Hydration of the Stroke Patient

[caregiver222]

I intend topost somecomments in regard to hydration. Any additionalones would be appreciated.

[caregiver222]

Constipation is a big problem and fibre is usually recommended--- except fibre won't work without water. The circadian issue is rarely addressed. Most elderly people start to goto bed earlier.At the same time their very elderlymothers and fathersmay develop stroke reated circadian problems that cause them to be up at midnight other ungodly hours.Last night I stayed up with my sweety-pie until 1:30 A.M. The night before 1 A.M.  Between ten P.M. and 1:30 A.M.I got nine ounces of fluid into her. She was alert, enjoyed watching televiusion and cuddling, and in the morning had a perfect full loose bowel movement. Earlier in the day I left at 4P.M. with instructions to the aides to "keep her hydrated". She was"offered" rink, refused, and got exactly "ungotz" between4 P.M. and ten P.M.In fairnessto the aides they are very affectionate.They just don't "get" the fact that offering a drink that gets a "sip" is not suffficient and that hydration is the difference between life and death.It takes a tremendous amount ofpatience to hydrate, because even smallamounts offluid take along time to transit down and you NEVER EVER want to force-feed liquids to a patient with thin-liquid swallowing problems. Jello works well, but as it melts, it again becomes an asphxiation hazard, soonly use fresh quantitiesof firm jello.I have had good success with unflavoired jello to which only a small quantity of flavoring has been added, because of concern over the sugar issue. I am also going to suiggest ocasional use of salt, provided there are no bloodpressure issues. People are under the misconception that salt is deadly. I take a saltine cracker, moisten it with a spray of water (I have alittle bottle with a spray head) and sprinkle on a little salt. Sometimes I put a bit of "hot sauce" on the cracker. This is not a daily routine, but depends whether or not the day is especially hot,or ifmylittle-camperisgoing outside or is constipated or has had a delayed bowel movement. Constipation can have very bad consquences and it can be avoided in many cases by proper hydration.I avoid honey as a sweetener,instead using organic maple syrup because, as many of you know, honey is toxic to bacteria.It should be used as a medicine. And bacteria help digest the food.I use lactose free organic milk, and Ilike to get at least a spoonful of yogurt aboard with every meal. There are many "guides"to whether or not a patient has good hydration, but the existence of regular soft bowel movements without straining is an indication you are on the right track.

[caregiver222]

Here's my rule I tell my aides: EDC. That means "Every Drop Counts". Every single morning and evening we have a "hydration report and consultation, sometimes three times a day. This could be by telephone. I demand to know how much liquid has been taken in to the ounce or the teaspoon or the drop. At the end of every evening and in the morning the hydration log is reviewed. As we know, stroke patients have "good days" and "nor so good days". The "not so good days are charcteriuzed by excessive sleepiness, and in some stroke patients for can have a cycxle of two sleepy days and two good days, or even three sleepy days and three good days. During the sleepy days the patient goes into dehydration. If the patient has swallowing difficulties, ESPECIALLY with thin liquids NEVER GIVE LIQUIDS OR FEED WHEN THEY ARE TOO SLEEPY. The liquid will be cheeked, end up down the trachea, and the chances of aspiration pneumonia increase. Often, patients with problems swallowing thin liquids can swallow more effectively during certain times of the day. Unfortunately those times are often after midnight or four A.M. The aides MUST use these opportunities for hydration. Theoretically you can hire a day aide and a night aide, but you find the night aides generally have a day job also and cannot be counted on to hydrate at night. Last night we gave my little sweety-pie cream of chicken soup and jello at one A.M. The aides will often give you a thousand reasons why these instructions are impracticable and can't be done. The life of your loved one depends on hydration and your mission if not to be a "nice person" and to "win friends and influence people". Your job is to insure your loved one gets the best of possible care. Going outside side for short periods is a good ideam but in the case of a female have a large brimmed loosely fitting hat and before going out take the previous hour to get in two to four ounces of hydration. Of course you have at least two or three small chilled thermos bottles in the backpack of the wheelchair with different thick liquid treats. And another bottle of water used to ocasionallly wet a small piece of cloth and wipe down the arms. A tiny spray bottle of water is useful. Take off the hat and spray underneath and spray the hair lightly. The evaporation will be cooling and refreshing. Take breaks under the shade of trees. And remember that strokes often affect ther ability to communicate discomfort as well as the ability to sweat.

