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Mom had a stroke July 1, rehab, then dx of vascular dementia in rehab. She's always been very anxious, with labile bp. She broke her hip last week, had surgery on Sunday to repair. She seems to have forgotten how to swallow. Speech has told hospital to without food and fluids, pending a more thorough swallow eval. She had an impacted esophogus three weeks ago; they had to scope her. They are witholding meds overnight, got them to give her Ativan in her IV instead of Klonopin by mouth, but I'm worried about bp meds not being given. Have pointed out esophogus issue to nurses, PAs, Docs every day, but they are not calling the GI folks who saw her in the ER or for followup. Is there something that I should be doing that I haven't thought of?

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A lot of times hospitals need to hire per dium (unsure of spelling) nurses especially at night. This is because money is very tight in the medical world and budgets are incredibly important for hospitals just to survive. One month the hospital needs a certain amount of nurses because it is incredibly busy and another month they need many less. These on-call nurses do not "belong" to the hospital, they are employed by a registry and are called in on an as needed basis. Most of them are excellent but there always are a few of them that are scarey. The real scary ones do not have pride in their work and have no sense of loyalty to strive for the hospital's excellence. They just want to finish their shift and go home. The permanent nurses rightfully resent this behavior because it makes them and their collegues look bad and the hospital look bad.

If something bad happens, and I don't mean little things or something that couldn't have been helped, I mean something significantly bad and careless happens due to a nurse having reckless and thoughtless care for your mother then you should calmly and nicely report it out of concern for the hospital, the other patient's and your mother. Politely and respectfully ask for the charge nurse and quietly, calmly, without blame or tone, and behind closed doors let him/her know what happened and ask how the situation can be corrected so that you can again feel comfortable about leaving your mother at night as you really need to go home and sleep so you can function at your job the next day. If you do it in a non-confrontational way trying to work as a team with the other nurses, believe me they will bend over backwards to help you. Most nurses go into nursing because they really want to take care of people.

Also, sk them what process the hospital has in place to make sure that this nurse's behavior is addressed and corrected. Also inquire if somehow you or your mother could be adversely affected by reporting the problem as you really do not want to make trouble for anyone. (You have enough troubles of your own to deal with.)

Hospitals are under obligation to write up formal complaints like this and address them. They will do the right thing for your as they really want to have an excellent reputation of care in the community. Administration takes this very seriously. They can do a million dollars of advertising but word of mouth in the community from patient's and their families pale in comparison.

Do not let the hospital nursing staff feel that you are confrontational at all. Allow them to have joy in helping you and your mom because they want to, not because a family member is angry or threatening to them. There is a lot of humanity in medicine in spite of the fact that there is alot of business and science in it. That is what makes the field of medicine so perplexing to "bean counters." They just have not found a way of taking out the humanity from the equation.

One more thing. If there is a problem that is episodic, like your mom's blood pressure, ask the doctor if he could write a standing prn order. For example: if the patient's systolic pressure is between "this" and "that" then give the patient this medication at this dose. That way night nurses already have an order to take care of the problem and is under obligation to follow it whenever the situation arises again.

Also, if there are particular nurses that you and your mom really work well with then see if they can be assigned to your mom's case as often as possible. Talk these individuals up to their superiors and thank them and complement them when they go out of their way to help you.

Lastly, be discrete. Do not openly complain to anyone about any of the nurses or any of the employees. You need to be reassured that if you talk to someone about a particular concern it will be in the strictest confidence so that no one feels uncomfortable around you.

Again, hope this helps.
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There is always tremendous risk with a 90 year-old, and recovery from hip surgery is a long road for anybody. They take a long time to come out of anesthesia, often with deficits, and great risk for more strokes. If the esophagus becomes paralyzed, it no longer contracts to move food along. Food added at this point leaks into the lungs and aspiration pneumonia follows. NPO is appropriate, injectables should have been ordered simultaneously. Get to know her nurses and tell them you will call in for daily updates, and get their direct phone number. Make sure mom signs the HIPPAA release.
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thank you so much for the very helpful information. Mom is now swallowing, getting pureed foods. Unbelievably, when they made her NPO, due to speech therapist's concerns about her airway, they stopped giving her bp meds. They said that they would monitor; this AM, her bp was 197/85, AM nurse called doc and got injectible bp meds ordered. Said she didn't understand why night nurse didn't do the same. I spent three months at my mom's bedside during rehab this summer and have used up the time I can take. She's 90 minutes drive; my brother and sister in law are close by, but they also work. We all need to work! Hospitals need to get this stuff right without a family member being at bedside!
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An esophageal stricture does not cause a person to forget how to swallow. The swallowing mechanism is an intricate "dance" all the muscles do in the throat to keep the windpipe shut while the food goes down an open esophagus. The brain regulates that. She could have had a stroke given her diagnosis of "vascular dementia" and hypertension. The other thing is that anesthesia on the elderly can take a long time to wear off affecting her cognition and swallowing. In either case she could gradually get better with her swallowing. However, until then her nutrition should bipass her lips and go directly into her stomach either through an NG tube or PEG which is a tube that goes directly through skin into the stomach. Medications should be given also in this manner.

Talk with the doctor who is the "captain of the ship." Usually that is the surgeon. If she has a "hospitalist" also on board, then talk to him/her also.

Ask to have your mother evaluated by a Neurologist to see if she has had a new stroke or if the anesthesia + trauma to her body from her fracture + other medications + change in environment could be causing her an "encephalopathy" which is temporary mental status changes due to a variety of factors.

Ask for a "Modified Barium Swallow with speech therapy to be present". This will identify if she is at risk for aspiration. If she is, then alternative nutrition needs to be arranged for. If it does not reverse shortly, then temporary PEG placement can be done to keep her adequately supplied with her dietary needs. It can be pulled if she decides she no longer wants it or if she gets better and no longer needs it. But until you know that her mental status changes and swallowing difficulties are for sure permanent or not, you would have her covered nutrition and medication wise.

If a PEG is found to be something that would be of benefit for your mom, then ask for the GI physician who evaluated her blockage in the Emergency Department to see her while in the hospital. She probably needs follow-up on that esophageal blockage anyway. If she has a blockage in her esophagus, she may need a PEG anyway for that reason also. The GI specialist needs to evaluate her GI tract to make sure that structurally PEG placement can be done. Placement of the PEG can be done either by the Gastroenterologist or the hospital Interventional Radiologist and is a pretty simple procedure with relatively little risk.

Inquire when the Dr. will be rounding and be there when they round. Do not get angry if they do not make it there on time or can only round late as they sometimes have little control over situations that effect their schedule.

Be direct and straightforward with what you would like. Be nice and non-confrontational. Some families are so pleasant to be around that the doctors will bend over backwards for them. Other families are so confrontational and unappreciative that it is a drag for the doctors to make rounds and talk with them. Also, being there for your mom shows that she is important to someone and that she is loved. Subconsciously, those people seem to get afforded a sort of leg up on the other patients as their perceived importance rubs off on others.

Hope your mom has a speedy recovery.
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What is the delay in getting the swallow evaluation?
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