60761960 Geriatric Nursing Midterm
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Transcript of 60761960 Geriatric Nursing Midterm
Care of the Chronically Ill and the Older Persons
ELECTIVE 2BSN 14B
July 20, 2011
Risk factors associated in Chronic Illness in elderly
Modifiable/non-modifiable
Risk factors: Modifiable
• Lifestyle–Smoking–Poor nutrition–Physical inactivity–Failure to use preventive and screening
services• Coping styles, stress
Risk factors: Non-modifiable
• Age• Pre-existing conditions
–Long term medication• Hereditary
Patterns of Illness in Elderly
• Multiple chronic conditions• Undiagnosed diseases• Accommodated to disease and impairment• Limits toleration (multiplicity of dis)• Functionally limited• Dependent on others
Comprehensive Geriatric Assessment
Comprehensive Geriatric Assessment
• A multidimensional, interdisciplinary diagnostic process to determine the:–Medical–Psychological–Functional capabilities of a frail elderly
person•
Comprehensive Geriatric Assessment
Purpose• Develop a coordinated and integrated plan
for treatment and long-term follow-up• Achieve quality and functional status of life
Comprehensive Geriatric Assessment
Purpose• Determine prognosis and outcome of care • Employment of interdisciplinary teams • Utilize standardized instruments to
evaluate aspects of patient functioning, impairments, and social supports
Goals and Objectives (CGA)
• To refer those at risk for other more thorough workup
• To improve process of care:– Improve diagnostic accuracy– Improve medical treatment– Arrange for long-term case management
Goals and Objectives (CGA)
• To improve outcomes of care:– Improve functional status– Better quality of life
• To contain costs of care:– Reduce use of unnecessary formal services– Prolong tenure in the home/community
COMPONENTS OF COMPREHENSIVE ASSESSMENT
Component Elements
Medical assessment Problem listComorbid conditions and disease severityMedication reviewNutritional status
Assessment of functioning Basic activities of daily livingInstrumental activities of daily livingActivity/exercise statusGait and balance
Psychological assessment Mental status (cognitive) testingMood/depression testing
Social assessment Informal support needs and assetsCare resource eligibility/financial assessment
Environmental assessment Home safetyTransportation and telehealth
CHRONIC ILLNESS IN ELDERLY
Wellness is the Goal at All Ages
SpiritualFaithMeaning in life
Emotional• Friendship• Connections to others• Sense of well being• Belonging to a family
and community
PhysicalNutritionExercise
MentalActivities and hobbiesProblem-solvingContinuing education
FinancialSecurityIndependenceFlexibility
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Age and Illness
• Aging does not cause disease nor does disease cause aging
• Dizziness, confusion, forgetfulness and incontinence are not normal aging, but usually signs of a disease process
• Even if someone has a disease, symptoms may be corrected or relieved
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Being an older adult,Does not mean being ill!
Chronic Illness and Chronic Care
• Estimated 99M Americans live with chronic illness
• Most with >1 chronic illness– 88% of >65yo have >1 chronic disease
– 25% of which have >4
• Chronic illness accts for 75% national health care costs
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Not just long-term conditions……
• Co-morbidity• Complexity• Frailty
And for the next steps…..
Unlike Acute Illness….
• Short-term• Either die or get
well– Influenza– Pneumonia– GI infections
Chronic Illness
• Persists for a long time and is either incurable and/or results in pathological changes that limit normal functioning.
• Virtually everyone will eventually develop some type of chronic condition.
Differences between acute and chronic conditions
Acute disease Chronic Illness
Onset Abrupt Generally gradual and insidious
Duration Limited Lengthy and indefinite
Cause Usually single Usually multiple and changes over time
Diagnosis & prognosis
Usually accurate Often uncertain
Intervention Usually effective Often indecisive; adverse effects common
Outcome Cure possible No cure
Uncertainty Minimal Pervasive
Knowledge Prof.’s - knowledgeable Patients - inexperienced
Prof.’s and patients have comple-mentary knowledge and experience
Chronic Diseases
• HTN• DM• CHF• OA• COPD• Cancer• Mental Health Illness- depression/
dementia/ psychosis etc• Chronic Infectious Diseases: HIV/AIDS,
Hepatitis
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Complexities of Chronic Illness
Cognitive impairment
Obesity
Diabetes
Impaired mobility
Cardiovascular diseases
Depression
Biggest Worries About Having A Chronic Illness (Age 50 +)
1. Losing independence
2. Being burden to family or friends
3. Affording medical care
The Increasing Burden of Chronic Illness
Additional Medical Problems * 45%
Functional Limitations ** 50%
> 2 Symptoms *** 35%
Poor Health Habits 30%
For example: Patients with diabetes have
* Arthritis (34%), obesity (28%), hypertension (23%),cardiovascular (20%), lung (17%)
** Physical (31%), pain (28%), emotional (16%), daily activities (16%)
*** Eating/weight (39%), joint pain (32%), sleep (25%), dizzy/fatigue (23%), foot (21%), backache (20%)
The Impact of Chronic Illness – The Individual
• Initial Impact– Shock– Denial– Loss and grief– Anxiety and depression
• 20-25% experience psychological symptoms
• If these reactions last too long, they can have an negative effect on the illness
The Impact of Chronic Illness – The Individual
• Must adjust to:– Symptoms of the disease– Stress of Treatment– Feelings of vulnerability– Loss of Control– Threat to self-esteem– Financial Concerns– Changes in family
structure
The Impact of Chronic Illness - The Family
• Must adjust to:– Increased stress– Change in the
nature of the relationship
– Change in family structure/roles
– Lost income
• Different issues for different relationships– Adult children of ill
