____________________________________________________________________
__________________________________________________________________________________________
3. Doctor has advised me of alternative treatments, benefits, and risks, which include, but are not necessarily limited to: _____________________________________________________________________
__________________________________________________________________________________________
4. Doctor has advised me that there are certain risks and potential consequences of any treatment plan or procedure and that in this case, the risks for treatment as outlined in no. 1 above would include but are not necessarily limited to: _____________________________________________________________________
__________________________________________________________________________________________
5. I understand that by the very nature of the proposed treatments and the uniqueness of myself as an individual, that no one can predict the certainty of any outcomes or successes, and that even in the event of treatment, my condition could worsen.
6. I understand that no guarantee or assurance has been given to me that the proposed treatments, or alternatives, if any, would fully satisfy my expectations. I believe that it is in my own best interests to proceed with the proposed treatments.
7. I have had ample opportunity to ask any questions about the proposed treatment, alternatives, and risks. All questions that I have asked have been fully answered to my satisfaction.
8. I have had the opportunity to discuss with Doctor my medical and health history indicating any serious problems, injuries, or allergies.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE AUTHORIZATION THAT I AM ABOUT TO SIGN FOR THE PROPOSED TREATMENT, MEDICATION, OR SURGERY, DESCRIBED ABOVE. I ACCEPT THE RISKS OF SUBSTANTIAL HARMS, IF ANY, IN HOPES OF OBTAINING THE DESIRED BENEFICIAL RESULTS OF THIS TREATMENT OR PROCEDURE. I FURTHER ACKNOWLEDGE THAT ALL BLANKS ON THIS FORM, REQUIRING  COMPLETION, HAVE BEEN FILLED IN, OR DELETED, IF NECESSARY, PRIOR TO MY SIGNING THIS FORM.

Date __________________ Patient ___________________________________
or Legal Guardian ______________________________
Doctor ______________________________________
Witness ______________________________________

ORAL HYGIENE CARE PLAN

Check all that apply: Resident _____________________________________

__________ 1. Wear gloves (for NA or nurse).

__________ 2. Lubricate lips before oral care.

__________ 3. Supervise/assist resident with self-care.

__________ 4. Do care for resident.

__________ 5. Brush teeth twice daily using
__________ a. fluoride toothpaste
__________ b. fluorodex
__________ c. Other ____________________________________________________

__________ 6. Brush denture(s) or partial(s) twice daily.

__________ 7. Floss teeth once daily using
__________ a. floss threader for fixed partials/bridges
__________ b. floss holder

__________ 8. Brush tongue twice daily

__________ 9. Swab/brush edentulous mouth twice daily using
__________ a. lemon glycerin (only if mouth is not dry)
__________ b. other _____________________________________________________

__________ 10. Rinse or swab teeth with prescribed oral rinse twice daily using
__________ a. fluoride rinse or gel
__________ b. chlorhexidrine rinse
__________ c. other ______________________________________________________

__________ 11. Use saliva substitute, ____________________________________________________

__________ 12. Use denture adhesive, ___________________________________________________

__________ 13. Store dentures in water at night or for 3-4 hours daily

__________ 14. Screen mouth for oral/dental problems

__________ 15. Label or relabel denture(s)

__________ 16. Special considerations: ___________________________________________________
__________________________________________________________________

LABELING DENTURES

Steps in labeling a denture

1. When labeling dentures be sure to wear gloves.

2. Make sure the resident’s denture cup is labeled.

3. Assemble all the necessary materials: an emery board, disposable brushes, clear acrylic nail polish such as Sally Hansen’s Hard As Nails, a fine-tipped indelible marker such as a Sharpie marker, and a piece of paper for fanning the denture dry.

4. Make sure the area of the denture to be labeled is dry before beginning.|

5. Using a disposable emery board, roughen a spot on the rear of the denture, making sure that the spot to be labeled is on the side toward the cheek and away from the palate. The area need be no larger than a fingernail.

6. Brush away the powdery residue which results from filing the area.

7. Using the fine-tipped marker such as a Sharpie, mark the denture with the appropriate initials or resident’s name. Check with the nursing supervisor on the method of coding a resident’s denture.

8. Using a disposable brush, paint the acrylic polish over the labeled area and allow to dry. Drying can be hastened by fanning the denture with a piece of paper.

9. When you are sure that the acrylic is dry, test the label by immersing the denture in a glass of water. If it doesn’t smear or smudge, then labeling has been done correctly. It is a good idea to check the dentures label periodically, at least every six months.

Be sure to dispose of the emery board, brush, and gloves, and wash your hands.