The End of Rashes

The End of Rashes

The 15 November conference in the previous post started what became a three week period during which I was present at each Nystatin treatment. It was absolutely necessary that the “the affected area and around the area be treated.”

Some 75% of recorded observations were ranked either GOOD or BETTER after being extracted from notes over a month old. None were ranked totally CLEAR. I did not know what totally CLEAR was. The area was usually swollen and red for months with an increase in the upper inner thigh rash during the last two months.

Her condition was slowly getting better but in a very random fashion. It was now winter. A change from powder to crème by the dermatologist and a daytime toileting schedule changed this in the next four days (yellow) in the groin area.

Each morning her groin condition was ranked GOOD. Each evening not GOOD. The abdomen showed a greater improvement with the first CLEAR and has remained so during next two weeks. The yeast infection was gone.

The first sight of totally CLEAR groin area skin was an experience. The swelling was gone. It looked normal. Suddenly a spark ran through my body. A tingle rattling around in an empty shell from head to toe. It radiated from deep within my body to the surface of my skin everywhere. In an instant it was gone.

For a moment I was weightless. I was once again looking down from over my right shoulder at the four of us. My body reacted far faster than my mind. My experience in the guided meditation class did not prevent this happening.

Now all the caregivers were reporting dryness around the clock. The rashes were coming to an end. The groin area during the next few days became so dry that it itched and was scratched. The fan was no longer used to dry.

With the yeast infection gone for over a month and the groin rash responding in a few hours, we were at last at the stage of management. Use Top Care and/or the fan as needed. We now know that wetness over four hours produces an odor and skin irritation, any time during the day or night.

A two-hour dryness check is the simplest way to promote healthy skin and odor control. The 10:00 pm and 2:00 am checks may be skipped if there are no skin problems (or MoliCare with pH control fiber is used). The night becomes two four-hour sleeping periods. Being up every two hours with a virus is exhausting. 

The pink blush on Christmas Day is a third cause for coloring on fully CLEAR skin. It is still not clear if this blush is just where the skin has been scrubbed or it is an allergic reaction in the general area.

The 95% cotton/5% spandex camisole replaces brassieres now and may help dry next summer. Now back to normal grooming with the fan and Top Care ready for next summer. A big thank you to the group of caregivers who helped out and now know that each shift has an important part to play on a winning team.

We now know that my wife's body is a far better monitor of the rashes than Arlo's video clips. A rash is an alert to health care practice. I am still puzzled that the yeast rash was so easily expected to last for a long time by both doctors when the packaging and other information imply that two to three weeks should bring it to an end with Nystatin. The implied dryness needed for it to be effective should prevent the infection in the first place!

Incontinence Management

I have made many drafts of posts as this chart grew; each had a different ending. This post tells a summary of an interesting and frustrating story.

Provision Living at Columbia used MoliCare incontinence pull-ups for almost two years. Their novelty was the control of pH that controlled skin irritation and odor. Attends stretch tabbed briefs are easier to change in bed than pull-ups. Attends pull-ups are less expensive than MoliCare pull-ups.

The hot summer of 2018 came without a spring. My wife likes the outdoors. She sweats. Nystatin powder requires dry conditions to work. We never achieved the necessary dryness until November; leaving her to endure five months of irritation to the point she was scratching in her sleep.

[She cannot talk. She also suffered a concussion at the end of August; with partial recovery of the use of her fingers at this date.]

The chart begins with my return from a week trip to San Antonio, TX. A one-hour conference in our apartment with the Director of Nursing and the Director of Memory Care, with two other family members, set the time for Nystatin treatment “at 12-hour intervals at the same time each day”: 8 AM and 8 PM. The effect was immediate (lower blue line).

The 1:00, 3:00 and 5:00 am (actually 6:00 am) dry checks found at the start of the chart continued for the next three weeks. After meeting with the dermatologist, December 11^th, , a toileting schedule was delivered to our apartment. Again the effect was immediately evident. In a few days the 12:00 and 4:00 am dryness checks were in place.

We found that my wife was dry at most of the checks at 10:00 pm and again at 12:00 am. These were dryness checks made at night.