parents– Spouse of ill
person– Parents of ill
children
Issues and trends in Chronic Care
• Poverty• Illiteracy• Centralization & Fragmentation of Care• Physician shortages concurrent with
restrictions in use of nurse practitioners• The Disease-Model of Care• Prevention a minor expenditure in health
care budget
……..Glimmers of Hope
• The Cancer, Kidney, Diabetes, & Heart & Stroke Associations working together
• Moves to develop true community clinics• Concerted efforts to produce model of
care that makes the best use of resources & improves access to relevant & effective care
• Government has identified priorities & improved collaboration
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
Improved Outcomes
Model Development 1993 --
• Initial experience at GHC• Literature review• RWJF Chronic Illness Meeting -- Seattle• Review and revision by advisory committee of 40
members (32 active participants)• Interviews with 72 nominated “best practices”, site
visits to selected group • Model applied with diabetes, depression, asthma,
CHF, CVD, arthritis, and geriatrics
Essential Element of Good Chronic Illness Care
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice
Team
• Assessment of self-management skills and confidence as well as clinical status
• Tailoring of clinical management by stepped protocol• Collaborative goal-setting and problem-solving
resulting in a shared care plan• Active, sustained follow-up
Informed,Activated
PatientProductiveInteractions
PreparedPractice
Team
What is a productive interaction?
Self-Management Support
• Emphasize the patient's central role
• Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up
• Organize resources to provide support
Delivery System Design
• Define roles and distribute tasks amongst team members
• Use planned interactions to support evidence-based care
• Provide clinical case management services• Ensure regular follow-up• Give care that patients understand and that fits
their culture
Decision Support
• Embed evidence-based guidelines into daily clinical practice
• Integrate specialist expertise and primary care
• Use proven provider education methods• Share guidelines and information with
patients
Clinical Information System
• Provide reminders for providers and patients
• Identify relevant patient subpopulations for proactive care
• Facilitate individual patient care planning
• Share information with providers and patients
• Monitor performance of team and system
Health Care Organization
• Visibly support improvement at all levels, starting with senior leaders
• Promote effective improvement strategies aimed at comprehensive system change
• Encourage open and systematic handling of problems
• Provide incentives based on quality of care• Develop agreements for care coordination
Community Resources and Policies
• Encourage patients to participate in effective programs
• Form partnerships with community organizations to support or develop programs
• Advocate for policies to improve care
Chronic illness by SYSTEM
Physical Illness
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Osteoporosis (“Porous Bones”)
• Disease process causing bones to become more fragile and likely to break
• Often progresses painlessly• First symptoms may be broken bone,
height loss, or curvature of the spine• Any bone can be affected, but hip and
spine are frequent sites
National Osteoporosis Foundationwww.nof.org/osteoporosis
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Osteoporosis Risk Factors
• Age:• Greater risk with aging, which• Tends to cause bones to weaken and lose
density
• Gender:• Four times more common in women than
men• One in three women and one in 12 men
over the age of 50
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Osteoporosis Risk Factors
• Family History and Personal History of Fractures as an Adult:
• Women whose mothers have a history of vertebral fractures seem to have reduced bone mass
• Personal history of a fracture as an adult
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Osteoporosis Risk Factors
• Race• Caucasian and Asian women are more
likely to develop osteoporosis • African American and Hispanic women at
significant risk
• Bone structure and body weight• Small-boned and thin women (under 127
pounds)
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Osteoporosis Risk Factors
• Lifestyle:• Cigarette smoking, alcohol abuse,
consuming an inadequate amount of calcium or getting little or no weight-bearing exercise
• Medications• Chronic Diseases (discuss with doctors)
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Bone Mineral Density (BMD) Test
• Safe and painless test for osteoporosis• Recommended for all women age 65 and
over, and younger women at risk• Often reimbursable by Medicare
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Prevention and Treatment
• Diet• Exercise• Hormone replacement therapy (HRT) –
talk with the doctor to understand the risks
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Osteoarthritis
• Cartilage surrounding joint breaks down
• Knees and hips most common sites, but may affect the back and fingers
• Those who overuse joints are at greater risk
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Rheumatoid Arthritis
• Disease of the immune system affecting tissue surrounding the joint
• Can appear at any age, but most commonly diagnosed among women between the ages of 20 and 50
• More rigorous drug therapy or surgery may be necessary
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Other Types of Arthritis
• Gout• Caused by a buildup of uric acid crystals in
the fluid that bathes the joint; usually affects the big toe
• Causes severe pain and swelling in that joint
• Ankylosing Spondylitis • Degeneration of the joints that support, and
are part of, the spinal column
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Risk Factors for Arthritis:
Certain foodsHormonal changes