[caregiver222]

As I once mentioned you must insist the aides/caregiver maintain a meticulous hydration log. One problem is the aides "fib" or tell you "she drank a lot". I was relying on the logs which clearly states "gave cup of hot chocolate". What the aides were not stating was that only a single sip of chocolate was taken. I took her our for a few days and did not realize the effect of the sun on fluid loss. That won't happen again. There is always something new to learn, however I should have known better. You want the amount recorded in a permanently bound marble-type children's book in ounces.  Jello is a mixed blessing. It can often stimulate the swallow reflect, but it high in sugar. I have some of my own recipes for using plaun gelatin and adding low sugar flavoring, but I used to mix the "sugar-free" jello with the "sugar jello" fifty-fifty. Remember, as the jellowmelts you again have a thin fluid, and can develop aspiration pneumonia, so keep enough in the cup so you don't have "melted jello". Never leave it out because it is a fine material to breed bacteria on, if exposed to the air. Watermelons are often sold in the store in a less that ripe condition. I always keep them four to five days. Unripened watermelon causes tummy aches. You should always serve hydrated banana. Never dry banana. There are several means to do this. You should use small pieces and unwrap them and simply rinse them in water. Or puncture the piece with a toothpick and then rinse it. Do those few extra drops of water matter? It depends. In my opinion it does.You should always have a "ready banana" and not serve them with meals but as "in-between meal" snacks. There are a variety of good reasons for this. The banana is an excellent food to strengthen the muscles involved in swallow that have atrophied. A nurse who hands a stroke patient a whole banana doesn't know what she is doing. I like a piece about 3/4 to an inch long. I like to provide a piece every half hour or so. You don't want to strain the muscles involved in swallowing. You can also take a tiny piece of banana and put it in a small teaspoon with a pureed drink such as a smoothy. I use very small teaspoons, all solid silver, because bacteria does not grow on silver. The watermelon can be very dangerous. I use very tiny pieces and observe whether the watermelon is "cheeked". NEVER leave tha patient alone with a piece of watermelon in his/her mouth. Yogurt is good, but add extra water. Always remember that "No!" or a wave of the hand often means "later". There is a long transit time for food in the stroke patient. Many aides simply take the :no" as an escuse to end hydration for the evening. If the stroke patient doesn't get the idea "mime" or stand directly in front of them and take the spoon of liquid youself. Stroke patients often have limited peripeheral vision and difficulty understand what is required. Also caution the aides to WAIT between spoonfulls. Just because the patient opens his/her mouth DOES NOT MEAN they are ready for another spoonful. Keep thei backs in a vertical position, offer to let them handle the spoon themself if they are able, and if you do so approach slowly from below the chin.

[caregiver222]

One treatment that is overly used in the elderly stroke patient is high-dose vitamin C. While it is true that Vitamin C goes after free radicals, it is also a powerful diuretic and high doses are  contraindicated in any patient with a dehydration issue --- which includes most stroke patients with swallowing disorders. There is more nonsense written about evaluation of swallowing disorders, and I sometimes think an ouiji board might provide a better result. The first thing to do is to start keeping meticulous track of the swallowing disorder over as period of at least two months. In particuliar, note if there is a difference in swallowing at different times of the day, or if there are"good days" and "bad days". It has not occurred to many in the busines of treating and rehabilitating stroke disorders that there is a circadian nature to a swallowing disorder. Since all hospitals are run on a 9-5 basis, this basically invalidates all the swallowing tests conducted in the hospitals. Not in every case, of course. Clearly there are (a) circadian based swallowing disorders and (b) non-circadian disorders. Differential diagnosis is essential. The normal nursing facility feeds during the day and lights out at night when the goblins come out. Decades ago I worked for a time in a nursing home and one of the old-timers told me "you can get a lot of the patients to drink or eat between midnight and two A.M.". Hmmmmm. That was news. I get a lot of hydration into my little sweety-pie between 10 P.M. and 1 A.M. There are ways to straighten out the circadian rhythym, but they are too complex for this post. I provide yogurt to which a small amount of liquid has been added. Sort of water-enhanced yogurt. Juices are mixed fifty-fifty with pediatrol. And you have to be VERY careful about summer outings inn the sun, beneficial as they are. I keep a de-humifier in the room, but no air conditioner. The airconditioner is in an adjacent room, and in the patient room a pair of small exhaust fans blowe air out, which draws in the cool air from the adjacent room without a draft.

[caregiver222]