Toileting was defined as placing the person on the toilet; and leaving them there for the time they needed to toilet. My wife comes from a family that has a small library in their bathrooms. Toileting needs 10 to 20 minutes.

To rush this invites a fight and a wet pull-up shortly after it is put on. Getting up in the morning takes about 15 minutes; combined the two is 25-30 minutes. Skilled and experienced caregivers leave our apartment after a few minutes to work on another resident for 10 to 25 minutes.

Curiously, all of this variation seems to have little to do with my wife’s abdominal skin condition. What does have an effect is what happens during the daytime toileting, that is not captured by the Arlo video clip camera in our apartment; that I am learning to use when the monarch butterflies return in the spring.

From the 13^th to the 15^th of December her abdominal skin condition was consistently GOOD and after the 23^rd of December totally CLEAR. The dermatologist determination that the infection was over by the 11^th of December was correct. Separating yeast and wetness irritation is another story summarized in the next post.  

Correct Nystatin Application

July 28 to December 11 covers five months. The battle is over (the burning, itching and scratching).

Cleaned skin break bleeding
at both ends when found
under right breast

That afternoon on a hot
July day

We started with leftover Nystatin cream that worked the past two summers.  No response. Got a new prescription. No response.

Next the powder formulation was used with some response and then with variable response. Nine caregivers were available each day, three per shift, to apply the Nystatin at bedtime and in the morning.

In hindsight we could see a failure of treatment related to each 13-day supply bottle. There was not enough powder to treat under two breasts and in the tummy fold. This allowed the tummy fold area to grow even larger to the far side of her body on both sides. An order for a 52-day powder supply ended the shortage. [11:22 today text. Yesterday’s new cream prescription by the dermatologist is ready at Schnucks Pharmacy.]

A caregiver came in one evening during the first weeks of treatment, took a look and announced: “This looks so good there is no need to make an application”, and left. She also deviated from the protocol all the other caregivers followed for the duration of the battle. We then knew of two ways the every 12-hour treatment was being broken. (A third one we found: the need to set a uniform time rather than flow with the workload.)

As the weeks passed, I looked for alternate treatments and what could be used to prevent a new infection. Success always seemed not too far away.

The application site must be dry. Wash, rinse off the soap, and dry with a third washcloth. Even using individual washclothes for each breast and the tummy fold made little progress.

I then found a very small electric fan. Mini Rechargeable Folded Fan

Mini Rechargeable Folded Fan

Dry is dry. But DRY is air dry. The medication does not cling or form little balls but remains a very fine powder during application. We could now see a proper application.

We now had a winning set of rules: (How this all came about is a long story.)

1.   Wash with a no-rinse self-sudsing disposable washcloth (no soap).

2.   Dry with a washcloth.

3.   Air dry with the fan.

4.   Make application, with fully exposed skin with Margaret on her bed, to the effected area and some of the surrounding skin.

5.   Have one person observe that the above was actually done across the three shifts (me).

6.   Set a uniform time to apply at 8:00 am and 8:00 pm.

A meeting on the 15^thof November approved these rules for the last try before we called in a dermatologist. Later, Monday 3^rdof December was the decision date to call it over. Monday AM it looked great. Monday PM the left breast was about as bad as it had been! Tuesday AM it was all clear again.

We went ahead with new rules for an additional week:

1.   Clean with rinse-free disposable washcloth.

2.   Wipe with dry washcloth.

3.   Liberally dust with Zeasorb.

We got an appointment with a dermatologist. She called our work done on the upper body, however, during the past few weeks the rash appeared in the groin area. “Continue your preventative measures on the upper body.”

She gave us new rules for the groin area: (Starting today 12 December.)

1.   Clean with rinse-free disposable washcloth.

2.   Wipe with dry washcloth.

3.   Apply and rub in a THIN layer of Nystatin Cream.

4.   Dry with fan.

5.   Dust with Zeasorb. 

A thick layer of Nystatin Cream in the spring resulted in a sweaty gooey mess and no results.

We also needed to learn how to liberally apply Zeasorb properly. Each caregiver had her own way of doing this that in general, was to invert the container and shake vertically. Erica held the container on its side and shook horizontally about six inches above the affected area.