HeredityGender
Age
Treatment
• Adequate rest• Stretching and daily ROM exercises• Maintaining ideal weight• Taking aspirin and ibuprofen• Hot and cold treatments for minor
discomfort• Over-the-counter preparations containing
capsicum, camphor, or menthol• For more severe cases, corticosteroid
injections to fight inflammation 55
Often the symptoms of arthritis can be relieved
by basic self-care practices
Call a doctor when…
• Pain is accompanied by fever• Sudden unexplained swelling, redness or pain in
any joint• Pain is so great that use of the joint is lost• Cannot use the joint or it limits regular activities• If the problem does not improve after five to six
weeks and home care is not working
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Assistive Devices
• Canes• Lid and jar rubber or synthetic
openers• Faucet turners• Reachers/grabbers• Flipper type door handles• Extended handles on tools
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Handout:
Tools and Gadgets (Assistive Devices)
For Independent Living
Hypertension (Blood Pressure above 140/90)
• Cause unknown• If untreated, is related to development of arteriosclerosis• If untreated, may cause stroke, heart attack, congestive
heart failure, and/or kidney failure• Treatment:
• medication• low salt diet• exercise• stress management• weight management
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Signs and Symptoms of Stroke American Stroke Association
Sudden onset of:• Numbness or weakness of face, arm or leg, especially on one side
of the body• Confusion, trouble speaking or understanding• Trouble seeing in one or both eyes• Trouble walking, dizziness, loss of balance or coordination• Severe headache with no known cause• Nausea, fever and vomiting distinguished from a viral illness by the
speed of onset (minutes or hours vs. several days)• Brief loss of consciousness or period of decreased consciousness
(fainting, confusion, convulsions or coma)
TIA – Transient Ischemic Attack (“small stroke”)
TIA – Transient Ischemic Attack (“small stroke”)59
Treatment and Rehabilitation
Rehabilitation:– Physical therapy (PT) to restore physical functioning and skills like
walking and range of movement– Occupational therapy (OT) to relearn the skills needed for
everyday living such as eating, toileting, dressing and taking care of oneself
– Speech/language therapy (ST)Lifestyle:
– Encourage use of affected extremity to increase muscle strength– Avoid doing things for him/her that he or she can do– Be supportive and sympathetic but firm and direct– Expect some emotional ups and downs– May need to install hand rails by toilet, bed, etc
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Aphasia American Stroke Association
Responses and Support•Be patient•Allow the person time to understand and respond•Use visual cues and gestures•Use short, clear words•Use visual aids•Nod when understanding•Allow person to write instead of speak
Stroke survivors, although able to think as well as before the stroke, may experience an interference in the use or understanding of language The individual is unable to get the right words out or is unable to process words coming in 61
Signs and Symptoms of a Heart Attack American Heart Association
• Discomfort in the center of the chest that lasts more than a few minutes
• Discomfort in other areas of the upper body in one or both arms, the back, neck, jaw or stomach
• Shortness of breath accompanied by chest discomfort or can occur before the chest discomfort
• Breaking out in a cold sweat, nausea or lightheadedness
Response: Call 9-1-1; Start CPR if individual stops
breathing (only if qualified) www.americanheart.org
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• The risk of dying from a heart attack is higher for women than men
• As with men, women's most common heart attack symptom is chest pain or discomfort
• Women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain
Women at RiskAmerican Heart Association
Response: Call 9-1-1; Start CPR if individual stops breathing (only if qualified) www.americanheart.org
“The Red Dress was designed to build
awareness that women are at risk;
give a sense of hope that women can
reduce their risk and empower them to do
so; and provide a clear call to action
coupled with a sense of urgency.”
The Heart Truth
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Angina
• Mild to severe chest pain which may radiate to the neck or shoulders, lasting less than three minutes
• Caused by some obstruction in a major blood vessel of the heart (arteriosclerosis)
• Brought on by exertion, cold, eating a heavy meal or excitement
• Management strategies: Losing weight, stopping smoking and managing stress
Response Nitroglycerin tablet is placed under the tongue and
allowed to dissolve Works in one-half to three minutes
Response Nitroglycerin tablet is placed under the tongue and
allowed to dissolve Works in one-half to three minutes
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Signs and Symptoms of Diabetes
American Diabetes Association• Frequent urination
• Excessive thirst• Extreme hunger• Unusual weight loss• Increased fatigue• Irritability• Blurry vision• Itching• Poor wound healing• Stress such as infection or surgery
may worsen symptoms
Caused when the body is unable to
make use of sugars and starches Glucose
accumulates in the blood and may appear
in the urine
www.diabetes.org
Diabetes is expected to increase as much as 165% over the next 50 years, especially among those age 75 and older
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Diabetes Lifestyle and Treatment
• Balanced diet• Controlled amounts of sugar and starch• Weight management• Exercise• Insulin injections• Oral medications• Good skin care, especially for the feet• Daily blood sugar monitoring
Diabetes requires
a life long focus
on diet, lifestyle, and
medical monitoring
Wear bracelet
or necklace to alert
responders to condition
66