Insights on toileting, dignity, and care delivery

Guest Author: Pat Quigley, PhD, APRN, CRRN, FAAN, FAANP, FARN, is a falls prevention expert. More detail can be found at the end of this article.

Takeaway: 
In my practice, I saw that falls and injury often led to loss of independence, forcing people to accept help from others – something that many found hard to accept. 

Loss of toileting independence is particularly difficult for people to manage.  It requires physical assistance from others.  It also requires medical equipment that must be prescribed and individualized to meet the person’s abilities, limitations and pain. Both patient and caregiver require special training to learn how to safely use the equipment for that particular patient.  Without special training, additional accidents can occur.   Acceptance of physical assistance and willingness to use medical equipment cannot be taken for granted. 

My Great Aunt Marty:  Sudden Change in Function

At 89 years of age, my Great Aunt Marty (Marty), was fully independent for all self-care  activities and daily living.  She lived independently in her senior living home in a senior  home neighborhood.  She did not drive, but she never drove.  As a result, she relied on family members to drive her to appointments, to the grocery store, bank, and hairdresser.  She did her own laundry.  Family members checked on her daily, by visit or by phone, but always daily.  Marty was healthy, taking only a low dose of heart medication for irregular heart rate, never smoked but did enjoy a class of wine before bed. She was lean,  at 5’5” and 125 lbs., strong, and ambulated without an assistive device.  Her vision was better than mine because I needed glasses – Mary never did.  Her only limitation was due to her posture.   She was osteoporotic and over the years, her spinal vertebra collapsed – especially in her neck.  She became kyphotic, which means that her posture progressively bent forward so that she could not stand up straight, severe by the time she was 89 years of age. Her posture was so impaired that as she walked, she looked at the ground, finding it very difficult to look forward to visually scan her environment for risk hazards.  Also, because she was osteoporotic, she was at greatest risk for fracture when she fell. 

The Fall.  That day came one fall evening when Marty fell in her garage while hanging up her washed laundry from her clothesline (she would not use a dryer).  My family and I laundered her linens, sheets and towels, but she handwashed personal items.   My husband and I called her that evening, without response.  We drove over to her home,  found her down, in pain but not bleeding, called 911 and off to the ER we went – for her first ER visit in her lifetime!   Marty was never a patient in the ER or hospitalized.  Remarkable and Resilient!  

X-rays were taken and she was found to have a fractured right pelvis, thank goodness not a hip!  Marty was admitted to the hospital and in 24 hours, because no surgery was needed, her healthcare team began talking to her about discharge planning to a skilled nursing facility. She was able to put weight on her right leg “as tolerated.”  Marty was seen by Physical Therapy; they found that she needed help to turn and position in bed, get from a lying position to sitting, sitting to lying, and sit to stand, stand to sit, dressing her lower body and putting on a sock and shoe on her right foot.   She needed training to walk with a walker because of her pain in her right hip and forward flexed posture.  

Marty graciously accepted all help with her care and with walking.  BUT she had difficulty accepting help with toileting, which she was very private about, embarrassed that someone would be helping with toileting hygiene.   

Bedside Commode In the Hospital: In the hospital, she used a bedside commode, which was very difficult for her.  She had to get to a sitting position at the edge of the bed, stand up, stand, pivot, and transfer going towards her left leg, which was her unaffected leg, get in front of the bedside commode, then reach back for the armrests of the commode, slowly sit down while extending her right leg forward due to the pelvic fracture.  Not only was this hard, she then had to lean forward enough to clean herself after elimination without tipping forward off the bedside commode – especially hard due to her flex posture.  Additionally, the bedside commode was not stable or secure. With enough motion and weight, it could tip to one side or the other if a body leaned too far.   Use of the bedside commode had to be supervised, requiring physical assistance of another person.  

Within three days of admission, her needs for care were well established.  My husband and I did not want her to go to post-acute care, we wanted her to come home with us, and she did.  We arranged home health services with physical therapy, occupational therapy, and skilled nursing.

Post-Acute Care Preparations: As a rehabilitation nurse, I knew how to prepare the care environment for her. My goal was  to maximize her functional independence and begin her restoration and rehabilitation post discharge.  I set up a room for her, moved the bed so she was getting in and out of bed towards her left side, the non-fractured side.  It also let her put the most weight on her left leg when she got up to move and transfer from the bed.  

The only limitation I had was her toileting because she could not walk from her room to the bathroom and my bathroom had no grab bars.   We needed a bedside commode.

Bedside Commode in the Home:  Home health services clinicians arrived, completed a home assessment, and agreed to the need for a bedside commode.  The bedside commode, ordered by the occupational therapist, was very similar to the traditional bedside commode that was used in the hospital.  The arm rests were fixed, not swinging out to the side or removable.  The toilet height, while adjustable, was still too high when placed at the lowest possible level compared to the height of her regular twin bed.   

As a result, just like in the hospital, she had to be assisted to stand after sitting on the edge of the bed with help, use the walker to place her hands on the walker, take steps towards her left side, turning enough to stand directly in front of the bedside commode, reach back and hold onto the armrest of the bedside commode, and with assistance lower herself to a sitting position, extending her right leg, all of which was very painful to her.  Additionally, because the bedside commode was not on wheels, it was very difficult for her to maneuver around  where it was last placed. She needed assistance with cleaning, standing up, turning around using the walker and sitting back down on the bed, always moving towards her left side.  

Through that first week with us, I taught my husband how to transfer her.  We had to work together to help Marty get to a standing position, place her hands on the walker – one hand at a time, turn towards the left, position in front to the bedside commode, and  reach back one hand at a time to hold onto the bedside commode armrests, feel the commode toilet at the back of her legs (then she was close enough to sit down) and finally lower herself onto the commode seat as we eased her down, standing on each side slightly in-front of her so that she did not tip forward due to her posture.

It became clear that we had to do something different. I had to do something different:  my experience as a rehabilitation nurse kicked in.

Bedside Commode with Wheels, Movable Armrests: I worked with the occupational therapist and found a bedside commode that had wheels and swing-out armrests.  We had to pay for this more appropriate commode because Medicare would only pay for one bedside commode.

Also Got a Slide Board:  I also ordered a slide board.  The new commode and slide board made transfers on and off the commode to and from the bed much easier, less painful for Aunt Marty.

Once we got the second bedside commode and the slide board, her transfer difficulty was reduced, as was her pain.  Also, because this bedside commode was on wheels, we could easily turn it around, place one end of the slide board under her left buttock, and the other end on the bed, and help slide her over  onto the bed.  We helped with foot and leg placement  and  balance control  This combination of equipment eased the burden of toileting for both Marty and us.  We also found a use for  the  original BSC – as a shower chair, which was perfect!   

Recovery Of Function:  As my Great Aunt Marty recovered, she became more independent in mobility and self-care.   I am happy to share that, in 2 months, she was independent enough to return to her home.  Her home bathroom did not have grab bars, which Marty needed.  BUT she would NOT allow grab bars to be installed in her bathroom.   However, we talked her into allowing the second bedside commode to be placed over the toilet, adjustable to her proper height, the wheels locked, and the elimination bucket removed. This option provided Marty with grab bars and a higher toilet seat.  She was very pleased and used this independently.  I also used that first bedside commode  – without the bucket – in the shower as a shower chair, moved next to her shower wall for stability, adjusted to her height, non-slip flooring, hand-held shower hose, and towels within reach.  As a result, my Great Aunt Marty was able to  shower while in her own home.   

I hope my lived experience caring for My Great Aunt Marty is an example of why finding the right equipment is so important. 

Together we learn more.