For a variety of reasons stroke patients (and Alzheimer's patients) often have a bizarre "day-night schedule". Many Alzheimer's patients end uo institutionalized because they "haunt the night". But let's  go back to stroke patients, especially with those with swallowing difficulties, which come under the heading of difficulty in swallowing solids and difficulty in swallowing thin liquids. Because hospitals and diagnostic facilities operate on a "9-5" schedule and most strokie patients have unusual circadian rhythyms, most of the hospital swallowing tests aren't worth the paper they are printed on. Often enough the "cycles" of swallowing both liquids and solids are not always 24 hours in duration. A good subject for a study. My little 102 year old ofteh has two or three day periods during which time she cannot swallow thin liquids without danger of aspiration. So one of the rules of care if before EVERY meal an assessment must be made of both the ability nto swallow (a) thin liquids and (b) solids. If there is any doubt by the aide/caregiver the meal is postponed. I often arrange meals at 2 A.M. for my little character. Fortunately this is the esception and not the rule. You can see the problem in a nursing home. Remember that movie with Robin Williams when he said "Carpe Diem?". With those who have swallowing difficulties you must SIEZE THE MOMENT. When they can swallow and eat well give them a good portion. And never miss an opportunity to hydrate. Never. Hydration is the key to everything. Inadequate hydration is the primary cause of conspitation and syncopal (fainting) episodes while straining on the toilet. The aides have to know that simply because the patient opens their mouth they shouldn;t have a spoon of jellow or a drink. They will often "cheek" the liquid, and then lie back and ten minutes later when the aide has left the room you end up with aspiration pneumonia. My rule is always assurre alertness when feeding or administering liquids, always in a sitting position with the back vertical and then observe the patient CLOSELY for the next ten minutes. If they seem to be "cheeking" liquid, have them ready to spit iot into your hand. Have a towel ready for this purpose. Thenh give them a big hug to make sure they aren't embarrassed. Cheeking in a stroke patient is rarely constant. It will  come and go. The worst thing aides do is to offer liquid, then permit the patient to lie down, or move from the vertical position before the liquid is assimiliated. If you try watermelon or jello remember that the last spoonful is the most dangerous. They may cheek than spoonful fifteen  minutes lkater you have an airway obstruction. So my advice is to sit and observe for at least fifteen minutes after the last spoonful of liquid or solid food. Never miss an opportunity to hydrate. For example, if you give a piece of cupcake, soak it in coffee or in milk. Never dry. Getting back to constipation and syncopal episodes, mnake sure there is a soft rug on the floor around the toilet area. NEVER TELL THEM TO PUSH! This encourages straining. The aide should NEVER leave the side of the stroke damaged person during toilet. Nor be on the cell phone. And privacy is important. With my aides, they have been informed in writing that if the door is open while the patient is on the toilet they can consider themselves fired. We also have a lighweight screen. A few weeks ago my little 102 year old had a vasovagal episode and fainted on the topilet. I was unavailable that morning. 911 was called and she was taken to what is considered one of the best hospitals in the United States. She had soiled herself and when awake in the hospital wanted to be cleaned. The nurse and physician refused to permit the aide (who went along) to do so). My little 102 year old became freantic. This was dealt with by summoning the brainless hospital psychiatricist who responded by ordering Haldol to "calm her  down". I arrived just in time to grab the syringe from the nurses hand, throw it to the ground and step on it. I can't tell you what I told the physicians if I want to still be allowed to post, but think about an episode of the Sopranos and you'll get the idea. She was there all day before I signed her out "against medical advice" . She was NEVER TOUCHED ONCE in a reassuring manner by a physician or a nurse. Quite naturally they started on nebulized oxygen (contraindicated in stroke patients who have no cough reflex) and naturally I again had a to-do with the respiratory tech.  You get respiratory tech credentials with three candy wrappers from M & M's these days. By the way, I do have a fine female geriatric physician I rely upon, so as not to give the wrong imnpression. The ambulance crew refused to take her to that hospital (which was an equal distance away).  They do this because they get cash bonus's and free meals and stethascopes and other "goodies" for steering patients with excellent insurance coverage to their voluntary hospitals. Another nationwide scandal. By the way, if an ambulance crew arrives, BEFORE THEY TREAT the patient slip them ten bucks, making sure to tell them "I know you guys can't take tops, but buy yourself some coffee and donuts." You don't want to give them fifty bucks. It's the thought that counts. Now in some cases it is best to take a patient to a trauma center and ignore the advice of the patient's relatives who "want them to go where their records are". Paramedics often have to make life or death decisions. Not all hospitals are certified trauma centers, for example. So they are not always making decisions based on personal gain. But this does ocasionally enter into the equation and you should be aware of it. If they give you good service and are polite write a nice letter to the hospital administrat praising them. It's also a good idea to do this for the "little people" in the hospital, such as the cleaning staff, if you see them taking especially good care of the cleanliness in the room. Anyways I signed my little camper out at midnight, wheeled her home in the great outdoor for a half mile point out the stars and cooked her a wonderfulo three course meal at one A.M. The next day I took her to the park and she lauighed and fed the pigeons. The night before the brilliant sixteenh year old who posed as an M.D. on duty told me "she might not live through the night". My little 102 year old has a little habit. When someone annoys her (like the doctor) she goes into "zombie mode". When we were going home under the starts she said "Thank god you got mer out of there!". She has continued to regain her ability to speak, incredibly enough. The life-force has been very good to her.