The first method produces an uneven distribution with clumps. The second creates a small snow shower that evenly covers the affected area and around the area. For someone new, this takes a bit of practice.

Our prediction is to have the infection over by New Year; a lot shorter than five months. Winter weather reduces getting an infection but did not prevent it from spreading. A change in the management of incontinence ware the past few weeks seems important here.

A new toileting and changing schedule was in our clean laundry cart. Everything to optimize the effects of Nystatin are now in place.

One day later. We were all surprised to see Margaret’s skin looking normal in all areas. What now must be called false positive blushes of red, that appear one day and vanish the next, can be caused by her clothing when she sleeps in a chair, and by pull-ups that were not changed soon enough.

Nystatin works, but only if the stringent conditions are met for a person who easily sweats during a very hot season.

[Three days later. We are so close to the end that I do not plan to write a second post on this topic, however the recent  bizarre developments will need to be added when they can be put in proper perspective. I also need to get the fan resized and running.]

Physical Fitness Instructors

Yesterday I spent a half hour with our fitness instructor, Brandon. He has picked out a few residents to work with on their special problems. We have graduated from the exercise class appropriate for beginners, which is attracting few new ones.

I think he wants us to be models for other residents to follow; residents who do not see fitness as necessary in an environment where everything is done for you. You need to be active to age well over time and then to die quickly.

About a year ago I found myself walking down the hall, placing each foot directly in front of its former location, shifting my weight from one leg to the other, rather than placing one foot ahead of the other, Indian fashion, as I had been told at less then 10 years of age. It just happened. I was not even thinking about walking. This was the result of a number of exercises in a fitness class.

But there was more to it than just walking. To hold the pelvic girdle in place so as not to waddle, as one of our city cousins did, to our amusement, requires strong muscles in the lower abdomen. That has taken me a year to acquire.

In the past six months, I have experienced walking correctly. I have two exercises that place my shoulders in the correct position. I can recalibrate by just facing a wall in about three minutes. The problem is I must be very conscious of each step.

Yesterday that changed. I knew that I have been crouching, walking with my legs bent a bit. There were several exercises leading up to yesterday, related to the knees and everything attached there to.

Yesterday we worked with ankle weights. It is like the big mud boots we wore as little kids. Repeating the first step, in the same exercise, without weights, let my feet fly into the air, to my surprise.

I could see again my solo flight. “Watch out. It will get up fast.” And it did. Instead of lumbering into the air, the little fabric covered aircraft leaped off the runway and up to the altitude needed to leave the airport traffic pattern shortly after clearing the end of the runway. You never forget looking back to turn left and seeing no one in the back seat.

This time it was my knees that were different. “Look at me. Stand there. Look to your left in the mirrors.” I was standing perfectly straight without being ware of it. My legs were straight. My back was in alignment. It felt good.

I noticed my knees felt different. They still do. They are unlocked. They feel like gimbals that can move in all directions instead of rusty hinges. My lower legs are almost weightless.

My new 13 inch MacBook Pro, computer, that I just finished a few hours ago transferring my old machine into, is also helping. It is positioned at the correct eye location with a $20 keyboard on the desk.     

Success requires practice with both mental and physical memory. Individual parts make up the one final performance when under the direction of skilled managers. Things must be done so they build on one another and with such effort as to not over-do. “If it hurts, stop.”

Each person needs to learn what feels right when doing things right. Only then can you benefit the most from instruction. Just mimicking the motions does not cut it.

Our bodies are surprisingly pliable even at 88 years of age. Therefore many exercises must adapt to the ever-changing body. The fitness instructor determines your current state and monitors your exercises to build on that base. This is different from doing more of the same thing to follow body development.

The lack of instant success, rather than long term incremental gain, is one reason residents avoid fitness programs, When the process is so seemingly easy it raises doubts that, “Doing this” seems imposable to have a desired benefit.

Twice now I have experienced a new me: walking and standing correctly. I discovered it happening. I did not see a gradual development.

Now to finish what is left of my back pain that can be managed collectively by a melody of chiropractic (monthly), physical therapy (finished), fitness exercises (daily),and  mediation, tai chi, and yoga (weekly). We will see what another year’s application and practice brings at Provision Living at Columbia.