[caregiver222]

I had decided to cease posting for a variety of reasons, but a friend caused meto change my mind and I might give it another shot. Hydration of the stroke damagedpatient, especially the truly elderly, is a terrible problem, and the nursing texts, which suiggest "encouraging hydration" are valueless.The problem is especialy dangerous in those who have problems swallowing thin liquids. I have my little102 and a half year old sweety-pie (who seems to get better every day) and she has episodic thin-liquid swallowing difficulties. Laclof hydration leadsto lack of mental acuitity and constipation. The constipation causes styraining and thatactivates the vagal system and you end up with a syncopal episode (fainting).. Sadly, many of these episodes sometimes result
in death. If you haveapatient with a syncopal episode,unlessyou aretrained and equipped, call911. But the first thing to do is tolie them flat on the floor, and elevate the feet six to twnh inches. A small blanket under the shoulder blades keeps the head extended backward and keeps the tongue clear  of the airway. Have someone open a window wide, if they are available.You can increase the percentage of oxygen in the air by a percent or two in this manner. Do not attemptto wake them or shake them or use smelling salts. As long as they are breathing normally,simply maintain the airway and hold then tightly. You don't want to wake them because you will immediately increase the oxygen demand on the heart, and this can precipitate death of tissue. Don't worry about" cleaning them up". Before calling 911, put the on the floor as indicated. If you have aides, the aides generally have a "call list". Bad idea. 911 is the only call needed. When the medics get there you can make all the calls you want to anyone on earth. Most of these syncopal episodes on the toilet are recaused by constipation. By the way I stopped laxatives on my 102 year old patient about two and a half years ago, except for ocasionally senna. They can be used judiciously, but a patient can become dependent. Proper hydration almost always takes care of constipation, with a few exceptions. Be cautious about going outdoors, because although the sunlight is helpful, the loss off fluid through sweating is significant. With my little 102 year old have found organic seedless watermelon to be a life savor.I cut them into very small pieces, because long pieces tend block the intestine. Because she has difficulty swallowing you have to make sure the piece if swallowed before offering another. Just because the patient with a swallowing disorder opens their mouth doesn't mean they are ready to swallow.I think any heathl care aide who "force feeds" a stroke patient with a swallowing disorder should be criminally prosecured. But anyway,let's get the the magix hydration method. WATERMELON. Small tiny pieces of watermelon.The consistency of the watermelon stimulates the swallow reflex in many of those who cannot swallow thin fluids. Consult your physician. There is another "dirty little secret". Thin liquid swallowing disorders are ofteh episodic and circadian mediated. This meand the patient who cannot swallow thinliquids at sixP.M.may be able to swallow at two P.M. And yes, I have arranged soup meals at 2 A.M., which annoys the aides to no end. It alsomeans that the swallowing studies conducted in the best geriatric journals are for the most part imnvalid because they do not take into considerration the circadian rhythym.Many strokepatients have strange body rhythyms.Often they can swallow after midnight and not be able to swallow during the day. It is amazing how this simple bit of knowledge has not penetrated the brains of one of the top geriatric facilities in the nation, who turn to enteral feeding or a trach at the snapof a finger. But then again,many institutions provideM.D. decreegs with boxtops these days. So anyway I keep meticulous hydration logs and my little sweetheart gets a dozenounces of fluid every day with watermelon.I also provide her with "hydrated banana"and lots and lots of jello.You make a hydrated banana by cutting a two inch segment,slicing and peeling it and then re-wrapping it. Remember you want to develop hand coordination. Hint:If the patient attemps to eat the banana without unwrapping the skin don'tethey could aspirate the contents into the lung.I hydrate the bananas by drilling thre small 3/26th inch holes with a hand bit,use an eyedropper to fill the holes,"squich the holes shut"with a butterknife,rinse the bana in water,and...voila...you have a hydrated banana. Does the extra smallamount help? Every teeensey little bit helps.You may also find that yourpatient develops thirst and the ability to sip a bit aftyer twn P.M.That means the aide does notgotosleep, but hydrates the patient. Goodd attentionj to hydration can avoid a"cascade"of undesireable events, avoid an enteral feeding situation and the last resort of intravenous hydration.I keep the watermelon until it gets perfectly ripe and then make sure to remove every single seed. Avoid any green pieces.You will have to lose 1/4 to1/2 of the waterlemon.Of course YOU can munch on the seed parts. Never lose an opportunity to hydrate.If I give her a piece of cupake I dipit in milk o rcoffee first. Hydration, hydration, hydration. When I feed jello alternate between two different flavors. Think hard about keeping a meticulous hydration log. And make sure the watermelon and banana are very ripe to avoid tummyy upset. And don't let the aides or the health care agency run the hydration schedule! And don't accept statementslike"she drank a lot today". If a log bookif kept do notpermit them to write"served hot chocolate". Have them write down how many sips. And alwats remember that there is a delayed transit time."No" when refusing jello or watermelon generally means"later". In my humbleopinion, however, the watermelon is a real winner.